1. Lynn A. Blewett, Ph.D.
Professor, Division of Health Policy and Management,
University of Minnesota School of Public Health
Julie J. Sonier, MPA
Sr. Research Fellow and Deputy Director, SHADAC
We are grateful to the State Health Reform Assistance Network, an initiative of the Robert Wood Johnson Foundation, for supporting this work.

2. 1. What problem istext stylestrying to solve?
Click to edit Master the ACA
• Minnesota and National Context
Second level
2. Access level
Expansions in the Affordable Care Act
Third
• Medicaid Expansion
Fourth level
• Health Insurance Exchange
Fifth level
3. Policy Issues for the Exchange
4. What’s next?
5. Q&A
2

3. Click to edit Master text styles
• 50 million uninsured
Second level
– Erosion of employer
Third level
sponsored insurance
Fourth cost
• Unsustainable level growth
Fifth level
• Adverse selection in
insurance markets
• Lack of consumer info to
compare options
• Increase access to affordable,
comprehensive coverage
through targeted subsidies
• Improve overall affordability of
coverage
• Spread risk more broadly
across the population
• Organize/present plan
comparisons
3

4. Click to edit Master text styles
60
Second level
Millions of uninsured people
Third level
Fourth level
Fifth level
50
40
30
20
10
0
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
4

5. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
5

6. Click toDistribution of Minnesota Population by Primary Source of
edit Master text styles
Second level
Insurance Coverage
Uninsured
9%
Third level
Fourth level
Fifth level
Public Coverage
28%
EmployerSponsored
Coverage
58%
Non-Group
Coverage
5%
MDH Health Economics Program (data for 2010)
6

7. Click to edit Master text styles
100%
Second level
80%
60%
Third level
Fourth level
Fifth level
Minnesota
U.S.
40%
20%
0%
Fewer 10 - 24
than 10
25 - 99
100 999
1000+
All firm
sizes
Source: 2012 MEPS-IC, Table IIA2
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8. Click to edit Master text styles
100%
Second level
80.4%
Third level
80%
Fourth level
60%
Fifth level
69.7%
71.4%
59.5%
Minnesota
U.S.
40%
20%
0%
2000
2011
Source: SHADAC, State-Level Trends in Employer-Sponsored Health Insurance: A State-byState Analysis. April 2013.
8

9. Click to edit Master text styles
• Medicaid expansion
Second level
• Subsidies for private insurance – through health
Third level
Fourth level
insurance exchanges
Fifth level
• Requirement for individuals to have health insurance
(“individual mandate”)
• Employer provisions – incentives and penalties
• Changes to private insurance market rules
9

10. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
10

11. • Peopleedit Master text below 138% of poverty guidelines* are
Click to with family incomes styles
eligible for Medicaid as of January 2014
Second level
• 2012 Supreme Court decision made this optional for states
Third level
• Goal was to simplify eligibility – no more variation by family status,
Fourth level
age
Fifth level
• ACA expansion of eligibility mostly affects adults, since children are
already eligible for Medicaid or CHIP at this income level in all states
• Only applies to U.S. citizens and legal immigrants in the country for
more than 5 years
*The poverty level for a family of four is currently $23,550
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12. Click to edit Master text styles
250%
350%
300%
Second
250%
200%
level
Third level
Fourth level 185%
Fifth level
ACA Medicaid
Expansion to 138% FPL
150%
22 million
63% Low-Income
37%
Uninsured
Adults 19-64
100%
50%
0%
Children
Pregnant
Women
Working
Parents
Jobless
Parents
0
Childless
Adults
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, 2012.
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13. Click to edit Master text styles
The following are differences across states that will affect
Second level
enrollment:
Third level
•
•
•
•
•
Fourth level
Fifth level
Medicaid expansion
is now optional for state
Current Medicaid enrollment and eligibility
Current Levels of Private Coverage
Levels of outreach and enrollment activities
Attitudes toward government programs
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14. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
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15. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
15

