1 The Affordable Care Act: Is Healthcare Becoming More Affordable? Houston Economics Club Federal Reserve Bank of Dallas, Houston Branch November 17, 2014 Vivian Ho, PhD James A. Baker III Institute Chair in Health Economics Director, Health Policy Forum Professor, Department of Economics at Rice University Professor, Department of Medicine at Baylor College of Medicine
2 Outline Changes in health insurance Marketplace plans (Healthcare.gov) Medicaid Large Employer Plans Small businesses Fiscal impact of the ACA The ACA and Medicare
3 Source: Gallop.com Daily News
4 Source: Gallop.com Daily News
5 Source: Congressional Budget Office, Updated Estimates of the Insurance Coverage Provisions of the Affordable Care Act, April 2014.
6 Marketplace Insurance Plans Healthcare.gov April 2014: 5.4 million selected plans through 36 federally facilitated marketplaces (FFMs) 2.6 million enrolled in HI through 14 state based marketplaces. In the FFM, 87% used tax credits to enroll in a plan.
7 Kathleen Sebelius Former US Secretary of Health and Human Services Sylvia Mathews Burwell Current US Secretary of Health and Human Services
8 Marketplace Insurance Plans Average Monthly Premiums before and after Tax Credits, Tax Credit Amount, and Percent Reduction in Premium after Tax Credits for Individuals Who Selected Plans with Tax Credits through the 2014 Federally-facilitated Marketplace Metal Level Percent of Individuals Who Selected Plans with Tax Credits Average Premium before Tax Credits Average Tax Credit Amount Average Premium after Tax Credits Average Percent Reduction in Premium after Tax Credits Bronze 73% $289 $221 $68 76% Silver 94% $345 $276 $69 80% Gold 65% $428 $220 $208 51% Platinum 64% $452 $232 $220 51% All Metal Level 87% $346 $264 $82 76% Source: ASPR Research Brief, June 18, 2014.
10 $263 x 12 = $3156. Source: ASPR Research Brief, June 18, 2014.
11 How do Marketplace premiums compare to premiums purchased by large employers for their workers?
12 Average Annual Premiums for Single and Family Coverage, $2,196 $5,791 $2,471* Single Coverage $6,438* $2,689* Family Coverage $7,061* $3,083* $8,003* $3,383* $9,068* $3,695* $9,950* $4,024* $10,880* $4,242* $11,480* $4,479* $12,106* $4,704* $12,680* $4,824 $13,375* $5,049* $13,770* $5,429* $15,073* $5,615* $15,745* $5,884* $16,351* $0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000 $18,000 * Estimate is statistically different from estimate for the previous year shown (p<.05). SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Source: KFF.org Employer Health Benefits Survey 2013
15 Source: Health Reform Monitoring Survey Texas, Issue Brief #3, April 14, 2014.
16 Source: Health Reform Monitoring Survey Texas, Issue Brief #3, April 14, 2014.
17 Source: Health Reform Monitoring Survey Texas, Issue Brief #6, July 7, 2014.
18 Employer Provided Health Insurance Source: 19th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care, 2014
19 Employer Provided Health Insurance Source: 19th Annual Towers Watson/National Business Group on Health Employer Survey on Purchasing Value in Health Care
20 Employer Provided Health Insurance Employers face new costs under the ACA Fees that insurers pay to the federal government, which they may pass on to employers. 2015: report whether and what insurance offered to employees. 2015: requirement for large employers to provide affordable coverage to their workers.
21 Employer Provided Health Insurance Excise tax on high-cost coverage ( Cadillac tax ) Plan sponsors must pay a 40% tax on the difference between $10,200 (self-only coverage) or $27,500 (family coverage) and the actual cost of any employer-sponsored insurance Dollar amounts increase, indexed to inflation Includes total cost of coverage (both employer AND employee share of premium) Not in effect until 2018, but many employers starting to think about and prepare plan design changes now
22 How much will insurance coverage and premiums change in 2014? TABLE 3: Changes in Per-capita Employer Spending Due to the ACA, Simulated as if the ACA is Fully Implemented in 2012 All Employers Small firms (100 or fewer employees) Mid-size firms (101-1,000 employees) Large firms (More than 1,000 employees) Total per-capita employer spending Total per-capita employer spending Total per-capita employer spending Total per-capita employer spending Without Reform ACA % Difference $3,653 $3, % $4,126 $3, % $3,509 $3, % $3,683 $3, % Note: Persons reporting ESI coverage in households where no policyholder is identified are included in the total calculations but not the firm size groups. Source: Urban Institute Analysis, HIPSM 2012
23 February 25, 2014
24 Fiscal Impact of the ACA Source: Congressional Budget Office,
25 Fiscal Impact of the ACA The insurance coverage provisions are only one way in which the ACA affects the federal budget. Other provisions are projected to reduce budget deficits. Smaller annual updates to Medicare provider payment rates. Reduced Medicare Advantage payment rates. Lower DSH payments In their most recent comprehensive estimates (July 2012), CBO and JCT predicted that the ACA s overall effect is to reduce federal deficits.
