THE COMMONWEALTH

FUND

Achieving and Maintaining Near Universal Coverage Under the Affordable Care Act: Key Issues

For Federal and State Policy Makers

Sara R. Collins, Ph.D.Vice President, Affordable Health Insurance

The Commonwealth Fund

Alliance for Health Reform BriefingKeeping Coverage Continuous: Smoothing the Path Between

Medicaid and the ExchangeMay 20, 2011

THE COMMONWEALTH

FUND

THE COMMONWEALTH

FUND

Exhibit 2. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2020

* Employees whose employers provide coverage through the exchange are shown as covered by their employers. Note: ESI is employer-sponsored insurance; “Other” includes Medicare.Source: Testimony Statement of Douglas W. Elmendorf, Director, before the Subcommittee on Health Committee on Energy and Commerce U.S. House of Representatives, CBO’s Analysis of the Major Health Care Legislation Enacted in March 2010, March 30, 2011. http://www.cbo.gov/ftpdocs/121xx/doc12119/03-30-HealthCareLegislation.pdf

Among 284 million people under age 65

Under Prior Law

163 M(57%)ESI

36 M (13%)Medicaid

56 M (20%)Uninsured

15 M (5%)Other

14 M (5%)Nongroup

162 M(57%)ESI

52 M(18%)

Medicaid

24 M (8%)Exchanges

(Private Plans)

15 M (5%)Other

8 M (3%)Nongroup

23 M (8%)Uninsured

Affordable Care Act

THE COMMONWEALTH

FUND

TX

FL

NMGA

AZ

CA

WY**

NV

AK

OK

MSLA

MT

TN

Exhibit 3. Status of State Legislation to Establish Exchanges,As of May 2011

*North Dakota pending legislation provides an appropriation for exchange creation (H 1126). **Wyoming legislation provides for a study of whether the state should establish and operate a Wyoming health insurance exchange or participate in a regional exchange, requires a report and specifying report requirements, provides an appropriation (H 50). *** Indiana Governor signed an Executive Order in Jan 2011 establishing an exchange (Executive Order 11-01). ****Wisconsin legislation is to study feasibility of exchange.Source: National Conference of State Legislatures, Federal Health Reform: State Legislative Tracking Database. http://www.ncsl.org/default.aspx?TabId=22122; Commonwealth Fund Analysis.

WA

ORID

SD

ND*

MNWI****

MI

IA

AR

IL

OH

WVVA

AL

PA

NY

ME

MA

NHVT

HI

Legislation signed into law

Legislation passed one or both houses Governors have pursued/considering non-legislative options

Legislation signed, intent to est. or study exchange

Legislation pending in one or both houses

UTCO

KS

NEIA

MO

ILIN***

KY

WVVA

NC

SC

DCMD

DE

NJ

CTRI

Legislation has been vetoed

THE COMMONWEALTH

FUND

Exhibit 4. Seven States Awarded Early IT Innovator Grants from HHS

State Department or Agency Grant Amount

KansasKansas Insurance

Department$31,537,465

MarylandMaryland Department of

Health and Mental Hygiene

$6,227,454

Multi-State ConsortiaUniversity of

Massachusetts Medical School

$35,591,333

New YorkNew York Department of

Health$27,431,432

OklahomaOklahoma Health Care

Authority$54,582,269-Declined

Oregon Oregon Health Authority $48,096,307

WisconsinWisconsin Department of

Health Services$37,757,266

Source: US Department of Health and Human Services News Release, States Leading the Way on Implementation: HHS Awards “Early Innovator” Grants to Seven States, February 16, 2011, http://www.hhs.gov/news/press/2011pres/02/20110216a.html

THE COMMONWEALTH

FUND

Four levels of cost-sharing

1st tier (Bronze) actuarial value: 60%2nd tier (Silver) actuarial value: 70%3rd tier (Gold) actuarial value: 80%4th tier (Platinum) actuarial value: 90%

Catastrophic policy with essential benefits package available to young adults and people

who cannot find plan premium <=8% of income

Annual OOP limits (individual/family)

100%–200% FPL: 1/3 HSA limit, $1,983/$3,967200%–300% FPL: 1/2 HSA limit, $2,975/$5,950300%–400% FPL: 2/3 HSA limit, $3,967/$7,933

Cost-sharing is eliminated for preventive services

Exhibit 5. Subsidized Health Insurance Under the Affordable Care Act

Federal poverty level

Income for a family of four

Premium tax credit cap as a share

of income

Average cost-sharing as share of

medical costs

<133% <$29,726 Medicaid Medicaid

133%–149% $29,726–<$33,525 3.0%–4.0% 6%

150%–199% $33,525–<$44,700 4.0%–6.3% 13%

200%–249% $44,700–<$55,875 6.3%–8.05% 27%

250%–299% $55,875–<$67,050 8.05%–9.5% 30%

300%–399% $67,050–<$89,400 9.5% 30%

>400% >$89,400 — —

Note: FPL refers to Federal Poverty Level. OOP refers to out-of-pocket costs. Actuarial values are the average percent of medical costs covered by a health plan. Premium and cost-sharing credits are for silver plan.Source: Federal poverty levels are for 2011; Commonwealth Fund Health Reform Resource Center: What’s in the Affordable Care Act? (PL 111-148 and 111-152), http://www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.