16. ClickIndividuals are required to maintain minimum essential
• to edit Master text styles
Second level themselves and their dependents.
coverage for
Third level
• Rationale: other changes to market rules (guaranteed
issue,Fourthlifetime benefit limits, ect.) will not work unless
no level
Fifth level
healthy people participate.
• Those who do not meet the mandate will be required to
pay a penalty for each month of noncompliance:
Once fully phased in, annual penalty
of $695 per person or 2.5% of
income, whichever is greater
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17. Click to edithardshiptext styles
• Financial Master
Second level
Religious objections
Third level
American Indians and Alaska Natives
Fourth level
Incarcerated level
individuals
Fifth
Those for whom the lowest cost plan option
exceeds 8% of income, and
• Those whose income is below the tax filing threshold
•
•
•
•
And the Undocumented
17

18. • Tax creditsMaster text styles (≤ 25 employees) and
Click to edit for small employers
average level wages below $40K who provide health
Second annual
insurance
Third level
•
•
For 2010-2013: Up to 35% of employer’s premium contribution,
Fourth level
depending on employer’s size and average annual wage
Fifth level
For 2014 and beyond: Up to 50% of employer’s premium
contribution for employers that purchase coverage through
Exchange, depending on employer’s size and annual wage
•
Can only receive credit for 2 years
18

19. • Employers subject to penalties if no coverage offered and at least one
Click to edit Master text styles
employee receives tax credits through an Exchange
Second level
• $2,000 multiplied by the # of full-time workers employed (minus
Third level
first 30 workers)
Fourth level
• Does not apply to businesses with fewer than 50 full-time workers
Fifth level
• Delayed to 2015
• Employers with > 200 employees must automatically enroll them into
health insurance
• Employees can opt out of the coverage
19

20. • Employers also have the option to buy insurance through an exchange
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• Limited to employers with fewer than 100 workers through 2016
Second level
(States can choose to limit employer size to 50 initially)
Third level
• States can expand to all employers beginning in 2017
Fourth level
• States can choose to combine the individual and employer
Fifth level
exchanges, and/or merge these 2 insurance markets
• Beginning in 2014, small employer tax credits available only to
employers that purchase through the exchange
20

21. ClickReviewed nearly 6,000 health insurance plans
• to edit Master text styles
marketed
Second level to individuals and families across US
Third 285
• Out oflevel plans in Minnesota, no coverage for
•
•
•
Fourth level
Labor and delivery
Fifth level
in 195 (apx 70%),
Mental health services in 170, and
Specialty drugs in 80
• The median deductible in Minnesota - $5,000, five
times as high as in Massachusetts
Source: US World News and Report http://bit.ly/TH1ldF
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22. • Ambulatory patient services
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• Emergency services
•Second level
Hospitalization
Third level
• Maternity and newborn care
Fourth level
• Mental health and substance use disorder services,
includingFifth level health treatment
behavioral
• Prescription drugs
• Rehabilitative and habilitative services and devices
• Laboratory services
• Preventive and wellness services and chronic disease
management, and
• Pediatric services, including oral and vision care
22

23. • No pre-existing text styles
Click to edit Mastercondition exclusions
• Second levelor annual limits on coverage
No lifetime
Third level
• First-dollarlevel
coverage for preventive services
Fourth
Fifth level
23

24. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
24

25. Click to edit an Exchange under the ACA?
• What is Master text styles
Second level web-based marketplace
• A (primarily)
• Third level information on health insurance coverage
Organizes
Fourth level
options
Fifth level
• Provides comparison across plans with respect to
premiums, cost-sharing, coverage and quality ratings
• Consumers can select and enroll in coverage through
the Exchange
• Vehicle for administering premium tax credits and cost
sharing subsidies
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26. Click to edit Master text styles
• Those who purchase in coverage
Second level
in the individual and small group market
Third level
- <50Fourth level
employees
Fifth level
• Don’t have same leverage as large employers
when purchasing coverage
• Apx 12% of MN population gets coverage in
small group or non-group markets pre-ACA
26

27. Click to edit Master text styles
•
Amount level
Second of credit is a sliding scale based on income
• Third level subsidies for families with incomes up to 400%
Premium
Fourth level
of poverty
Fifth level
• In addition, cost sharing subsidies up to 250% of poverty
• Reduces deductible and other enrollee out of pocket costs
• Available in silver level plans only
27

28. Click to premium contribution, based on income for family of four in 2013:
Maximum edit Master text styles
Second level
300-400% FPL
Third level
9% of income
Fourth level
250-300% FPL
8.05-9% of income
Fifth level
6.3-8.05% of income
200-250% FPL
4-6.3% of income
150-200% FPL
3-4% of income
138-150% FPL
<138% FPL
2% of income
$0
$2,000
$4,000
$6,000
$8,000
$10,000
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29. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
29

