U.S. Health Insurance Policy: Recent History and Future Directions - PowerPoint PPT Presentation

U.S. Health Insurance Policy: Recent History and Future Directions North Carolina Institute Of Medicine Legislative Health Policy Fellows Program S ara R. Collins, Ph.D. Vice President, Health Care Coverage and Access The Commonwealth Fund Morrisville, NC January 22, 2018

EXHIBIT 1 ‘Mirror Mirror’ Rankings of Health System Performance S ource: The Commonwealth Fund, Mirror, Mirror On the Wall, 2017 Update

EXHIBIT 2 U.S. Spends More than Other Countries Health Care Spending as a Percentage of GDP 1980–2014 Percent United States (17%) 18 France (12%) 16 Sweden (12%) 14 Switzerland (11%) 12 Japan (11%) 10 Germany (11%) 8 Netherlands (11%) 6 Canada (11%) 4 United Kingdom 2 (10%) New Zealand* 0 (11%) 1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013 Norway (9%) 2013, ** 2012 GDP refers t o gross domest ic product . S ource: OECD Healt h Dat a 2016. Not e: Aust ralia, Germany, Japan, Net herlands and S wit zerland dat a is for current spending only, and excludes spending on capit al format ion of healt h care providers.

EXHIBIT 3 U.S. Patients Often Get Less Care 15 9.9 8.0 10 Doctor visits 7.6 7.3 6.3 OECD median 5.0 4.3 3.9 4.0 3.7 2.9 Per capita 5 0 SWE NZ SWIZ US NOR UK FRA AUS CAN NETH GER 300 255 250 119 125 128 150 153 163 168 170 174 200 OECD median Hospital discharges 150 84 Per 1,000 100 50 0 CAN NET US UK NZ SWE FRA NOR SWI AUS GER 10 7.6 7.5 8 OECD median 6.4 6.0 Hospital average length of stay 5.8 5.8 5.5 5.4 5.4 5.2 4.7 6 Days, acute care 4 2 0 AUS NZ SWE US NOR FRA SWIZ UK NET CAN GER S ource: OECD Health Data 2016 and 2017. Data years: 2015, 2014, 2013, 2012, 2010, 2009.

EXHIBIT 4 … Although, Som etim es Get More Care Magnetic Resonance Imaging (MRI) machines per 1,000,000 population 60 52 50 38 40 31 30 20 15 13 11 9 10 6 4 0 ISR UK CAN FR NETH AUS GER US JPN S ource: OECD Healt h Dat a 2016 Canada MRI machine dat a from 2013, Germany MRI exam dat a from 2012, Japan and Net herlands exam dat a from unpublished Commonwealt h Fund grant .

EXHIBIT 5 US Adults Often Have Poorer Outcom es Avoidable Deaths: Mortality Am enable to Health Care, 20 14 Deaths per 100,000 population* 120 112 100 87 85 83 78 80 72 69 64 62 61 55 60 40 20 0 S WIZ FRA AUS NOR S WE NETH CAN GER UK NZ US Marina Karanikolos, European Observat ory on Healt h S yst ems and Policies (2017). Trends in amenable mort alit y for select ed count ries, 2014. Dat a from 2014 in all count ries except Canada (2011), France (2013), Net herlands (2013), NZ (2012), S wit zerland (2013), UK (2013). WHO Mort alit y files (number of deat hs by age group) and populat ions (except Human Mort ality Dat abase for Canada, UK and t he US A). List of amenable causes: Nolt e & McKee 2004 (Aust ralia, Canada, NZ, Nor, US ) Calculat ions by European Observat ory on Healt h S yst ems and Policies (2016), Amenable mort alit y causes based on Nolt e & McKee, 2004. Mort alit y and populat ion dat a from WHO mort alit y files, released S ept ember 2016 (populat ion dat a for Canada and t he US A from Human Mort ality Dat abase). Age-specific rat es st andardised t o European S t andard Populat ion 2013.

EXHIBIT 6 The U.S. Health Insurance System is Highly Fragm ented Other 4 m Uninsured 28 m Medicare 50 m Employment- Based Coverage Marketplace & 156 m Individual Coverage 17 m Medicaid & CHIP 69 m 324 million people, 2017 S ources: Federal S ubsidies for Healt h Insurance Coverage for People Under Age 65: 2017 t o 2027. Congressional Budget Office, S ept ember 2017. Current Populat ion S urvey dat a.

