what it means for states and public health king vs burwell...act ii: justice anthony kennedy justice...
TRANSCRIPT
The Supremes vs Obamacare: Act II What it Means for States and Public Health
Daniel Derksen MD College Wide Seminar | March 16, 2015
King vs
Burwell
A Top Topic for Governors: Supreme Court Case on Health Law
States eager to know what Congress, president will do if high court strikes down tax credits
03/16/15 Dan Derksen MD
By LOUISE RADNOFSKY and JANET HOOK WASHINGTON—
If the Supreme Court overturns the Affordable Care Act’s tax credits in most of the country, governors
firmly expect the next move is Washington’s. SCOTUS Hearings: March 2015
SCOTUS Decision: June 2015 February 22, 2015: http://www.wsj.com/articles/a-top-topic-for-governors-supreme-court-case-on-health-law-1424646651
Legislative Branch - ACA 12/24/09 HR 3590 passed by Senate “Patient
Protection and Affordable Care Act” v: 60-39 03/21/10 HR 3590 passed by House vote: 219-212 03/23/10 HR 3590 President signed PL 111-48 (906 pages)
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Affordable Care Act Titles TITLE V – HEALTH CARE WORKFORCE
Subtitle B – Innovations in the Health Care WorkforceSec. 5508. Increasing Teaching Capacity-Teaching Health Centers
http://www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf 03/16/15 Dan Derksen MD
Dan Derksen MD Senator Jeff Bingaman
Act I: Supreme Court Upholds Affordable Care Act June 2012
Medicaid Expansion
Tax Mandate
Alito No No Breyer Yes Yes
Ginsburg Yes Yes Kagan Yes Yes
Kennedy No No Roberts Yes Yes
Scalia No No Sotomayor Yes Yes
Thomas No No Total Y/N 5-4 5-4
Tax Mandate UPHELD
Medicaid Expansion UPHELD*
*States can choose not to expand Medicaid –
‘unduly coercive’ to lose all Medicaid funding if a
state doesn’t choose to expand Medicaid
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Gov. Romney Massachusetts Exchange
http://www.newyorker.com/magazine/2011/06/06/romneys-dilemma 03/16/15 Dan Derksen MD
“Having 30 million people in this country without health insurance and having those people show up
when they get sick, and expect someone else to pay, that’s a Democratic approach.”
“The Republican approach is to say, ‘Everybody should have insurance. They should pay
what they can afford to pay. If they need help, we will be there to help them, but no more free ride.’ ”
The Role of Think Tanks in Health Policy
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Heritage Foundation CATO Institute
Competitive Enterprise Institute
Heritage Foundation – Robert Moffit
YouTube video: https://www.youtube.com/watch?v=WCrkFVBr4pE http://www.newyorker.com/magazine/2011/06/06/romneys-dilemma 03/16/15 Dan Derksen MD
“The real trick is to retain what is best in American health care while correcting its
deficiencies and expanding upon its indisputable benefits. Massachusetts has
done just that.” Robert Moffit 4/12/06
ACA – THE TAX MANDATE • 2015 tax penalty fee for individuals without coverage is $95 per person or 1% of household income, whichever is greater
• 2016 penalty is 2% or $325 per person • 2017 penalty is 2.5% or $695 per person • Large businesses >50 employees w/o insurance $2000/fte (after the first 30 FTEs)
• The most unpopular ACA provision!
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SCOTUS Act II: King vs Burwell
For the Plaintiffs Michael Carvin
For the Government Solicitor General Donald Verrilli
Health Insurance Exchanges Must Be “established by the state” ACA page 58
“Failure to Establish Exchange. The secretary shall establish and operate
such exchange within the State.” p68
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CATO Institute – Michael Cannon Are you 100% convinced it was Congress’s intent to withhold subsidies in the federal exchanges? Sarah Cliff
Meet Michael Cannon, the man who could bring down Obamacare. http://www.vox.com/2014/11/19/7242671/obamacare-lawsuit-supreme-court 03/16/15 Dan Derksen MD
I’m 100 percent convinced they meant to do that. Michael Cannon
Competitive Enterprise Institute
“This bastard has to be killed as a matter of political hygiene.
CEI Donors: Charles and David Koch, Exxon, General Motors
New Yorker: http://www.newyorker.com/magazine/2015/03/09/hard-cases-jeffrey-toobin 03/16/15 Dan Derksen MD
I do not care how this is done, whether it’s dismembered, whether we drive a stake through
its heart, whether we tar and feather it and drive it out of town, whether we strangle it.”
