Transcript: The Patient s Perspective

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1 Transcript: The Patient s Perspective Tom Donohoe, MBA Director, UCLA Pacific AIDS Education and Training Center The Affordable Care Act and Tuberculosis Control: Navigating New Territory A National Webinar August 23, 2013 Archived Webinar Recording:

2 [Start of recorded material] 00:00:06 Speaker: Tom Donohoe Hi everyone, this is Tom Donohoe from the UCLA School of Medicine and I m going to be talking about the patient s perspective on the ACA. 00:00:14 So after participating in the next minutes, in this section, you ll be able to: explain the basic concepts of Medicaid expansion and market places; review the rights, responsibilities and decisions of impacted consumers- not just at the end of this year, but into the next two years-and consider the decision making process for impacted consumers through the interactive cases. So hopefully at the end of this presentation you ll be able to go home and have dinner and talk about the basics of the Affordable Care Act from the consumer s perspective. 00:00:47 So this act has been law for the last couple years. Signed into law in March 2010, it eliminated pre-existing condition exclusions, so starting January first, when you go and get new insurance in these market places (that you can sign up for October 1 st ) pre-existing conditions will no longer matter. It expanded Medicaid to non-disabled adults up to 138% of the federal poverty level- and we re going to talk about federal poverty level (or FPL) more. It included subsidies to purchase insurance through these exchanges (or marketplaces) for people who make % of the federal poverty level. Most importantly, it expanded Medicaid and introduced these marketplaces that go into place January 1 st, :1:34 So even though this is the biggest change in healthcare since Medicare in (and it s coming up pretty soon) people really don t understand it well and have some misperceptions about it, and haven t heard a lot about it, especially the people who are most impacted. So if you look at as late as April, 2013, this is information from Kaiser s very interesting health tracking poll, if you want to look those up. So as late as April 2013, you can see that 42% of people were unaware that the Affordable Care Act was still the law in the United States. 7% thought that the Supreme Court overturned it. 12% thought that congress repealed it and 23% just didn t know. And then if you ask as late as June, 2013, what have people heard, so the group that we re most concerned about- the 1 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

3 uninsured- who should be going to the marketplace, or the exchanges, or getting Medicaid expansion, in Medicaid expanding states. So, uninsured people, what have they heard? You could see that only 4% said a lot. 8% said some, 32% only a little, and then most alarming, 55% said (as late as June), nothing at all. 00:02:42 So let s talk about the federal poverty level for a second. You re going to hear it throughout my section and heard it from the other presenters, because it really drives whether you get Medicaid in a Medicaid expanding state or those people who need to go to the exchange in every state. So 100% of the federal poverty level for a family size of one individual (and my examples will be individuals to keep it simple but you can see here the different federal poverty levels for different family sizes). So 100% for individual is $11,490. Now an important number to remember is 138% of the federal poverty level or in 2013 $15,856. Because 138% of the federal poverty level, anyone who makes less than that or less than that, in a Medicaid expanding state is going to get Medicaid. 00:03:32 So if you are gonna remember one slide from these minutes, I would say remember this one. This is the one that s gonna be able to have you explaining new concepts to a family member. So if we look here, in Medicaid expanding states, if you make less than the 138% of the federal poverty level, you re gonna get Medicaid- and so for an individual that s $15,856, like I mentioned. And you can see here for a household of four, that s $32,500. So if you re in a Medicaid expanding state, make less than 138% of poverty, you re gonna get Medicaid. Now in all states where the exchanges exist, if you re between % of the federal poverty level, you qualify for immediate or deferred premium tax credits. What does that mean? That means federal assistance with your monthly premium for health insurance. We are going to talk a little bit more about in the coming slides. So if you make % you get help with your monthly payment. You can take that help right away with a reduced monthly payment. Or you can defer it to when you file taxes. And this is projected income we re talking about, remember. So you re projecting your income for Now if you make between % of the federal poverty level you ll also get cost sharing subsidies. So what does that mean? That means that you ll get help at the point- 2 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