26 Healthcare Spending Source: Congressional Budget Office presentation to Stanford Institute for Economic Policy Research, May 13, 2014.
27 Healthcare Spending
28 Source: Health Affairs, 33, No. 1 (2014):67-77.
29 Medicare Spending Year Calendar Year Expenditures Medicare Trust Funds, Oct-June Source: CMS.gov, National Health Expenditure Data, and Actuarial Studies
30 How is Medicare Bending the Cost Curve? Accountable Care Organizations Bundled Payments for Care Improvement Hospital Readmissions Reduction Program
31 Accountable Care Organizations Reimbursing health care providers using the current fee-for-service system rewards providers for quantity, not quality. No one provider takes responsibility for the overall health of the patient. On the other hand, capitated payment systems provide incentives to deny services. We have a fragmented health care delivery system, leading to waste, which drives up costs.
32 Accountable Care Organizations Section 3022 of the Affordable Care Act established the Medicare Shared Savings Program for Accountable Care Organizations (ACOs) as a potential solution to balance the incentives to overprovide vs. underprovide services. An ACO is a group of health care providers caring for a specific patient population who will share savings with Medicare that are achieved through delivering quality health care.
33 Accountable Care Organizations ACO must agree w/medicare to participate for at least 3 years. Must be legally structured in a manner to receive and distribute payment within that ACO. Include primary care providers sufficient to cover beneficiaries, which must number at least 5,000 Demonstrate that it meets quality criteria related to patient/caregiver satisfaction, care coordination, and patient safety.
34 How are patients assigned to the ACO? Organization and providers decide to participate in an ACO (PCPs must be exclusive to one ACO; Specialists can be part of multiple ACOs) Patients assigned to PCPs providing most primary/preventive care relative to other primary care physicians in other ACOs or non-aco organizations. If unassigned, consider other provider types.
35 Medicare ACO results as of September ACOs caring for 5.6m elderly Americans 64 saved Medicare enough $ to earn bonuses summing to $445m. Overall savings to Medicare of $372m. Quality measures also improved for ACOs.
36 Bundled Payments Traditionally, Medicare makes separate payments to providers for each of the individual services they furnish to beneficiaries for a single illness or course of treatment. e.g., A patient admitted to a hospital with heart failure will generate a payment for the hospital, payment for multiple physician services, and perhaps post-discharge costs (skilled nursing facility or hospital readmission). Medicare is experimenting with offering a provider one bundled payment to cover all services associated with an illness or course of treatment. Hospital admission for heart failure and for the subsequent 30 days, regardless of when the patient is discharged.
37 Bundled Payment Participating Facilities Model Organization Name City State Episodes Model 1 JFK Medical Center Edison NJ All DRGS Model 1 Robert Wood Johnson University New Brunswick NJ All DRGS Model 2 Baptist Medical Center San Antonio TX Congestive Heart Failure Model 2 Model 3 Hospital of the University of Pennsylvania Encompass Home Health of Houston Philadelphia PA UTI, Stroke, Revision of the hip/knee, etc. Houston TX UTI, Stroke, Revision of the hip/knee, etc. Model 4 Valley Baptist Medical Center - Harlingen Harlingen TX Spinal fusion, Major joint replacement of the lower extremity, etc.
38 Hospital Readmissions Reduction Program CMS reduced payments to acute care hospitals with excess readmissions, effective 10/1/12 Initially targets AMI, Heart Failure, and Pneumonia Excess readmission ratio Comparison of hospital s risk-adjusted readmission performance to national average Based on 3 years of discharge data with minimum of 25 cases per condition per hospital Payment reductions applied to all Medicare admissions if riskadjusted readmission rate exceeds average Capped at 1% in FY 2013; 2% in FY 2014; 3% in FY 2015 Source: https://www.cms.gov/medicare/medicare-fee-for-service-payment/acuteinpatientpps/readmissions- Reduction-Program.html
39 Hospital Readmissions Reduction Program Analysis of year-1 results 2,189 (66.7%) will receive payment cuts. Percent of Hospitals Highly Penalized Large (400+ beds) 40% Teaching 44% Safety Net 44% Small (<200 beds) 20% Non-Teaching 33% Non-Safety Net 30% Source: K.E. Joynt, A.K. Jhan, JAMA 2013: 309(4):
40 Source: U.S. Department of Health and Human Services, May 7, 2014
41 Is Health Care Becoming More Affordable: For the previously uninsured? Yes. Several million have received subsidies to purchase insurance through the Marketplace, or received Medicaid in expansion states. For workers covered by large employers? On the positive side, premium growth has slowed, which may or may not be related to Obamacare. On the negative side, insurers must now pay fees associated with the ACA.
42 Is Health care Becoming More Affordable: For workers covered by small employers? No. Premiums are expected to rise on average. There is no good estimate of how much premiums will rise, or which small firms will offer coverage. There are likely to be some big winners and losers. For the taxpayer? The ACA is estimated to be deficit reducing in the long run. However, health care is consuming an increasing portion of the federal budget. While ACA measures may reduce Medicare spending somewhat, we must do much more to reduce the federal debt.
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