DEFICIENCIES OF HEALTH CARE MARKETS & INSURANCE EXCHANGES

Transcription

1 DEFICIENCIES OF HEALTH CARE MARKETS & INSURANCE EXCHANGES Stefan Gildemeister Health Economics Program The Economics of Welfare Loss 1

2 Overview Health Care Coverage Health Care Costs Small Group & Individual Market Benefits Competition Administrative Load Additional Thoughts on Deficiencies Delivery System Reform HEALTH COVERAGE 2

3 Access to Insurance Coverage: Distribution of Primary Source of Coverage in MN (2011) 5 TriCare, 1.2% Large Group, 49.2% Uninsured, 9.1% MA, MNCare, 13.9% Medicare, 15. Small Group 6.4% Individual, 4.7% MCHA/PCIP, 0.5% Source: MDH Health Economics Program; population estimates are from the U.S. Bureau of Census, June 2013 MA is Medical Assistance, MNCare is MinnesotaCare, MCHA is Minnesota Comprehensive Health Association, PCIP is Pre-Existing Condition Insurance Plan Access to Insurance Coverage: Uninsurance in Minnesota (2007 to 2011) 6 *Indicates statistically significant difference (95% level) from prior year shown. Source: 2007, 2009, and 2011 Minnesota Health Access Surveys. 3

4 Disparities in Rates of Coverage in 2011 Remain Largely Unchanged Disparities in coverage Age & income Race/Ethnicity Education Differences in coverage also exist by Region Marital status & health status Nativity In 2011, rates of uninsurance between Greater Minnesota and Twin Cities do not differ from each other (but metro rate rose) 7 8 Minnesota Uninsurance Rates by Income, 2009 and % 16% 16.9%^ 16.4%^ 17.1%^ 15.8%^ 14% 12% 12.4%^ 13.^ % 8% 6% 7.2% 6.4%^ 4% 2.9%^ 2.6%^ 2% 0 to to to to %+ All incomes ^ Indicates statistically significant difference (95% level) from all incomes within year. Source: Minnesota Health Access Surveys, 2009 and

5 Potential Sources of Health Insurance Coverage for Minnesota Uninsured, Differences to previousyears (not shown) are not statistically significant. Source: Minnesota Health Access Survey, 2011 Main Reason For Not Enrolling in Public Health Care Programs, Category other includes among other responses: privacy concerns over government involvement, concerns over embarrassment, and that respondent is rarely sick Source: Minnesota Health Access Survey,

6 HEALTH CARE COSTS FACED BY CONSUMERS Main 4 Reasons for Lack of Coverage Among the Uninsured, 2011 Did not Take-up of ESI When Offered Did Not Purchase Coverage Directly Too expensive/ could not afford 47.6% 73.6% 12 Reason for Loss of Coverage Too much hassle/ paperwork 3.6% Not eligible for reason other than health 5.5% 3.4% Don t like benefits package 6.9% Expect to be covered shortly 2.9% 18 or older so does not qualify as dependent 5.2% Job that provided coverage ended 32.7% No longer eligible for public insurance 14.9% Did not get information to stay on coverage 11.6% Just moved to state, haven t gotten coverage 8.1% 6

7 Barriers to Care Because of Costs, 2011 (Unmet Health Care Need) 13 *Indicates statistically significant difference between insured & uninsured Source: 2011 Minnesota Health Access Survey Percent of Minnesotans with Unmet Health Care Need Related to Cost in 2011, by Type of Coverage 14 ^Indicates statistically significant difference to rate for all. Source: 2011 Minnesota Health Access Survey 7

8 SMALL GROUP & INDIVIDUAL HEALTH INSURANCE MARKET Access to Insurance Coverage: Distribution of Primary Source of Coverage in MN (2011) 16 TriCare, 1.2% Large Group, 49.2% Uninsured, 9.1% MA, MNCare, 13.9% Medicare, 15. Small Group 6.4% Individual, 4.7% MCHA/PCIP, 0.5% Source: MDH Health Economics Program; population estimates are from the U.S. Bureau of Census, June 2013 MA is Medical Assistance, MNCare is MinnesotaCare, MCHA is Minnesota Comprehensive Health Association, PCIP is Pre-Existing Condition Insurance Plan 8

9 17 Premium Increases in Minnesota's Individual Market, 2000 to % Percent Change in Premium Per Member % 19.5% 15% 1 5% -5% 11.2% 9.8% 6.1% % 5.2% 5.2% 3.4% % -1.1% Sources: Minnesota Health Coverage Reinsurance Association ( ) and Minnesota Department of Health ( ). 18 Distribution of Deductibles in the Individual Market, 2005 to 2011 Percent of Enrollment % 26.6% 41.6% 26.8% 40.6% 55.8% 19.6% 73.2% 25.9% 11.8% 20.2% % % % 0.5% Less than $500 $500 to $999 $1,000 to $1,999 $2,000 to $2,999 $3,000 or Higher Source: MDH, Health Economics Program. Deductible levels are per person. Distribution of deductibles only includes enrollment in plans with a deductible and excludes enrollment in plans with per sickness deductibles. 9