4 of-service. So your co-pays will be lower for drugs and for office visits, for example. Now it s important to remember for these cost sharing subsidies, you gotta be between % of the federal poverty level and you need to be in the Silver Plan. So to get the subsidies think Silver Plan. So if you can remember all of this information from this slide, you are going to know a lot about the basics to have a discussion with your patients about how Medicaid expansion and the marketplaces will work. 00:5:24 So let s go ahead and do a polling question. What is the penalty for someone who should have had health insurance in 2014 but didn t get it? So is it A- a tax penalty of $95 or 1% whichever is greater? A tax penalty of $95 or 1% whichever is smaller ; There is no penalty the first year; or, I don t know. So we ll give people a minute to vote. There are over 100 people who have already voted. OK, so let s close that. Great, so you can see 27% said A tax penalty of $95 or 1% whichever is greater, and that s actually the correct answer. So thank you to the 43.8% who said you didn t know, but now everybody should know. If you didn t get insurance in 2014 and you should have, in your 2015 taxes, you re gonna pay a tax penalty of $95 or 1% whichever is greater- when you file in your 2014 taxes. OK, so a tax penalty of $95 or 1% whichever is greater. 00:6:29 So this is what the phase-in of the tax penalty looks like over the next three years. So when you re doing your 2014 taxes, which obviously you ll be doing in the year 2015, so for your 2014 taxes it s 1% or $95, whichever is greater, then it goes up to 2% or $325 whichever is greater in 2015, and then in 2016 and beyond it goes to 2.5% or $695, so there is much more of an incentive to get insurance as the years go on. 00:7:00 Patients who are new to insurance are going to have to learn some health insurance terminology; I think that most of us are probably familiar with. And there are concepts like premium, how much you re going to pay each month for your insurance, deductible, how much per year you have to pay before your insurance kicks in. Co-pay, like co-payments for drugs or co-insurance (if you have to pay 10% for MRI, for example). Your annual total out of pocket expenses - the most you have to pay each year. Your premium assistance/or tax credit, that s the assistance you get each month when the government helps 3 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

5 pay a portion of your premium, or you can wait until the end of the year and you can get it as a tax credit if you make less than 400% of poverty. And then those cost sharing subsides I talked about on the Silver Plan for people making between % of poverty. So people are going to have to know this terminology, and they are also going to have to understand the concept that you are projecting income for the year, so if you underproject your income and you make more and you took the full subsidy, you re going to have to pay that back at tax time during a process called reconciliation. 00:08:01 And they re also going to have to understand how the different plans work, so the qualified health plans throughout the country are defined by metal groups. The Platinum and the Gold plans have no deductible and they cover on average, using assumptions, for Platinum, on average 90% of the cost of someone s healthcare; Gold- 80%, so these are two of the more expensive plans. And then Silver covers 70%, on average (talking about large numbers of people), of healthcare costs. And so Silver actually does have a deductible, it s $2,000, but it s a sliding deductible, so if you make less than 250% of poverty that deductible amount is gonna go down and we re gonna see that through an example in a minute. And then finally the Bronze plan which just covers 60% of cost averaged over all the people in the Bronze plan. And people also need to understand a lot of the terminology I think we re used to using all the time, like, what s the difference between a Health Maintenance Organization, where clinicians contract with an HMO and you ve got to go to that network and maybe you can only go outside the network for emergency care, and a PPO, a Preferred Provider Organization, where you can go to anyone in that provider network or pay more to go outside of the provider network. Or an EPO, like here at UCLA we use an EPO, because we are an exclusive group of providers within the UCLA organization. 00:09:28 So let s talk a little bit about ACA and immigrants. We know that immigrants have much higher rates of TB, and so if we look at the two places where immigrants get coverage: exchanges or marketplace and Medicaid expansion, you can see that exchanges all lawfully cover immigrant residents, including even those this is a special case for immigrants- where if they make less than 100% of the federal poverty level they can also get subsidies and tax credits in the 4 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

