The Patient Choice, Affordability, Responsibility, and Empowerment Act

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1 The Patient Chice, Affrdability, Respnsibility, and Empwerment Act January 30, 2014 In January 2014, Senatrs Richard Burr (NC), Tm Cburn (OK), and Orrin Hatch (UT) made public a prpsal the Patient Chice, Affrdability, Respnsibility, and Empwerment (CARE) Act. The CARE Act wuld repeal the Patient Prtectin and Affrdable Care Act f 2010 (PPACA) and the Health Care and Educatin Recnciliatin Act f 2010 (HCERA) with the exceptin f all prvisins relating t Medicare and replace it with several refrms. Key prvisins include a premium credit fr all individuals earning less than 300 percent f the federal pverty limit, a cap n tax-exempt incme spent n emplyer spnsred health insurance, and a capped alltment funding design fr Medicaid, amng thers. This reprt details the findings f the Center fr Health and Ecnmy s (H&E) Under-65 Micrsimulatin Mdel n the prpsal s impact n health insurance premium prices, insurance cverage, patient access t prviders, medical prductivity, and the federal budget. While ur estimates are assciated with sme degree f uncertainty, the summary f ur findings is as fllws: Premium Impact: The CARE Act is prjected t prduce lwer average premiums when cmpared t current law. Narrw netwrk and PPO insurance prducts fr single cverage are estimated t experience the largest premium reductins. Cverage Impact: The number f insured individuals under the prpsal is prjected t be nearly equal t current law in By 2023, the number f insured under the prpsal in estimated t be 1 percent higher than under current law. In 2017, the prpsal is estimated t yield a 17 percent decrease in the Medicaid ppulatin cmpared t current law. By 2023, H&E estimates there will be 30 percent mre enrllees in the individual insurance market and 2 percent fewer enrllees in the emplyer spnsred insurance market under the CARE Act when cmpared t current law. Prvider Access: The CARE Act is prjected t result in similar patient access t prviders (measured by the H&E Prvider Access Index) as under current law. The average prvider access in the individual market is expected t decline under the CARE Act. Hwever, a reduced reliance n Medicaid is prjected t ffset the decline in the individual market, leading t the same average prvider access fr the under-65 ppulatin as under current law. Medical Prductivity: The CARE Act is expected t lead t 2 3 percent greater medical prductivity (measured by the H&E Medical Prductivity Index) as cmpared t current law in This reflects the prpsal s ability t reduce health csts while maintaining r increasing the quality f health utput. Budget Impact: Cmpared t current law, the prpsal will yield an estimated 10-year net savings f $1,473 billin. HealthAndEcnmy.rg

2 Micrsimulatin Analysis This analysis utilizes a micrsimulatin mdel develped fr use by the Center fr Health and Ecnmy. The mdel emplys micr-data available thrugh the Medical Expenditure Panel Survey t analyze the effects f health plicies n the health insurance plan chices f the under-65 ppulatin and interpret the resulting impact n natinal cverage, average insurance premiums, the federal budget, and the accessibility and efficiency f health care. 1 The key plicies and assumptins used by H&E t analyze the CARE Act are as fllws: The CARE Act becmes effective n January 1, PPACA and HCERA are repealed with the exceptin f any prvisins relating t Medicare. A grup health plan r health insurance issuer ffering grup r individual health insurance cverage may nt establish lifetime limits n the dllar value f benefits fr any participant r beneficiary. A grup health plan r health insurance issuer ffering grup r individual health insurance cverage will prvide guaranteed issue fr all enrllees with cntinuus cverage. In the first year f implementatin, there will be a natinal pen enrllment perid fr health insurance nt lnger than 6 mnths. During this perid, health plans must ffer a plicy and may nt discriminate with regard t health status r pre-existing cnditin. Insurers are required t ffer cverage t peple wh have stayed cntinuusly insured, withut exclusins fr pre-existing cnditins, and at standard rates based n age and residence. An lder individual will pay n mre than 5 times what a yung individual pays fr health insurance premiums in all states. 2 Health insurance plans are required t cntinue t cver dependents until age 26 in all states. 3 States have high-risk pls that are leveraged and enlarged with limited federal funding. Individuals and families earning less than 200 percent f the federal pverty level (FPL) are eligible fr an age-adjusted health insurance premium credit with the fllwing in 2013 dllars, indexed by ne percentage pint higher than the Cnsumer Price Index (CPI+1): Age Individual Family $1,560 $3, $2,530 $6, $3,720 $8,810 Individuals and families earning mre than 200 percent f FPL are eligible fr a partial subsidy, phased dwn t zer at 300 percent f FPL. Emplyees f firms with less than 100 full time equivalent emplyees are eligible t receive a refundable tax credit which they can use t buy insurance thrugh the individual market. Small grup and individual market pling in rder t facilitate lwer premiums is allwed. 1 Mre infrmatin n the H&E Under-65 Micrsimulatin Mdel can be fund at 2 The prpsal allws states the ptin t pt-ut f this plicy. H&E assumes that n states will chse t pt-ut. 3 ibid HealthAndEcnmy.rg

