Click to edit Master title style Click to edit Master subtitle style 1 CPPP.org Where Texas Stands: Launching the ACA Marketplace in 2014, and Texas’ Uninsured Coverage Gap LWV Austin's annual kickoff meeting Anne Dunkelberg, Associate Director – [email protected]Sunday, September 15, 2013
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CPPP.org
Where Texas Stands: Launching the ACA Marketplace in 2014,
INFORMATION NOW: HealthCare.govAvailable 24/7: 1-800-318-2596; TTY: 1-855-889-4325Or, Chat Online 17
• Build on current system: Most Americans still get coverage through their employer.
• Medicaid expansion: US citizens to 133% FPL ($14,856 individual; $30,657 for 4 in 2012). State option.
• Reform private health insurance: standard minimum benefits, can’t charge more based on health status, limits on premium differences by age, no denial of coverage, no excluding pre-existing conditions, no annual or lifetime maximums.
• New Health Insurance Marketplace where private insurers’ options can be compared and purchased.
• Sliding scale help with premiums in the exchange from 100% up to 400% of FPL ($92,200 for family of 4).
• Sliding scale help with deductibles/co-pays and out-of-pocket caps in the exchange
• Individual mandate to have coverage (with major exemptions for lowest-income).
• Employer penalties possible if employees get sliding-scale help in Marketplace, but exemption for all employers with 50 or fewer FTE workers.
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Marketplace and Medicaid: Building Blocks of ACA’s 2014 Reforms
>$89,400 for a family of four;
>400% of FPL
Job-based coverage, or Full-cost coverage in the exchange
$67,100-$89,400; 300-400% of
FPL
Job-based coverage, or Subsidized exchange coverage: premiums capped
at 9.5% of income
$44,700-$67,100;200-300% of
FPL
Job-based coverage, or Subsidized exchange coverage: premiums capped
e2014: ACA Provides Public Support Fitted to Income
Family income based on 2011 federal poverty income levels for a family of four 19
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Texas Uninsured by Income 2011… 89% of the 6.1 million uninsured have incomes <400% FPL
<100% FPL<$22,350/yr for family of four
100-125% FPL$22,350-$27,938
150-200% FPL$33,525-$44,700
200-250% FPL$44,700-$55,875
250-300% FPL$55,875-$67,050
300-400% FPL$67,050-$89,400
>400% FPL>$89,400
125-150% FPL $27,938-$33,525
656K
501K
626K614K
1.912 Million
421K
Annual income limits given for a family of four, 2011 federal poverty level U.S. Census, 2012 CPS
921K
6.1 million includes 1.7 million non-US
citizens; ~2/3 of these
(about 1.1 million)
likely undocumented
525K
About 1.5 million Texans would gain insurance with Medicaid expansion
• Experts and Texas HHSC estimate 1.3-1.8 million uninsured US citizen adults in Texas will be eligible for the Medicaid option in 2014,
• HHSC projects just over a million of these adults would actually enroll by 2016 (note the difference between who is eligible, versus who actually signs up).
– HHSC also estimates that over 400,000 more children—already eligible today, but unenrolled—will sign up for Medicaid by 2016 because of higher public awareness: called the “welcome mat” effect.
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But, If Texas Opts Out• ACA sliding-scale premium help is available only to persons
above 100% FPL (exception: legal immigrants excluded from Medicaid) , so: – Uninsured Texas adults below 100% FPL would have NO
assistance available in 2014.
– Those from 100-133% FPL would be eligible for premium assistance in the Marketplace
– Costs of care for uninsured poor Texas adults will continue to be carried primarily by local property taxpayers, secondarily by other charity care providers, and without benefit of the 90%+ federal matching dollars.
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Texas Uninsured: Without Medicaid Expansion, Only half as many gain coverage
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6.1 million uninsured
Michael E. Cline, Ph.D., and Steve H. Murdock, Ph.D. , Rice University, Estimates of the Impact of the Affordable Care Act on Counties in Texas, April 2012.