10 Per Person Out-of-Pocket Limits in the Individual Market, 2002 to 2011 (by share of total enrollment) % 8.7% 36.5% 13.7% 11.4% 39.7% % 45.6% 17.1% 48.8% % 26.8% 35.2% 19.2% 16.7% 10.5% Less than $2,000 $2,000 to $2,999 $3,000 to $3,999 $4,000 and up Source: MDH, Health Economics Program. Median calculation and distribution excludes enrollees with no out-of-pocket limit. Out-of-pocket limit applies to covered services only. Loading Fee in the Individual Market Per Member Annual Premium $3,811 $2,590 $3,144 $1,683 $906 $667 Individual Insurance Employer Sponsored Insurance Type of Insurance Purchaser Loading Fee Other Uses Note: Employer sponsored premium is based on single coverage. Source: NAIC Supplementary Health Care Exhibit for Minnesota, 2010 and Relative distribution of total expenses to administrative load based on Swartz, K. (2007). Reinsuring health: why more middle-class people are uninsured and what government can do. Russell Sage Foundation. 10

11 21 Health Plan Market Shares: Individual Market, 2011 Total Premium Volume in 2011: $678 Million % Blue Cross Blue Shield of MN 11.6% 9.8% 7.7% Medica Healthpartners Time Ins. Co. (Assurant Health) 1.5% 1.1% 0.7% 0.4% PreferredOne Insurance Co. American Family Mutual Ins. Co. World Ins. Co. Other 3 firms Note: Companies with common ownership were treated as one entity. Market shares based on premium volume; fully insured market only. Source: Minnesota Department of Commerce, "Report of 2012 Loss Ratio Experience in the Individual and Small Employer Health Plan Markets for: Insurance Companies, Nonprofit Health Service Plan Corporations, and Health Maintenance Organizations," September ADDITIONAL THOUGHTS ON DEFICIENCIES 11

12 Hospital Uncompensated Care and Components by Insurance Status, % 72.1% 50.3% % 27.9% 49.7% Uncompensated Care Charity Care Bad Debt Insured Patients Uninsured Patients Source: MDH analysis of data from the Health Care Cost Information System. Concordance of Health Coverage Within Families in Minnesota, % Immediate Family Members Have Same Coverage % 73.5% 82.8% Public Group Individual Uninsured Overall MDH/Health Economics Program analysis of data from the Minnesota Health Access Survey 2011 Note: "Immediate Family" defined as target's spouse, target's parents (if target<26),target's child (if child<26), and target's sibling (if <26 and target lives with parents) 12

13 Mobility and Portability: Job Lock and Entrepreneurship 400,000 Estimates of Self Employment in Minnesota in 2014: With and Without Reform 300, , , , ,000 0 Absent Reform Post-Reform Source: Blumberg, L. J., S. Corlette, and K. Lucia. The Affordable Care Act: Improving Incentives for Entrepreneurship and Self-Employment. Timely Analysis of Immediate Health Policy Issues, Urban Institute, May Preliminary Thoughts on Premium Aggregation % 88.8% One Job 2.5% 17.2% 2.8% 80. Multiple Jobs Uninsured, not eligible for ESI Uninsured, eligible for ESI Has ESI MDH/Health Economics Program analysis of data from the Minnesota Health Access Survey

14 Choice & Transaction Costs of Search Source: McWilliams JM, Afendulis et al, Complex Medicare Advantage Choices May Overwhelm Seniors Especially Those With Impaired Decision Making, Health Affairs, August 2011 Pathways for Exchanges to Address Market Shortfalls Increase number of sellers in the market foster greater competition Broaden the risk pool required insurance coverage & Medicaid expansion Reduce the costs to some of purchasing coverage and accessing costs premium and cost sharing subsidies Create greater transparency in coverage options exchanges that present QHPs along established standards Halt benefit deterioration essential benefits & removal of life-time limits 14

15 THE NEXT CHALLENGE FOR EXCHANGES: COMPETITION ON VALUE 30 Optimal Diabetes Care, 2009 to Patients % % 39% 28% 29% 46% 45% 45% 34% % 25% 25% 2 18% 1 All Products Commercial Medicare MHCP/Uninsured ^ ^MHCP is Minnesota Health Care Programs, which include Medicaid and MinnesotaCare. Service year: January 1 through December 31. Source: MDH Health Economics Program analysis of SQRMS data. 15

16 31 Health Care Costs and the Economy 12 Cumulative Percent Change in Key Minnesota Health Care Costs and Economic Indicators 10 8 Health Care Cost MN Economy Per Capita Income Avg. Weekly Wage Consumer Price Index Note: Health care costs is MN privately insured spending on health care services per person, and does not include enrollee out of pocket spending for deductibles, copayments/coinsurance, and services not covered by insurance Sources: MDH/Health Economics Program; U.S. Department of Commerce, Bureau of Economic Analysis; U.S. Bureau of Labor Statistics, MN Department of Employment and Economic Development. Potential Waste in Minnesota Health Care System Assuming Nat l Trends, Total Health Spending (Billions of dollars) $17.9 $12.9 $7.9 $3.9 Fraud and Abuse Pricing Failures Administrative Complexity Overtreatment Failures of Care Coordination Failures of Care Delivery 1 - High, 47% Waste Medium, 3 Waste Low, 21% Waste Very Low* MDH/Health Economics Program estimates based on: Berwick, D. and A. Hackbarth. Eliminating Waste in US Health Care. The Journal of the American Medical Association (14): * Very low estimates represents alternative assumption that Minnesota experiences medical waste at half the rate of lowest national surveys. 16

17 Concentration in Health Care Expenditures in the U.S Cumulative Percent of Total Spending Top 1% of population 50.5 Top 5% of population Percent of Civilian Non-Institutionalized Population (Ordered from Lowest to Highest Health Care Spending) Source: National Institute for Health Care Management analysis of data from 2009 Medical Expenditure Panel Survey. Additional Information from the Health Economics Program Available Online 34 Health Economics Program Home Page Publications Health Care Market Statistics (Presentation Slide Decks) Interactive Health Insurance Statistics 17