EXHIBIT 7 Federal and state revenues are a m ajor source of financing across all coverage types Source of Financing Medicaid Federal and state general revenues Medicare Federal payroll taxes and enrollee premiums Employer- Federal employer and employee tax exclusion; S ponsored employer and employee premium contributions Insurance Individual Various federal taxes and general revenues, enrollee and premiums, employer and individual mandate penalties, Marketplace insurer fees

EXHIBIT 8 Benefits vary by coverage source Benefits Medicaid Comprehensive Medicare Comprehensive, no long-term care Employer- S ponsored Comprehensive on average, but no national standard Insurance Individual/ Marketplace & Comprehensive, federal floor set by ACA S mall Group

EXHIBIT 9 Cost-sharing varies by coverage source Cost-Sharing Medicaid Minimal with monthly or quarterly cap 5 % of income Medicare High; supplemental public and private insurance Employer- S ponsored Variable, but has increased significantly over time Insurance Individual/ Marketplace & High; lower for lower income ACA marketplace enrollees S mall Group

EXHIBIT 10 Major U.S. Policy Changes That Increased Insurance Coverage 2010 1964 Affordable Medicare Care Act 1970 1990 2010 1960 1980 2000 1997 1965 Children’s Health Medicaid Insurance Program

EXHIBIT 11 Uninsured Rates Have Fallen In Response to Policy Changes Percent of individuals without health insurance*, 1997 – June 2017 25 20 15 10 5 0 Under 18 18 - 64 Not es: * At t he t ime of int erview. 2017 dat a is for January – June 2017. S ource: Early Release of S elect ed Est imat es Based on Dat a From t he January– June 2017 Nat ional Healt h urvey . Nat ional Cent er for Healt h S t at ist ics, December 2017. Int erview S

EXHIBIT 12 Uninsured Rates Fell in All States After The ACA Major Coverage Expansions Percent of Population Under Age 65 Uninsured, 2013−2016 2013 2016 < 10% (4 states plus D.C.) < 10% (27 states plus D.C.) 10% –14% (18 states) 10% –14% (18 states) 15% –19% (18 states) 15% –19% (5 states) ≥20% (10 states) Not es: “ D.C.” st ands for Dist rict of Columbia. Dat a source: U.S . Census Bureau, 2013 and 2016 1-Y ear American Communit y S urveys, Public Use Micro S ample (ACS PUMS ).

EXHIBIT 13 North Carolina Im proved on Key Access Measures, but Gains Were Sm aller Com pared to Kentucky Percent of low-income (<200% FPL) adults* 2013 2016 50% 42% 38% 40% 34% 34% 31% 29% 30% 19% 20% 11% 10% 0% Kentucky North Carolina Kentucky North Carolina Went Without Care Uninsured Because of Cost Not e: FPL refers t o Federal Povert y Level. *Ages 19-64 for uninsured rat e, age 18 or older for going wit hout care because of cost and wit hout a usual source of care. S ource: S . L. Hayes, S . R. Collins, D. C. Radley, and D. McCart hy, What ’s at S t ake: S t at es’ Progress on Healt h Coverage and Access t o Care, 2013– 2016, The Commonwealt h Fund, December 2017.

EXHIBIT 14 Low-Incom e Adults in Arkansas and Kentucky Experienced Marked Im provem ents in Health Care Access and Affordability Following Medicaid Expansion Com pared to Adults in Texas, Which Did Not Expand Medicaid, 20 16 Percent age point change since baseline (2013) compared t o non-expansion st at es (Texas) 20 16.7 10 11.2 5.1 0 -6.6 -10.5 -10 -20 Has a personal S kipped Any ED visit s in Regular care for Excellent self- physician*** medication due t o past year** chronic condition** reported health* cost*** p < .10. ** p < .05. *** p < .01. Adapt ed from B. D. S ommers, B. Maylone, R. J. Blendon et al., “ Three-Y ear Impact s of t he Affordable Care Act : Improved Medical Care and Healt h Among Low-Income Adult s,” Healt h Affairs Web First , published online May 17, 2017.

EXHIBIT 15 Major Federal Insurance Policy Developm ents, 20 17-18 : Im plications for State Individual and Sm all Group Markets • Trump Administration’s decision to end cost-sharing reduction (CS R) payments. • Open enrollment 2018: Cuts in advertising and navigator funding; shortened by 45 days. • Repeal of the individual mandate penalties in tax bill. • New DOL proposed rule to increase access to association health plans. • Expected proposed rule to extend short term insurance policies to 12 months. • New regulations for 2019 marketplace plans allow states greater flexibility to determine what health plans cover.  Points to fragmentation of insurance markets with considerable challenges for states.

EXHIBIT 16 States Managed Loss of CSR Paym ents Effectively • Premiums were 20 percent higher on average. • 36 states followed CA and allowed insurers to load their premium increases on silver marketplace plans. • This meant that federal premium tax credits increased: many subsidized consumers paid less than 2017, federal government paid more in tax credits than it would have on CS Rs. • Unsubsidized enrollees in some states faced higher premiums, but enrolling outside marketplaces may have saved people money. • Alexander-Murray bill would restore the CS R payments for future years but fate is uncertain.

EXHIBIT 17 Final Healthcare.gov Open Enrollm ent 95% of 20 17; Ten States Extended OE 2017 2018 10,000,000 8.7M plan selections total 9,000,000 for OE 2018 9.2M plan 8,000,000 selections total 7,000,000 for OE 2017 6,000,000 5,000,000 4,000,000 3,000,000 OE 2018 ended 2,000,000 on Dec. 15, 2017 1,000,000 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 Week of Open Enrollment Dat a: Cent er for Medicare and Medicaid S ervices. Not e: The above dat a are for st at es using healt hcare.gov and do not include st at e-based market places.