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Texas Medicaid/CHIP: Who is Helped Today
Medicaid Children, 2,547,199
Maternity 86,975
TANF Parent, 83,772
Poor Parents, 144,040
Elderly, 326,501
Disabled, 422,467
CHIP, 591,756
January 2013, HHSC data
Total enrolled 1/1/2013:
3.6 million Medicaid;
592,000 CHIP
1 in 7 Texans,
but 42% of Texas kids
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Why So Few Poor Parents Covered in Texas Medicaid
• Texas Medicaid has VERY low coverage of parents (must live below 12% of poverty; work less than 10 hrs/wk @ min wage; must be under $308 a month for family of 3). – This dollar limit set by Texas legislature 1985 and never updated.
• Today, about 226,000 poor Texas parents get Medicaid, even though there are about 2.6 million children enrolled.
• Medicaid Maternity coverage income limit is much higher, but coverage ends 2 months after birth.
• Medicaid does not cover undocumented at any age.
• LEGAL immigrant adults NOT covered in Texas Medicaid (state choice, AL, VA, ,MS, ND, OH, WY also exclude). (Legal immigrant kids through age 18 are covered in Texas Medicaid and CHIP)
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Income Caps for Texas Medicaid and CHIP, 2012
0%
50%
100%
150%
200%
250%
Pregnant Women
Newborns Age 1-5 Age 6-18 TANF parent of
2, no income
Working Parent of
2
SSI (aged or
disabled)
Long Term Care
CHIP
Mandatory Optional
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$25,390/yr
$35,317/yr $35,317/yr
185%185%
133%
$19,090
100%$2,256 $3,696
12% 19% 75%
$8,376
225%
$25,128$38,180
200%
Figure 27
NOTE: Applies to states that do not expand Medicaid. The current median state Medicaid eligibility limit for parents is 48% FPL in the 21 states that are not moving forward with the Medicaid expansion at this time.
In states that do not expand Medicaid, there will be large gaps in coverage, leaving millions of low-income adults with no affordable options.
NOTE: Ten states (CT, IL, ME, MA, MN, NJ, NY, RI, VT, WI) and DC already offer coverage to parents at or above 133% FPL; under the ACA an income disregard of 5 percentage points will be applied to this limit increasing the effective income limit to 138% FPL .SOURCE: Based on the results of a national survey conducted by the Kaiser Commission on Medicaid and the Uninsured and the Georgetown University Center for Children and Families, 2013.
The Medicaid expansion will significantly increase eligibility for parents in many states.
Medicaid Eligibility Levels for Parents, January 2013:
138%*
25%
Status of State Action on the Medicaid Expansion Decision, as of July 1, 2013
Source: KFF.org
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What does Texas pay, and what does federal government pay if we expand Medicaid to
adults under the ACA?
• Federal government picks up 100% of the costs for the first three years of Texas’ expansion to the adults,
• 95% in 2017, 94% in 2018, 93% in 2019, and no less than 90 percent every year after that.
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El Paso Dallas Harris Lubbock Travis
Yearly Avg. $222 million
$580.1 million
$935.3 million $77.7 million
$224.1 millionNEW Fed $
Uninsured NOW
208,379 601,492 1,025,922 66,405 233,067
Estimated # Gaining
Medicaid 51,462 131,042 223,165 19,693 55,676
Large Urban Counties & Medicaid Expansion2014-2017
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, 2010. Cline & Murdock estimates of ACA insurance gains by county.
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Bexar Cameron Hidalgo Nueces Webb
One-year Avg. $ 503.5
million$ 198.4 million
$ 404.7 million
$ 127.1 million
$92.0 millionNEW Fed $
Estimated # Gaining Medicaid
179,654
27,987
50,509
22,403
16,031
Largest South Texas Metro Counties & Medicaid Expansion:
2014-2017
Sources: Texas HHSC projections of ACA Medicaid expansion costs; THHSC historical Medicaid spending by county, 2010. Cline & Murdock estimates of ACA insurance gains by county.