30. • States have a lot oftext styles how to establish and run the
Click to edit Master control over
exchange – for example, whether to be selective about what
Second level
health plans can be sold through the exchange
Third level
• In states that do not establish their own exchanges, the
Fourth level
Fifth level
federal government will establish and operate an exchange
30

31. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
31

32. • Levels of coverage (bronze,
Click to edit Master text styles silver, gold, platinum)
correspond to enrollee cost sharing requirements
Second level
•
•
•
Third level
Deductibles
Fourth level
Coinsurance
Fifth level
Rx copays, etc.
• Tradeoffs between premiums and cost sharing
depend on individuals’ expectations about how much
care they will need
32

33. Monthly Exchange Premium for Second-Lowest Cost Silver
Plan
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450
400 Second
350
300
250
level
Third level
Fourth level
Fifth level
200
150
100
50
0
CA CO CT KY MA ME MN MS MT NH NY NV RI VT WA
Source: Breakaway Policy Strategies and the Robert Wood Johnson Foundation, “Looking Beyond
Technical Glitches: A Preliminary Analysis of Premiums and Cost Sharing in the New Health Insurance
Marketplaces,” November 2013.
33

34. Average Annual Integrated Deductibles
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4500
4000
Second
3500
level
Third level
3000
Fourth level
Fifth level
2500
2000
1500
1000
500
0
CO
KY
MA
ME
MN
MS
MT
NV
RI
WA
Source: Breakaway Policy Strategies and the Robert Wood Johnson Foundation, “Looking Beyond
Technical Glitches: A Preliminary Analysis of Premiums and Cost Sharing in the New Health Insurance
Marketplaces,” November 2013. (Policies with a single deductible for medical and rx expenses
combined
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35. Click to edit Master text styles
• Too early to draw conclusions from this preliminary
Second level
data onlevel
Third premiums and cost sharing
•
Fourth level
Need to know what consumers actually buy in the
Fifth level
exchanges vs. what is being offered for sale
• Will likely take some time for markets to sort out in
both Minnesota and other states over the next couple
of years
35

36. Click to edit Master text styles
• Churn & continuity of providers
Second level
•
Third level especially concerned about churn between
States are
Fourth and
Medicaidlevel the exchange
Fifth level
• Breadth of provider networks (related to continuity of
providers)
• Demographics of exchange population and market
stability
• Degree of standardization in health plan
choice/design
36

37. 100%
Click to edit Master text styles
90%
80%
Second
70%
60%
50%
level
Third level
Fourth level
Fifth level
40%
30%
Eligible for
Medicaid/CHIP
Eligible for financial
assistance
Not eligible for financial
assistance
20%
10%
0%
CA CT HI KY MDMN NV NY OR RI VT WA
Source: Department of Health and Human Services, Office of the Assistance Secretary for Planning and
Evaluation, “Health Insurance Marketplace: December Enrollment Report for the period: October 1 –
November 30,” December 11, 2013.
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38. Click to edit Master text styles
Second level
Third level
Fourth level
Fifth level
38

39. Access expansions of the ACA are targeted to a relatively
Click to edit Master text styles
small segment of the population in Minnesota
Second level low incomes
• Those with
•
• Third level
Those without employer-sponsored insurance
Fourth level
• Small employers
•
•
Fifth level
Comprehensiveness of benefits in the individual market
has improved – but comes at an additional cost
Tradeoffs between premium cost, enrollee cost sharing,
and provider networks are an issue that warrants attention
and monitoring
39

40. • Payment reform
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• Transforming the way we receive and pay for care
Second level
Third level
• Immigrant Populations
•
Fourth level
Not covered by
Fifth level
Medicaid expansion but represent almost
1/5 low-income non-elderly adult
• Baby boomers retiring
•
Growth of federal entitlements with continued deficit
spending
• Incremental reform in political battlefield
40

41. Click to edit Master text styles
Lynn
Second level Blewett
Julie Sonier
jsonier@umn.edu
blewe001@umn.edu
Third level
Fourth level
Fifth level
www.shadac.org
@shadac