6 marketplace, so all lawfully present immigrant residents are eligible for healthcare reform subsidies, those premium tax credits and cautionary reductions that I ve talked about. Now, undocumented immigrants unfortunately, including children and pregnant women, are not eligible for these subsidies or even the full priced health insurance plans in exchanges or marketplaces. Now in terms of Medicaid expansion eligibility, most lawfully present residents must wait five years for federal Medicaid, unless the state picks up federal options, for those under 18 or pregnant, or has some sort of other state funded program. Refugee survivors of trafficking and other humanitarian groups are federally eligible with no wait. So, undocumented immigrants are only eligible for emergency Medicaid and in some states prenatal services. Now this is important because in 2011 it s important to think about the Affordable Care Act and immigrants, because in 2011, a total of 62% of TB cases in the United States occurred in foreign born persons and many of them were undocumented. So the TB case rate among foreign-born persons was approximately eleven and a half times higher in that year, 2011, than among US born persons. So it s really important to remember how the Affordable Care Act impacts immigrants when you are talking about TB. Many of them may not be covered. 00:11:23 Let s go to a case. Pedro is a 28-year-old phone sales representative who estimates he will make $12,065 in 2014, so that s 105% of the federal poverty level. He lives and receives his medical care at a health department clinic serving the uninsured. He lives in a state that is not expanding Medicaid. He is lawfully present, so let s just say Pedro was born here. So he s lawfully present, he lives in a state that is not expanding Medicaid, and he makes 105% of the federal poverty level so let me ask you a question: 00:11:55 Under the Affordable Care Act, will Pedro be required to purchase a health insurance policy or pay a penalty? So, Yes, No he qualifies for Medicaid, Yes but he will get help with his insurance payments and co-pays, or I m not sure. Go ahead and vote. And we already have 100 people so I ll go ahead and show the results. OK, so the people who said Yes, you re right, more than half of you got the right answer, the right answers is Yes. But I think that most correct answer is Yes, but he will also get help with his insurance payments and co- 5 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

7 pays. Remember he just barely make over 100% of poverty, his state is not expanding Medicaid, so he s gonna get a lot of help- and have very low, well relatively low payments and co-payments. 00:12:49 Let s look at another case. Dewayne is a 40 year old construction worker who estimates that in 2014, he s going to make $19,000, or 165% of the federal poverty level. He was born in and receives his medical care at a county health department clinic in Los Angeles, California. So he lives in a Medicaid expanding state- California, he was born there so he s lawfully present and he s getting his medical care from a county health department. But he thinks he ll make $19,000 in 2014 and so let me ask you a question about him: 00:13:23 Under the Affordable Care Act, will Dewayne be required to purchase health insurance or pay a penalty? So the first response is Yes, second response again is No he qualifies for Medicaid, third is Yes but he ll get help with his insurance payments and co-pays, or fourth I m not sure. Go ahead and take a minute and vote. Quick voters out there. So I will wait until we get 200. We re over 100 but let s see what you said. OK, so again people overwhelmingly have the correct answer which is Yes, probably the more important thing is Yes, but he ll get help with his insurance payments and co-pays, because he makes less than 400% of the federal poverty level. 00:14:11 So in California we heard earlier that our state exchange is called Covered California, the website is: I underlined dot com because it is important to remember this is private insurance. It s not government or even non-profit per se, it is a private insurance marketplace where people go up and sign up for plans. So this is what the Covered California website looks like. This is a shot of the screen that I took about a year ago for our border project, so I wanted to emphasize here that it s only 38 days as of today until the Covered California marketplace opens on October 1st along with all the other marketplaces across the country. You can go there right now though, today, and look at this cost estimator calculator and people can go ahead and enter their income and get that for their family size what a premium on average would cost them. So you can go and do that today. 6 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