Michael Greve CEI Chairman, 2010 Washington, DC
On the subject of ‘Obamacare’
Act II: Justice Anthony Kennedy
Justice Anthony Kennedy
“…if your argument is accepted, the States are being told either create your own Exchange, or we'll send your insurance market into a death spiral.
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We’ll have people pay mandated taxes which will not get any
credit on the subsidies. The cost of insurance will be sky high, but
this is not coercion.” Transcripts 3/4/15 King v Burwell at: http://www.supremecourt.gov/oral_arguments/argument_transcripts/14-114_lkhn.pdf
Act II: Justice Anthony Kennedy
Justice Anthony Kennedy
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“It seems to me that under your argument, perhaps you will prevail in the plain words of the statute, there’s a
serious constitutional problem if we adopt your argument.” Justice Kennedy
Mr. Carvin: “The government never made that argument.”
Justice Kennedy: “Sometimes we think of things the government doesn’t.” (LAUGHTER)
Transcripts 3/4/15 King v Burwell at: http://www.supremecourt.gov/oral_arguments/argument_transcripts/14-114_lkhn.pdf
Act II: Chief Justice Roberts
Chief Justice Roberts
“Mr. Carvin, we’ve heard talk about this other case.
Did you win that other case?” (Laughter)
“So maybe it makes sense that you have a different
story today?”
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Transcripts 3/4/15 King v Burwell at: http://www.supremecourt.gov/oral_arguments/argument_transcripts/14-114_lkhn.pdf
Federal Government Facilitating Health Exchanges in States
Prediction ACA
Upheld Alito No
Breyer Yes Ginsburg Yes
Kagan Yes Kennedy Yes Roberts Yes
Scalia No Sotomayor Yes
Thomas No Total Y/N 6-3
Prediction: ACA Upheld Federal Government Can
Operate Exchanges in States
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http://www.cbpp.org/files/policybasics-taxexpenditures.pdf
Tax Expenditures Tax Code Subsidies
Delivered as: • Deductions • Exclusions
Employer sponsored health insurance costs excluded from taxable individual and payroll
income, costs U.S. $248 billion
These subsides have been in place for decades
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ACA Tax Reform – Advance Premium Tax Credit to Make
Buying a Plan Affordable
ACA in 2014 • Created health insurance marketplaces • Mandated coverage (levied a tax penalty) • Expanded Medicaid: <138% FPL • Subsidized premiums:138-400% FPL • Guaranteed issue (prohibited coverage denial for
pre-existing conditions)
FPL – Federal Poverty Level 2013
Household Size 100% 138% 400%
1 $11,490 $15,856 $45,960 2 $15,510 $21,404 $62,040 3 $19,530 $26,951 $78,120 4 $23,550 $32,499 $94,200
Accessed 11/23/14 at: http://aspe.hhs.gov/poverty/13poverty.cfm#thresholds 03/16/15 Dan Derksen MD
U.S. Health Coverage 2012 – Before the Affordable Care Act (Pre-ACA)
US Census Bureau, accessed 11/22/14 at: http://www.census.gov/prod/2013pubs/p60-245.pdf
# covered (millions) Private Health Insurance
Employer Sponsored ESI
Individual Purchase
202 171 31
Medicaid 51 Medicare 49
Uninsured 48 Total Population 311
Note: Many covered have dual coverage: for example, many on Medicare have supplemental private health insurance, most in long term care have both Medicaid and Medicare.
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Uninsured Rates Among Nonelderly by State, 2010-2011: Before ACA
<14% Uninsured (13 states & DC) 14 to 18% Uninsured (20 states) National Average = 18.2%
SOURCE: KCMU/Urban Institute analysis of 2011 and 2012 ASEC Supplement to the CPS (two-year pooled data).
AZ
WA
WY
ID
UT
OR
NV
CA
MT
HI
AK
AR
MS
LA
MN
ND
CO
IA
WI SD
MO KS
TN
NM OK
TX
AL
MI
IL OH
IN
KY NC
PA
VA WV
SC
GA
FL
ME
NY
NH
MA
VT
NJ
DE
MD
RI
DC
CT
>18% Uninsured (17 states)
NE
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Pre-ACA Half U.S. Uninsured in 10 States
0.6m
Average US Census Uninsured over 3 years 2010-12.
