End of the Beginning or Beginning of the End?
Virginia Academy of Nutrition and Dietetics
April 7, 2014
Carolyn Long Engelhard, MPA
Director, Health Policy Program
Department of Public Health Sciences
University of Virginia School of Medicine
THE PROMISE of the Affordable Care Act: to expand health
coverage through…
Individual mandate
Health Insurance
(up to 138% FPL)
(subsidies 100-400% FPL)
Employer-Sponsored Coverage
The CBO estimates that under the ACA 92% of legal U.S. residents will have
health coverage by 2022 – up from 82% in 2012
HEALTH COVERAGE makes a difference
Ratio of probability of diagnosis of late vs. early stage
cancer, Uninsured/private insurance
Equal likelihood
Uninsured and
Uninsured women with
breast cancer have a
risk of dying that is
between 30-50%
higher than for insured
women (IOM)
Colorectal Cancer
Lung Cancer
Breast Cancer
81% of the nonelderly uninsured say they have delayed or skipped care in the last year
Uninsured have a 25% greater mortality risk than adults with coverage
SOURCE: Kaiser Family Foundation, based on Halpern MT et al, Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis." The Lancet Oncology. March
AN UNINSURED patient’s perspective
One night on stage, 28-year-old comedian
Julian McCullough had an intense pain in his
stomach, which he assumed was food
He was diagnosed in the ED with a ruptured
appendix, treated with IV antibiotics for 4
days, followed by surgery
Julian: I grew up in a family without health
insurance my whole life, and our policy was
Julian’s story was recorded at Told, a
storytelling show in NYC and then heard
on PBS’ This American Life
basically ‘Give it a couple of weeks’… so I
didn't want to call 911 or go to an
Emergency Room
AN UNINSURED patient’s perspective
Clip courtesy of This American Life from WBEZ Chicago (#429, June 24, 2011)
THE NEED for “good enough” insurance…
Medical bills are the leading contributing
cause for personal bankruptcy in the U.S.
78% of filers of personal bankruptcy caused
by medical problems have medical
insurance at the start of their illness (2007 data)
CDC 2014 survey: 1 in 4 Americans struggle
to pay medical bills
The director of the federal Consumer
Financial Protection Bureau reports that
half of all accounts reported by collection
agencies now come from medical bills, and
the credit record of 1 in 5 Americans is
Himmelstein DU, Warren E, Thorne D, Woolhandler S. MarketWatch: Illness And Injury As Contributors To Bankruptcy. Health Affairs, no.W5(63), 2005; ;
KEY ELEMENTS of the ACA insurance coverage provisions
Individuals and families will be able to
purchase subsidized insurance through
exchanges operated by the federal or a state
States may expand Medicaid but may decline
to do so
Most legal residents in the U.S. must either
obtain insurance or pay a penalty tax
Employers with more than 50 employees that
decline to offer minimum health coverage will
be assessed penalties
Insurers may not deny coverage to people on
the basis of their health status or charge
enrollees in poor health higher insurance
GOING TO the Health Insurance Exchanges
Open enrollment Oct ‘13 – Mar ‘14
4 tiers of “metal plans”
All plans must offer 10 categories of
essential benefits
Plans can charge people more only
because of age and/or tobacco use
Premium tax credits 100-400% FPL
80% of enrollees are expected to
be eligible for tax credit subsidies
Insurers are counting on enrollment from relatively
healthy participants to balance out the higher
medical claims incurred by older, sicker people
NEWLY INSURED under Medicaid expansion
11 million
newly insured
Medicaid by
New Medicaid enrollees will be younger, less obese, and
less depressed compared to traditional Medicaid
population – but will include more smokers and heavy
WHERE WE ARE NOW: Health Insurance Exchanges (HIX)
and Medicaid Expansion
Who is running the HIXs?
• 14 + DC run own HIX
• 36 states have federally run HIX
• Enrollment: Oct 1, 2013 – Mar 31, 2014
– Majority of uninsured unaware of deadline
– Only 27% of HIX enrollees previously uninsured
Estimates = 6M in HIX in 2014; 24 M by 2017
Over 4 million people picked
a health insurance plan
through the exchanges
through Feb 2014 – and
about 1.5 million in 28 states
are opting to stay in plans
that are not compliant with
the law (option recently
extended through 2016)
Will states accept Medicaid expansion?
States can opt in or out at any time
Expanding program (25 + DC; 4 states leaning)
= +8.9M eligible but only ~3.5M new sign-ups
Not expanding so far (21)
= ~ 5M who would have been covered in 2014 ;
WHO ARE the 4.2 million enrolled through 3/1/2014?
55% are female
45% are male.
31% are age 34 and under
25% are between 18 - 34.
63% selected a Silver plan
18% selected a Bronze plan
83% of those who selected a plan are
eligible for premium tax credits
The Obama Administration last year estimated that 5.65 M would be enrolled by February
The proportion of younger Americans signing up for coverage has remained below the
numbers believed to be necessary to keep premiums stable (40%).