8 00:15:08 Looking back on Dewayne, remember he makes $19,000 a year. If he had chosen the Silver Plan where he is gonna get lower co-pay with a lower deductible you can see what this would mean for him. So he chose the Silver Plan, for $19,000 a year. The calculator would show that his premium will cost $294 a month, but he d only pay $75, if he took the immediate tax credit. So you can see significant help for him with his payment because he only makes $19,000 a year, and you can see his co-pays would be relatively lower, only $5 co-pays for drugs, and his deductible would go down from $2,000 to $500, and he would have a lower out of pocket maximum-only $2,250 per year. That would be the most he would ever have to pay in any given year no matter how sick he got. So given that, if you could take a moment to think: he makes $19,000 a year, and he d have to pay $75 a month or face a penalty of 1% or $95, so 1% of his income is $190. Dwayne s decision actually coming in October would be do I take insurance with $75 a month and these different co-pays, or pay the $190 penalty on my taxes next year. 00:16:27 I m gonna ask you your opinion. So in your opinion, do you think Dewayne will sign up for health insurance in Covered California during the open enrollment period-which is October first through March thirty-first- or do you think he s gonna pay the penalty when he files his taxes, so in 2015 when he files his 2014 taxes he d pay the penalty. So what do you think he d do? Makes $19,000 a year and we could go back and see what his premium and his co-pays would be. 00:16:54 So go ahead and answer here. First one is, I think he will sign up for affordable health insurance during open enrollment, that He ll pay the tax penalty in the first year, I m undecided. I can see both equally, I still don t know. Go ahead and give me your opinion, and we ll stop the voting at 100. Quick voters, so we are already over 100. Oh, OK, so the majority of people think that he d pay the tax penalty the first year, and I have to say I ve been teaching this both at UCLA and in the community in Los Angeles and using audience response even in the live in-person sessions, and most of the clinicians and community groups I have presented to agree with you. They think that just knowing this little bit that we know about Dewayne a lot of people think that he would choose the penalty. Now for those of you who think he would sign up for affordable health insurance-that s absolutely possible, too- he could suffer from back problems, or 7 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

9 have other reasons for him wanting to sign up. But I think most people s gut reaction if given the choices the first year, some people will opt for paying the penalty. So remember that s going to increase in coming years and so it s much more likely that more people in the coming years would go for number one taking the affordable health insurance because the penalty is gonna be higher. 00:18:08 Finally let s look at the case of Tonya. So Tonya is a single 52 year old hotel worker, who was born and living in south Los Angeles, she thinks she will make $21,027 in 2014, so that s 108% of the federal poverty level, and she currently has no health insurance. She says that she s always wanted it but could never afford rates for someone my age. She has not seen a doctor for years; sometimes she goes to an urgent care clinic to get antibiotics. She really wants health insurance now, especially as she s inherited a home from her parents and worries that one visit to the emergency room or the hospital could bankrupt her or cause her to lose her home. She s had a cough recently but she thinks she s in pretty good health. So she s someone who wants insurance, she s 52 years old, she works in a hotel in south Los Angeles and she s afraid of losing her home. So remember for the new insurance marketplaces and for Medicaid expansionassets don t matter. So here s someone who s really motivated to get insurance and will have an offer of affordable insurance in the exchanges. So the other thing about Tonya is that she doesn t know that she s living with latent TB infection. So let s think about the situation for Tonya and I m gonna ask you a question. 00:19:25 So Tonya signs up and chooses a qualified health plan and a primary care provider in Covered California. Do you think she will be evaluated for TB as part of her routine care with her provider at her first visit in 2014? So she signs up, she gets insurance, she chooses a plan, she signs up with a primary healthcare provider, goes there for her first visit. Do you think she s gonna be evaluated for TB? And let s just say she still has that cough. So, Yes, no or I m not sure. OK, so we got almost 100. Ok, over 100 votes. Let s go ahead and post those. OK, so I think I would agree with you too, and I presented these types of cases to Hepatitis and HIV providers and they said largely the same thing. That even though there s CDC guidance for example for testing baby boomers for Hep C 8 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

10 and there s certainly CDC and US Preventative Services task force guidance and even a grade A recommendation from them, that makes it billable, most providers that you go to at qualified health plans, like these insurance plans, it s not part of routine, standard care. So this is a role for the TB advocates- TB community to take with the qualified health plans, not just in California, but around the country. And it s something we re actually learning in the HIV world, from TB, because they ve sort of taken the initiative here. So if you looked in the resources section of the webinar, you ll find three documents. And those documents are letters that the TB advocacy community and health department officers and others have written to Covered California to make the case for TB care, especially for no co-payment for TB screening. So that s the end of my presentation and thank you so much and once again do go to the documents section of the webinar and look at those letters to Covered California from the TB community. 9 P a g e The Affordable Care Act and Tuberculosis Control: Navigating New Territory

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