3 States receive Medicaid funding thrugh capped alltments. States wuld cntinue t receive passthrugh funding fr pregnant wmen, lw-incme children, and lw-incme families. States als receive a defined budget fr lng-term care services fr lw-incme elderly r disabled individuals chsing nt t use the health insurance premium credit. States have the authrity t aut-enrll Medicaid eligible residents. The tax exclusin fr emplyer spnsred health insurance (ESI) premiums is capped. The value f ESI plans in excess f the tax exclusin cap is subject t incme and payrll taxatin. Fr this analysis we assume a tax n thse wh chse health insurance benefits greater than $5,400 fr single cverage and $11,250 fr family cverage, in 2013 dllars, equal t the emplyee s marginal incme tax rate times the amunt ver thse threshlds. These threshlds are indexed t CPI + 1. Active duty military, veterans, and Native Americans are eligible t cntribute twards a health savings accunt (HSA). The definitin f qualified health expenditure fr HSAs is expanded t include insurance premiums and ver the cunter medicatins. New prtectins are granted t HSAs, such as bankruptcy prtectins equivalent t retirement funds. In this analysis, H&E uses ther ecnmic literature t target the effects f plicies the micrsimulatin is nt adequately able t capture: Research suggests that ending the practice f defensive medicine can result in health care expenditure savings. 4 The Cngressinal Budget Office finds that reducing lawsuit abuse can create savings in the federal budget. 5 4 Avraham, Rnen et al, The Impact f Trt Refrm n Emplyer-Spnsred Health Insurance Premiums, Wrking Paper Series, Natinal Bureau f Ecnmic Research, September 2009; Cngressinal Budget Office, Limit Medical Malpractice Trts, Nvember 13, 2013; 5 Cngressinal Budget Office, Reducing the Deficit: Spending and Revenue Optins, p.56, March 2011 HealthAndEcnmy.rg

4 Premium Impact The CARE Act is expected t lwer premiums in all categries f insurance cmpared t current law. By 2023, the prpsal is expected t yield substantially lwer premiums than current law in individual insurance prduct categries with savings f 2 11 percent fr single plicies. H&E predicts that family plicies will see a mdest decrease ranging frm percent. In bth categries f cverage, health savings accunts and high deductible health plans (HAS/HDHP) see the smallest premium decrease cmpared t current law. This is in part because the prpsal extends subsidies t anyne wh wishes t enrll in this type f plan, whereas current law des nt subsidize these plans and penalizes any enrllees ver the age f 30. Annual Premiums Under the CARE Act (in thusands) Single Plicy High PPO $6.8 $7.0 $7.3 $7.1 $7.5 $10.2 Medium PPO $6.0 $6.2 $6.5 $6.3 $6.6 $9.0 Lw PPO $5.2 $5.3 $5.6 $5.4 $5.7 $7.7 Narrw Netwrk $4.1 $4.0 $4.0 $3.8 $3.8 $4.5 HSA/HDHP $4.5 $4.3 $4.3 $4.7 $4.6 $6.0 Family Plicy High PPO $19.4 $20.4 $21.5 $22.8 $24.1 $32.4 Medium PPO $17.2 $18.0 $19.0 $20.1 $21.2 $28.6 Lw PPO $15.1 $15.7 $16.6 $17.6 $18.5 $25.0 Narrw Netwrk $12.0 $12.2 $12.5 $12.9 $13.1 $15.2 HSA/HDHP $14.8 $14.9 $15.3 $16.4 $16.9 $21.7 Percent Change frm Current Law Single Plicy High PPO 0.0% 0.0% 0.0% -8.2% -9.6% -9.2% Medium PPO 0.0% 0.0% 0.0% -8.2% -9.8% -9.4% Lw PPO 0.0% 0.0% 0.0% -8.3% -10.1% -9.7% Narrw Netwrk 0.0% 0.0% 0.0% -8.9% -11.2% -11.0% HSA/HDHP 0.0% 0.0% 0.0% 3.0% -2.6% -2.5% Family Plicy High PPO 0.0% 0.0% 0.0% 0.0% -0.6% -0.5% Medium PPO 0.0% 0.0% 0.0% 0.0% -0.6% -0.5% Lw PPO 0.0% 0.0% 0.0% 0.0% -0.7% -0.6% Narrw Netwrk 0.0% 0.0% 0.0% 0.0% -1.0% -1.0% HSA/HDHP 0.0% 0.0% 0.0% 2.1% -0.3% -0.3% HealthAndEcnmy.rg