WHERE STATES stand on Medicaid expansion
The states that have rejected the
Medicaid expansion are home to
about half of the country’s
population but 60% of the poor – 5M
uninsured with incomes <100% FPL
live in states that are not expanding
Medicaid – and they also are not
eligible for insurance subsidies on
the state-based Exchanges
states rarely refuse federal dollars. More than half of states implemented
Medicaid within the first year federal funding became available, and nearly all
states were participating within four years
Virginia and the ACA
Gov. McDonnell decided in December, 2012
To default to a federal health insurance exchange with the understanding that
the state could change course later
To bow out of the Medicaid expansion, warning of Medicaid's skyrocketing costs
and other state needs
Eligibility for coverage as of 2014 among currently uninsured Virginians
Virginia has some of the strictest
criteria for Medicaid eligibility in the
country, ranking 48th in per-capita
spending for the program
If Virginia expands Medicaid and
fully implements the Health
Insurance Exchange, the number of
uninsured would fall to
approximately 436,000 from 1
million (6% from 15%)
If Virginia does not expand
Medicaid, the number of uninsured
is estimated to remain around
800,000; ;;
VIRGINIA and the Federal Health Insurance Exchange
580,000 currently uninsured nonelderly people
in Virginia are eligible for coverage through the
HIX -- 352,000 are eligible for premium tax
Virginians will choose from an average of 47
different plans; 4 “metal” levels of coverage
(bronze, silver, gold, platinum)
Cheaper plans carry higher cost-sharing
Average premium in Virginia, w/o tax
credits = $237/mo for bronze plan, and
$335/mo for benchmark silver
Family of 4 making $50,000 will pay
$282/mo with tax credit ($799 without)
27 yo making $25K will pay $80/mo w/
tax credit for bronze and $145/mo for
HIX activity: VA vs (total nat’l) thru 3/1/2014
251,566 eligible to enroll in HIX plan (8.7 M)
133,492 eligible for financial assistance (5.2 M)
33,897 eligible for Medicaid/CHIP (4.4M)
102,815 (80% subsidized) have selected a plan (4.2 M) ; ;
VIRGINIA and the Medicaid Expansion
Typically, Virginia hospitals
defray indigent care with DSH
funds. In 2013, Virginia
hospitals received over $90M
in DSH payments – the 28th
highest in nation
These payments will be
reduced under the ACA b/c the
Medicaid expansion was
envisioned as a coverage
substitute. The indigent care
shortfall for UVA & VCU will be
$386M 2017-2022
69% of uninsured Virginians would be eligible for coverage
assistance using HIX tax credits and Medicaid if expanded, but only
37% if the state does not expand Medicaid, leaving approximately
190,000 in a coverage gap – unable to enroll in Medicaid and
unable to get tax credits in HIX
If Virginia expands Medicaid
the state would save $1B over
9 years and replace 95% of
DSH payments (VHHA: Va losing
$5M/day by not expanding Medicaid);;
THE POLITICS: Current status of ACA in Virginia
The VA General Assembly adjourned
March 8th without a budget, mainly
because of the stand-off between the
new Governor McAuliffe and the
Republican controlled House of
Delegates. They will reconvene March
24th for a special session
Between 2014 and 2022, Virginians will
pay over $26 B in taxes related to the
ACA, subsidizing either its own or other
states’ Medicaid expansion programs;
FINDINGS What do we know?
Getting to universal coverage will be a long
Unlike other countries, Americans have to
“opt in” voluntarily – and many will choose to
opt out and pay the penalty (estimated 40%
of uninsured in 2014)
Tax credit (subsidy) eligibility is strongly
correlated with enrollment
Enrolling in an HIX is 62% for those eligible
for a tax credit and 19% for those who are not
– generating more unrest among higher
In states that have not expanded Medicaid,
people are falling into the coverage gap
Childless adults are generally ineligible for
Medicaid no matter how low their incomes
PROMISES AND PITFALLS of the Affordable Care Act
CBO projects 25 million will gain coverage by 2021,
but 31 million will still be without coverage
ACA regulates insurance, pushes payment changes
based on value and provider accountability – but
unclear that will help persistent disparities by socioeconomic status, race, and ethnicity
Premiums (with tax credits) may be lower than ESI on
the HIX but they often come with high deductibles
and narrow networks – unaffordable and unpopular
– may promote “underinsured” among low-income
Labor force effects: 2.3 million fewer equivalent jobs
in 2021 – no more job lock vs. less work for gov’t
subsidies - positive or negative for the economy?
ACA has winners and losers (ill vs healthy; older vs
younger, low-income vs higher-income, etc.)
HOW ACA will benefit nutritionists and dieticians
The ACA will now cover preventive counseling services related to healthy diets
Counseling w/o complaint or sickness
Dietary counseling
Exercise counseling
Counseling for health – advice, education, instruction
Nutritionists and registered dietitians (RDs) may be
included in patient-centered medical homes
Although insurance companies and networks are required to provide coverage under
the ACA, there may be some restrictions (prior authorization requirements,
deductibles and co-insurance, etc.) – so read “fine print” carefully
MGMA Connextion – July 2012, p. 32-33
LOOKING AHEAD: Will the 2014 elections be a referendum
on the ACA?
Wall Street Journal / NBC News Poll – March 5-9, 2014
36 senate seats
are up in 2014
36 Governors will
be elected in 2014
70% of Republicans support repealing the ACA (47% all voters)
75% of Democrats support fixing and keeping the ACA
37% of Republicans and 55% of Democrats said their views of the health
care law will not necessarily reflect their vote for Congress
34% said their member of Congress deserves re-election, compared to
55% who want to give someone else a chance
54% said they would oust every single member of Congress if they could;