Non Elderly Uninsured Rate Federal Politics and California’s Potential to Resist Andrew B. Bindman MD Professor of Medicine and Epidemiology & Biostatistics University of California San Francisco >20 million have gained coverage Kaiser Family Foundation 2017 Change in Coverage by Race/Ethnicity Impact on Safety Net Payer Mix Current Population Survey 2014-2016 Kaiser Family Foundation 2016 ASPE 2017 1 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Presidential Politics Impact on Safety Net Financing � For the first time since Medicare and Medicaid enacted, Republicans control White House and Congress � Will a change in the White House bring a change in health policy and practice of medicine ASPE 2017 Republican Critique of ACA Actual Projected � Focus on access/coverage rather than cost � Expansion of entitlement programs • Medicaid • Subsidies in Exchanges � Makes floor of what insurance covers too high � Individual mandate 17.6 million have gained coverage since ACA 2 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Federal Mandatory Entitlements: 2015 Aging of the US Population Elderly Poor 882 634 Billions $ 350 38 9 Social Security Medicare Medicaid Exchange CHIP Subsides Repeal, Replace or Repair Reach of Reconciliation � Federal budget items � Full repeal would require • Tax on individual and 60 Senate votes employer mandates � Partial repeal possible • Medicaid expansion with 50 Senate votes • Tax credits for exchange (reconciliation) • Cadillac tax � Extent of • CMMI, PCORI replacement/repair will � Not private insurance regs determine whether need 50 or 60 Senate votes • Dependent coverage <26 • Non exclusion for pre- existing conditions 3 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Problem of Repeal without Replace Republican Health Care Alternatives � Steep insurance � No consensus yet enrollment declines • WH, House and Senate among low income not in agreement individuals � House leadership has issued a policy brief but no � Insurers will leave legislation individual market for � Senate has not organized everyone if have to around a specific approach provide coverage to the � Final product will need to sick without guarantee of healthy pool from be scored by CBO to result in federal savings individual mandate No Recipe But Some Ingredients Republican Tax Credits � Tax credits to voluntarily purchase coverage � Purchasing insurance in Exchange (Covered CA) � Cross-state purchasing of � Similar but very different from ACA health insurance � ACA � Protection for those with pre- existing health conditions • Premium tax credits vary by income, age, and local premiums, rising with premium growth rate. � High-Risk Pools Additional cost-sharing subsidies available. � Consumer-directed arrangements like HSAs � GOP replacement proposals � Greater flexibility for states in • Tax credits vary by age but not local premiums Medicaid program design and not necessarily by income, rising at a fixed growth rate. No cost sharing subsidies. 4 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Cross State Insurance Pre-Existing Conditions � Guaranteed coverage with continuous enrollment without the guarantee it will be affordable � Cost of maintaining continuous coverage between jobs could create a significant financial barrier � Eliminate the floor of essential health benefits � Allow low-cost, less comprehensive, catastrophic � Could contribute to job lock insurance plans � Undermine states with higher insurance standards by allowing cross state purchasing of coverage � High risk pools in which government subsidizes high cost individuals never proven to work Health Savings Accounts Medicaid Program Flexibility � Tax-free savings account for health care expenses • Reduced federal requirements of state run programs � Typically combined with high deductible plan • Limits on federal contribution � “Individual self insured ‒ Block grants plan”- no insurance pool ‒ Capitation � Poor and sick least • Based on a prior Republican legislation anticipate prepared to save 20% reduction in federal spending � Regressive tax benefit ‒ $1 trillion over 10 years which favors the wealthy 5 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Medicaid Program Flexibility Medicaid Program Flexibility = Applying “Physical Laws” to Health Policy Federal Resistance Strategy � Swing 3 Republican senators to prevent repeal � First Law of Motion (Inertia): through reconciliation • A health policy law (e.g. ACA) in motion will tend � House is also option but requires turning about 25 to stay in motion unless an external force is Republican members applied to it (i.e. a new law is passed) � Activate stakeholders who will be hurt by a repeal • Individuals at risk for losing coverage • Hospitals/health systems at risk for losing $ • Red state governors who expanded Medicaid � Undermine ability of WH and Congress to work together by emphasizing differences in local vs national agenda 6 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Congressman McClintock Town Hall Applying “Physical Laws” to Health Policy � First Law of Motion (Inertia): • A health policy law (e.g. ACA) in motion will tend to stay in motion unless an external force is applied to it (e.g a new law is passed) � Second Law of Thermodynamics (Entropy): • It is easier to undermine a health policy law (e.g. ACA) by not maintaining it than to pass a new law HHS Secretary State Flexibility � HHS Secretary is a physician � Supreme Court made ACA Medicaid expansion • Orthopedic surgeon optional • Former congressman from Georgia � Current federal statute provides opportunities for � Advocate for ACA repeal states to modify implementation of ACA through � Authored 2015 legislation waivers which was vetoed by Obama � Federal executive branch has approval authority for � Has power over ACA regs state waivers: • > 700 places where it says • requests to modify Medicaid rules “Secretary shall..” • requests to modify the rules on the availability of • > 200 places where it says “Secretary may ..” subsidies to purchase insurance through an Tom Price, MD exchange 7 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
Unraveling ACA Through State Flexibility State Resistance Strategy � Medicaid waivers to reduce enrollment/use � Support state efforts to push back on federal reform and to maximize federal funds for health care • Co-payments � If state given more “flexibility” resist efforts to adopt • Financial penalties for unhealthy behaviors counterproductive cost-saving measures • Linking entitlement to work requirements � Hold state accountable for our values • Limit benefits? Income eligibility? � universal access, equity, patient-centered care � State basic health plan waivers can � Pursue higher value care • Redirect low income subsidies to state control � Promote primary care • Remove minimum benefit floor of exchange plans � Lower administrative costs –single payer? • Remove individual mandate Safety Net Providers Thank You � You will be on the frontlines of witnessing impact of changes in ACA � Any Questions ? � Share what you observe � Confront adversity with solidarity � Remember to care for yourself so you can continue to care for others 8 [ADD PRESENTATION TITLE: INSERT TAB > HEADER & FOOTER > NOTES 2/24/2017 AND HANDOUTS]
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