5 Cverage Impact The CARE Act achieves nearly equal gains in the number f insured persns cmpared t current law. By 2023, the prpsal is prjected t achieve a slight increase in cverage f 1 percent ver current law. A significant increase in individual market participatin is facilitated by mre widely applicable premium credits enrllees in high deductible plans and enrllees earning belw the federal pverty level are eligible under the CARE Act. Hwever, the increase in cverage thrugh the individual market is expected t be ffset by large reductins in the Medicaid ppulatin. Insurance Cverage Under the CARE Act (in millins) Individual High PPO Medium PPO Lw PPO Narrw Netwrk HSA/HDHP Emplyer HMO HRA HSA/HDHP - Emplyer Pay HSA/HDHP - Emplyee Pays Narrw Netwrk PPO High PPO Lw PPO Medium Medicaid Ttal Insured HealthAndEcnmy.rg

6 Cverage Impact (cnt.) Percent Change frm Current Law Individual 0% 0% 0% 18% 21% 30% High PPO 0% 0% 0% -30% -44% -80% Medium PPO 0% 0% 0% -88% -89% -92% Lw PPO 0% 0% 0% 58% 47% 12% Narrw Netwrk 0% 0% 0% 38% 43% 47% HSA/HDHP 0% 0% 0% -3% -5% -6% Emplyer 0% 0% 0% 0% -1% -2% HMO 0% 0% 0% 1% 0% -2% HRA 0% 0% 0% 1% -1% -3% HSA/HDHP - Emplyer Pay 0% 0% 0% 0% 0% 0% HSA/HDHP - Emplyee Pays 0% 0% 0% 3% 44% 98% Narrw Netwrk 0% 0% 0% -17% -12% -12% PPO High 0% 0% 0% 1% 1% 0% PPO Lw 0% 0% 0% 1% 0% 0% PPO Medium 0% 0% 0% 0% -1% -5% Medicaid 0% 0% 0% -17% -16% -11% Ttal Insured 0% 0% 0% 0% 0% 1% HealthAndEcnmy.rg

7 Prvider Access With respect t patient s access t their prviders f chice, the CARE Act is expected t achieve similar access t current law, based n the H&E Prvider Access Index (PAI). 6 The prpsal is prjected t reduce the average PAI in the individual market, due t an influx f cnsumers enrlling in lw-cst narrw netwrk plans. Hwever, that reductin is ffset by a reduced reliance n Medicaid t insure the lwincme ppulatin. Prvider Access Index (PAI) Under the CARE Act Individual Emplyer Medicaid Ttal Insured Prvider Access Index (PAI) Under Current Law Individual Emplyer Medicaid Ttal Insured Infrmatin n the PAI is available n ur website: HealthAndEcnmy.rg

8 Medical Prductivity In general, the CARE Act is expected t result in higher medical prductivity, as measured by the H&E Medical Prductivity Index (MPI). 7 Increased enrllment in high deductible plans, which are assciated with higher medical prductivity, and a smaller Medicaid ppulatin are the primary causes f a higher MPI under the prpsal. As premiums increase ver time, cnsumers are prjected t shift twards higher deductible plans, leading t a rise in MPI thrughut the analysis perid. Medical Prductivity Index (MPI) Under the CARE Act Individual Emplyer Medicaid Ttal Insured Medical Prductivity Index (MPI) Under Current Law Individual Emplyer Medicaid Ttal Insured Infrmatin n the MPI is available n ur website: HealthAndEcnmy.rg

9 Budget Impact Cmpared t current law, the CARE Act is prjected t generate $1,473 billin in taxpayer saving ver 10 years. Much f these savings are generated by reducing the emplyer-spnsred insurance tax-exclusin and refrming Medicaid. Spending Prjectins Under the CARE Act (in billins) 10 Year Medicaid Refrm $0 $0 $0 $28 $29 $25 $193 Medical Malpractice Refrm $0 $0 $0 $5 $6 $8 $45 Tax Revenue $6 $9 $10 $189 $196 $226 $1,485 Other Federal Spending -$234 -$245 -$253 -$206 -$218 -$268 -$2,389 Net Budget Effect -$229 -$236 -$243 $16 $13 -$9 -$666 * Psitive numbers dente budget surplus and negative numbers dente budget deficit. Budget Impact f the CARE Act (in billins) 10 Year Medicaid Refrm $0 $0 $0 $28 $29 $25 $193 Medical Malpractice Refrm $0 $0 $0 $5 $6 $8 $45 Tax Revenue $0 $0 $0 $177 $143 $148 $1,057 Other Federal Spending $0 $0 $0 $52 $46 -$7 $178 Net Budget Effect $0 $0 $0 $262 $224 $174 $1,473 * Psitive numbers dente budget surplus and negative numbers dente budget deficit. HealthAndEcnmy.rg

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