7.3m
1.2m 0.4m
6.2m 0.8m 0.5m
0.9m
3.9m
1.9m
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Pre-ACA: 4 US-Mexico Border States: 57% U.S. Hispanic Uninsured
7.3M uninsured total in CA 4.1M uninsured Hispanic
6.2M uninsured total in TX 3.8M uninsured Hispanic
1.2M uninsured total in AZ 0.7M uninsured Hispanic
0.4M uninsured total in NM 0.2M uninsured Hispanic
Accessed 10/14/14 at: http://kff.org/uninsured/state-indicator/rate-by-raceethnicity/
• 47.3M US Total Uninsured 2012 • 15.3M US Total Unins. Hispanics • 8.7 M (57%) in 4 Border States
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Hispanic Marketplace Participation Was Low in 2014
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Accessed 01/07/15 at: http://www.medicaid.gov/medicaid Accessed 11/23/14 at: http://kff.org/health-reform/slide/current-status-of-the-medicaid-expansion-decision/
é10.8m Medicaid Enrollees in 2014
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ACA Medicaid Expansion in
2014
Accessed 2/23/15 http://kff.org/health-reform/state-indicator/state-health-insurance-marketplace-types/#
ACA Marketplace Decisions by State
13 state + 3 fed-supported state run 27 fed-facilitated, 7 fed-state partner
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>10M Enrolled in the 34 FFM / Fed Partner exchanges, 85% receive subsidies averaging
72% of premium costs
17%
ACA Marketplace Round 1: Oct 2013-Apr 2014 % Eligible Pop. Selecting a Marketplace Plan
U.S. 28% ‘Participation Rate’
Accessed 02/23/15 at: http://kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population-2014
43%
19% 21%
24% 20% 21%
27%
39%
29%
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In the 10 states with highest % uninsured pre-ACA and having half the nation’s uninsured
28%
ACA Marketplace Round 2: Nov 2014-Feb 2015 % Eligible Pop. Selecting a Marketplace Plan
U.S. 41% ‘Participation Rate’
Accessed 02/23/15 at: http://kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population-2015/
44%
33% 33%
39% 35% 37%
48%
64%
49%
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What’s going on in Florida?
71%
Medicaid Enrollment: Through 2014 % Eligible Pop. Enrolling in Medicaid
U.S. 59% Medicaid ‘Take Up Rate’
Analysis by Dan Derksen MD, Arizona Center for Rural Health
89%
60% 91%
26% 19% 94%
81%
63%
67%
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No Medicaid Expansion – R-Gov childless adults not eligible: gap 0 to 100%FPL
Medicaid Expansion R-Gov
State Marketplace
R-Gov
ACA in 2014
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STATE Round 2
Marketplace Sel/Renewed Plan
Nov 2014-Feb 2015
Round 2 Marketplace %Eligible
Sel/Renewed
Net Gain Medicaid Pre-ACA to 2014
%Eligible for Medicaid that
Enrolled
CA 1,418,000 44% 2,762,314 89% AZ 204,187 33% 294,896 60% NM 51,857 33% 183,975 91% TX 1,189,316 39% 223,019 26%
US Total 11,636,073 41% 10,751,820 78%
Pre-ACA: AZ, NM Health Coverage Payer Source # AZ #NM Medicaid 1,200,000 550,000 Uninsured 1,200,000 450,000 Medicare 800,000 300,000 Private Insurance 3,300,000 900,000 Total Pop. AZ 6,500,000 2,200,000
www.statehealthfacts.org http://quickfacts.census.gov http://www.azgovernor.gov/hix/documents/Grants/UpdatedBackgroundResearchReport.pdf
Medicaid + Uninsured Comprised 40-45% AZ, NM Pop.
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“Weigh the evidence and do the math”
$2 billion per year 20,000 jobs
250,000 uninsured covered
Governor Brewer – Medicaid Expansion
http://www.huffingtonpost.com/2013/01/14/arizona-medicaid-expansion_n_2474726.html 10/26/14 Dan Derksen MD 03/16/15 Dan Derksen MD
Governor Brewer restored Medicaid eligibility to 100% FPL for childless adults in 2014 (Prop. 204 passed in 2001), & expanded
it from 100% to 138% FPL as ACA allows
Do the math!
5% Medicaid Provider Cut • ‘Saves’ state $127 million/2 yrs • Costs 0.5 billion fed match • Eliminates est. 5,000 jobs • Levies hidden tax to Arizona
hospitals & docs >$0.6 Billion!
Governor Ducey – Medicaid Cuts
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Health Insurance Coverage Disparities Persist in U.S.
