N ATIONAL H EALTH C ARE R EFORM : I MPACT I N T HE D ISTRICT OF C - PowerPoint PPT Presentation

N ATIONAL H EALTH C ARE R EFORM : I MPACT I N T HE D ISTRICT OF C OLUMBIA Presentation to Eastern Medical Pharmacy Administrators Association (I have no actual or potential conflict of interest related to this presentation) Wayne Turnage Washington DC Department of Health Care Finance August 2018

P RESENTATION O UTLINE   Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia (DC) Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels  Medicaid-Specific Impact of ACA In The District of Columbia Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC  The District’s Approach To Innovation Payment Reform Establishing Health Homes 2  Monitoring Efforts To Repeal Or Destabilize The ACA

T HE A FFORDABLE C ARE A CT (ACA) H AS T HREE P RIMARY G OALS 1. Increase private coverage rates for persons who live above the poverty level by using an individual mandate, health insurance exchanges, and subsidies or premium tax credits to make health care more accessible and affordable 2. Expand the Medicaid program to cover all adults with incomes below a certain level of federal poverty 3. Support innovative medical delivery methods and payment reform policies that offer the promise of increased health care 3 access at lower cost

T HE D ISTRICT OF C OLUMBIA H AS F ULLY E MBRACED T HE G OALS O F ACA Provision In ACA Law Purpose Did DC Implement Individual mandate Requires most Americans to have a basic level of health insurance coverage or be subject to a Yes penalty. Goal is to create healthy risk pools that are large enough to cover the cost of the sick members in the pool Health Insurance Exchange Health insurance marketplaces established by Yes quasi-government organizations to facilitate the purchase of private or commercial health insurance Medicaid Expansion Provide Medicaid eligibility for childless Yes adults with incomes up to 138% of the federal poverty level to increase coverage of persons with low-income Basic Health Plan (Early Medicaid Provide Medicaid eligibility for childless Yes Expansion in DC) adults with incomes from 139% to 206% of federal poverty levels to increase coverage for persons with low income Innovative programming Promote the use of a variety of health care Yes service delivery models, strategies, and payment structures to improve health care 4 access, quality, and outcomes

P RESENTATION O UTLINE  Broad Goals Of The Affordable Care Act (ACA)   ACA Impact In The District of Columbia (DC) Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels  Medicaid-Specific Impact of ACA In The District of Columbia Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC  The District’s Approach To Innovation Payment Reform Establishing Health Homes  Monitoring Efforts To Repeal Or Destabilize The ACA 5

T HE I MPACT O F T HE DC H EALTH E XCHANGE ( DC H EALTH L INK ) H AS B EEN S UBSTANTIAL Key Performance Metrics  More than 96% of DC DC Health Link enrollment: residents covered  17,000+ individual marketplace  Uninsured rate cut in half  77,000+ small business  DC in the top 3 states with marketplace (includes 11,000 lowest uninsured rates Congressional staff & Members)  DC has 2 nd lowest individual health insurance rates in the  ~5,000 small businesses U.S. (CMS May 2018) covered through SHOP 6  800 brokers participate in DC Health Link 6

2018 HEALTH INSURANCE OPTIONS THROUGH DC HEALTH LINK  Plans :  151 Small Group Plans  26 Individual Plans (includes 2 catastrophic)  Insurers :  3 United HealthCare Companies (group only)  2 Aetna Companies (group only) Also offer Dental (SHOP and  CareFirst BlueCross BlueShield Individual) and  Kaiser Permanente Vision 7 (Individual)

ACA P OLICY H AS H ELPED T HE D ISTRICT C UT T HE U NINSURED R ATE A LMOST IN H ALF DC Uninsured Rate 7.8% 7.1% 6.7% 6.1% 5.2% 4.0% 3.9% District of Columbia Unisured Rate 8 2010 2011 2012 2013 2014 2015 2016 Source: “Selected Characteristics of Health Insurance Coverage in the United States” and “Health Insurance Coverage Status”, American Community Survey. United States Census Bureau, 2009-2016