Research on Medicaid Expansion and Texas:1. Choices and Challenges: How Texas County Uninsured Rates Will Drop Under Health Care
Reform Cline & Murdock, of Rice U. (former Texas State Demographer and Director of the US Bureau of the Census) includes estimates of the much smaller reduction in uninsured rates expected if Texas does not accept the Medicaid Expansion. (see www.cppp.org)
2. Your County and the ACA Medicaid Expansion. CPPP compiled data for all 254 Texas counties on impact of ACA on uninsured, and the new federal dollars by county, based on Rice data above and the Texas Health and Human Services Commission’s latest official Medicaid expansion estimates. (see www.cppp.org)
3. Texas Has Only One Rational Choice: Expanding Medicaid Under the Affordable Care Act: Study by The Perryman Group Finds that Expanding Medicaid More than Pays for Itself . Analysis by The Perryman Group, every $1 spent by the State of Texas to expand Medicaid coverage under the Affordable Care Act (ACA) returns $1.29 in dynamic State government revenue over the first 10 years of the expansion. http://www.perrymangroup.com/
4. Government Effectiveness and Efficiency Report 2013 (January 2013). This biennial report to the Legislature by Legislative Budget Board staff includes a chapter analyzing the costs and benefits of the ACA Medicaid expansion and recommending that counties be enabled to finance and implement the expansion.
5. Smart, Affordable and Fair: Why Texas Should Extend Medicaid Coverage to Low-Income Adults (January 2013). This new report from Billy Hamilton Consulting provides a comprehensive model estimating the costs and benefits to local taxing authorities (including cities, counties and hospital districts) and state government. Using the Cline-Murdock model data, the authors conclude that state match needed for the Medicaid expansion are far less than current state, local, and hospitals spending on health care for low-income adults, and project $1.8 billion in new state revenue will be generated by the expansion from 2014 through 2017, offsetting about half of the required state match.
What’s Happened?• 13 House and 6 Senate billed filed to expand Medicaid per ACA; each chamber
included a bill authored by a Republican in a leadership role (Rep. Zerwas; Senator Deuell).– Also Senate budget “rider” by Finance committee Chairman Tommy Williams
• Widespread Support, Executive Opposition. Statewide support for Medicaid expansion from doctors, hospitals, county officials, chambers of commerce, and even the Texas Association of Business eventually supporting the Zerwas coverage option. – Polling by Texas and national firms found 58-59% of Texas voters
support accepting federal ACA funds to cover the poorest uninsured adults.
– Twenty-two chambers of commerce have called on the state to accept this funding, and new chambers continue to add their names to the list.
• Despite this support, the Legislature did not move the very-conservative, market-based “Texas Solution” alternative offered by Rep. John Zerwas HB 3791. – There was more than sufficient support by House members for
Zerwas’ “Texas Solution” bill. But the Governor’s office began to communicate a veto threat
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What’s Next?Texas’ decision means that in January 2014:•Texas adults above the poverty line will begin to get publicly funded sliding-scale help with health insurance, •but Texans below poverty will qualify for nothing.
Estimates of the number of uninsured Texas adults who will be left without a coverage option in the near term range:•from around 935,000 (HHSC, out of 1.1 million below 138% of poverty)
•to as high as 1.3 million (Urban Institute/Kaiser Family Foundation, out of about 1.7 million below 138% of poverty).
A Diverse network of Texans and Texas Organizations will keep working to find health care for the Texans in the “Gap Group,” to tell their stories, and to seek inclusion of Texas’ working poor in the ACA’s health reform. www.texaswellandhealthy.org
The Center for Public Policy Priorities encourages you to reproduce and distribute these slides, which were developed for use in making public presentations. If you reproduce these slides, please give appropriate credit to CPPP.
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