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Pre-ACA Uninsured
%Uninsured thru Feb
2015
#Uninsured Gaining
Coverage (Millions)
Whites 14.3% 9.0% 6.6 African
Americans 22.4% 13.2% 2.3
Latinos 41.8% 29.5% 4.2
Total US 20.3% 13.2% 16.4
Outreach Programs Needed to Assist Populations with Low Participation Rates
http://aspe.hhs.gov/health/reports/2015/uninsured_change/ib_uninsured_change.cfm
Marketplace +11.7 Million
Income < 138% Income 138% to 400%
AHCCCS – AZ Medicaid <138% FPL ($32,499 Family of 4)
Jan 2014-Feb 2015 Net Gain
+323,744
AZ MARKETPLACE 138-400% FPL ($32,499-$94,200) Round 2 Enrollment thru 2/15/15
+205,166
Age <26 Parents’ Plan +2.3 Million
AZ <26 Parents’ Plan +70,000
2015 ACA Medicaid Gain + Round 2 Marketplace Enrollment for U.S. / AZ Jan 2014-Feb 2015
Arizona ACA Total: +600,000
UNITED STATES
ARIZONA ACA ENROLLMENT
Medicaid +10.8 Million
http://aspe.hhs.gov/health/reports/2015/MarketPlaceEnrollment/Mar2015/ib_2015mar_enrollment.pdf http://kff.org/health-reform/state-indicator/marketplace-enrollment-as-a-share-of-the-potential-marketplace-population-2015/ http://www.medicaid.gov/medicaid-chip-program-information/program-information/downloads/december-2014-enrollment-report.pdf
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06/05/14 Dan Derksen, MD
Round Two ACA Marketplace Enrollment 11/15/14 - 2/15/15 Percent
Uninsured Pre-ACA
2012
Number Uninsured Pre-ACA
2012
Round One Oct 2013-Apr 2014 # Selected Plan in 6.5 Months
Round Two Nov 2014-Feb 2015
Sel/Renewed Plan in 3 Months
AZ 18.5 1,201,000 120,071 205,666 NM 20.6 416,000 32,062 52,358 TX 24.6 6,192,000 733,757 1,205,174 US 15.7 49,183,000 8 million 11.7 million
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Compiled by: DJ Derksen: Data Accessed at: healthcare.gov 11/10/14 Dan Derksen MD
Pima County, Arizona Marketplace Insurers and Plans Second Enrollment Period: 11/15/14 to 2/15/15
03/16/15 Dan Derksen MD
ACA in 2014 to 2015 • 2nd Marketplace enrollment 11/15/14 – 2/15/15 • Marketplace Tasks – renew, enroll uninsured, in 3 months (1st enrollment was 6.5 months)
• é 25% Insurers offering plans • ê $5.7B hospital uncompensated care 2014 • 75% of that êis in Medicaid expansion states • Special Enrollment: 3/15/15 to 4/30/15
Accessed 2/23/15: https://www.healthcare.gov/coverage-outside-open-enrollment/special-enrollment-period/ Accessed 1/11/15 at: http://aspe.hhs.gov/health/reports/2014/NewEntrants/ib_NewEntrants.pdf
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Avg. Annual Percent Increase in National Health Expenditures 1960-2012
10.6%
13.1%
11.0%
6.7%
5.8%
6.4%
7.1% 8.4%
9.7%
8.6%
7.2% 6.8%
6.5% 6.3%
4.7% 3.8% 3.8% 3.6% 3.7%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
1960 1970 1980 1990 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012
Proj. 2013 3.6%
SOURCE: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2012; file nhe2012.zip). NHE Projections 2013-23. Health Affairs Sept 2014. At healthaffairs.org
Last 5 years: Lowest spending growth in 50 year history
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11/10/14 Dan Derksen MD
AZ Marketplace 2014 to 2015 • AZ: 10% Decrease monthly Silver premiums
(ex. 40 y.o. making $30,000 /yr) • AZ: 2nd Lowest Silver premiums in U.S. • AZ: 5th Lowest Bronze premiums in U.S. • Choice: Min.7 Insurers 60 plans in all counties • 628,000 uninsured Arizonans were eligible for
Arizona Marketplace coverage in 2015 • 204,187 (33%) renewed or selected plan 2015
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Did you know? Arizona’s land area of
113,594 sq. miles would encompass the state of New York, the
six New England States (CT, ME, MA, NH, RI, VT)
and DC + Delaware
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CHALLENGE: Distributing the
health workforce to the areas of high need
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Access to Care
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• 75% Pop. Lives-Phoenix, Tucson • 86% Physicians-Phoenix, Tucson
HPSA = federally designated health professions shortage area
Teaching Health Centers Teaching Health Centers – move the primary care training
pipeline to areas of need. Grads have higher rates of practicing in rural and medically underserved areas.
Accessed 5/17/14 at: http://bhpr.hrsa.gov/grants/teachinghealthcenters/index.html
States: AL, AK, AZ, CA, CT, ID, IL, IA, KY, ME,
MA, MI, MO, MT, NM, NY, NC, OK, PA, TX, WA, WV
State Pacesetters
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