ACA P OLICY H AS H ELPED T HE D ISTRICT C UT T HE R ATE O F U NINSURED S IGNIFICANTLY F OR A LL I NCOME G ROUPS DC Uninsured Rate 12.0% 10.6% 11.8% 9.3% 9.1% 7.8% 6.8% 6.5% 5.9% 4.9% 4.0% 3.1% 9 2010 2011 2012 2013 2014 2015 2016 Note: Data on sub-group health coverage rates are not available for 2010. Source: “Selected Characteristics of Health Insurance Coverage in the United States” and “Health Insurance Coverage Status”, American Community Survey. United States Census Bureau, 2009-2016

P RESENTATION O UTLINE  Broad Goals Of The Affordable Care Act (ACA)  ACA Impact In The District of Columbia Performance of DC Health Exchange – DC Health Link Trends In Coverage Rates Across Income And Poverty Levels   Medicaid-Specific Impact of ACA In The District of Columbia Coverage Changes To DC Medicaid Eligibility Levels Post ACA Medicaid Enrollment and Cost Trends In DC  The District’s Approach To Innovation Payment Reform Establishing Health Homes  Monitoring Efforts To Repeal Or Destabilize The ACA 10

In Combination With It’s Legacy Coverage Levels, The District’s Eligibility Thresholds Under ACA Significantly Exceed Federal Requirements And Statewide Averages 319% 319% 319% 319% 228% 216% 213% 211% 210% 205% 199% 198% 187% 180% 133% 133% 133% 133% 133% 129% 95% 86% 74% 74% Children Ages 0-1 Children Ages 1-5 Children Ages 6-18 Pregnant Women Parents/ Caretaker SSI Childless Adults* Relatives* DC Eligibility Level Federal Minimum* Avg Level for Expansion States National Average 11 Source: Centers for Medicare and Medicaid Services State Medicaid and CHIP Income Eligibility Standards, updated June 2016. 11

Since ACA Implementation, Medicaid Enrollment Growth Is Now More Than Double Pre-ACA Levels Medicaid Enrollment Trends, FY2003-2017 Medicaid Enrollment Trends, FY2003-2017 Post- Medicaid Expansion Expansion Notes: Excludes ineligible individuals (individuals who failed to recertify due to lack of follow-up, moving out of the District, excess income, or passed away), and those in 12 the Alliance and Immigrant Children programs. Source: Data for 2000-2009 data was extracted by Xerox from tape back-ups in January, 2010. Data from 2010-present are from enrollment reports.

Now, Four In 10 District Residents Rely On Publicly- Now, Four In 10 District Residents Rely On Publicly- Funded Heath Care Services Funded Heath Care Services DC Residents DC Residents *Total Residents 693,972 on Medicaid or on Medicaid or Other DC Other DC Alliance Alliance Residents Residents 40% 40% 60% 60% Source: District population estimate from 2017 United States Census Bureau. Medicaid Source: District population estimate from 2017 United States Census Bureau. Medicaid 13 and Alliance data reported from DHCF’s Medicaid Management Information and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). System (MMIS). Note: These data excludes some District residents Note: These data excludes some District residents who are not United States Citizens and thus the who are not United States Citizens and thus the percent of residents on publicly funded percent of residents on publicly funded health care may be slightly overstated.. health care may be slightly overstated..

This Represents A 33 Percent Increase Since 2009 – The Year Before The District Pursued Medicaid Expansion Policies * 693,972 *599,657 3% Percent of 7% Uninsured DC Residents Percent of DC 57% Residents with 59% Medicare, Individual or Group Commercial Insurance Percent of DC 40% Residents with 34% Medicaid or Alliance Insurance 2009 2017 *Total Residents Source: District population estimate from 2009 and 2017 United States Census Bureau. Source: District population estimate from 2009 and 2017 United States Census Bureau. Medicaid and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). Medicaid and Alliance data reported from DHCF’s Medicaid Management Information System (MMIS). 14 Note: These data excludes some District residents who are not United States Citizens and thus the percent of residents on publicly funded health care may be slightly overstated. Note: These data excludes some District residents who are not United States Citizens and thus the percent of residents on publicly funded health care may be slightly overstated.

Medicaid Cost Trends Track ACA-Driven Enrollment Growth Trends Source: Spending totals extracted from Cognos by fiscal year (October, 1 through September, 30). Includes fee-for-service paid claims only, including adjustments to claims, 15 and excludes claims with Alliance or Immigrant Children's group program code. Only includes claims adjudicated through MMIS; excludes expenditures paid outside of MMIS (e.g. pharmacy rebates, Medicare Premiums).