The Affordable Care Act and it's impact on physician practices in Kansas.

1. ACA: Impact on
Physician Practices in Kansas
September 12, 2013

2. Agenda & Introductions
Discussion Topic Presenter
Ascension Health’s Role in this Work
& SGR Update
Mary Ella Payne
Senior Vice President
Policy & Legislative Leadership
Ascension Health
What The ACA Means
for Physician Practices in Kansas
Beth C. Fuchs, Ph.D.
Principal
Health Policy Alternatives

3. Our Mission
Rooted in the loving ministry of Jesus as healer, we
commit ourselves to serving all persons with special
attention to those who are poor and vulnerable.
Our Catholic health ministry is dedicated to spiritually
centered, holistic care which sustains and improves the
health of individuals and communities.
We are advocates for a compassionate and just society
through our actions and our words.

4. Health
Ministry
Ascension
Participating Entities
appoint members of
Ascension Health Ministries
“Ascension Health Ministries”
(PJP composed of up to 12 individuals)
Founding Participating Entities
Participating
Entities
Sponsor
System
Parent
Health
Ministries
Approved by Rome
June 30, 2011
Oak Hill
Capital Partners
Ascension
Health
Ventures
Ascension Health
Care Network
Management
Agreement
Leadership
Academy
Ascension
Health
Solutions
Ascension
Health
Services
Ascension
Health
(Delivery)
Health
Ministry
Health
Ministry
Affiliate
Organizations
Appoint
Participating Entities
Infrastructure
Support
Congregation
of St. Joseph
Sisters of St. Joseph
of Carondelet
Daughters of Charity
Province of St. Louise
Alexian
Brothers
Sisters of the
Sorrowful
Mother

5. Ascension Health, part of Ascension, is the largest Catholic
health system, the largest private nonprofit system and the
third largest system (based on revenues) in the United
States, operating in 23 states and the District of Columbia.
Our System
Daughters of
Charity Health
System is
an affiliate of
Ascension Health

6. Our System
Care of Persons Living in Poverty and
Community Benefit Programs: $1.3 Billion*
*Financial information reflects Ascension
Financial Information (FY 12) (in millions)
Total Assets $23,776
Operating Revenue $16,611
Operating Income $934
Excess of revenue and gains $968
over expenses and losses,
controlling interest

7. Ascension Health‘s Major Healthcare Delivery Platforms
Ambulatory Care and Diagnostics
Ambulatory Surgery Centers 70
Employer/Occ Health 44
Free-standing Imaging 83
Retail Lab Collection Sites 256
Primary Care Clinics 491
Specialty Clinics 260
Retail Pharmacies 35
Sleep Centers 28
Telemedicine Programs 59
Inpatient Facilities
General Acute Care 100
Long-term Acute
Care
3
Rehabilitation 3
Psychiatric 7
Total 113
Prevention & Wellness Programs
Alternative Care 13
Community/Social Services 120
Wellness/Fitness 20
Post Acute Service Sites
Behavioral Health – Acute units 31
Behavioral Health – Outpatient 76
Cancer Centers 20
Durable Medical Equipment 23
Home Health Agencies 26
Hospice/Palliative Programs 35
Infusion Therapy Programs 23
Private Duty Services 4
Rehabilitation – Outpatient 226
Rehabilitation – Inpatient units 35
Updated May 2013
Long-term Care & Senior Living Sites –
38 communities comprised of the
following:
Adult Day Care 11
Assisted Living (AL) 7
Independent Living (IL) 3
Skilled Nursing (SNF) 21
CCRC (combined SNF/AL/IL) 9
PACE 3

8. FY12 Systemwide Statistics*
• Discharges 693,544
• Available beds 18,450
• Number of births 72,121
• Total surgical visits 529,341
• Home health visits 534,232
• Clinic visits 1,877,970
• Emergency visits 2,454,455
• Physician office visits 6,974,451
• Total outpatient visits 20,155,034
• Associates 122,000
*FY12 Statistics do not include Ministry Health Care,
St. John Health System, or Via Christi Health.

9. Strategic Direction:
‗Architecture‘ for Realizing our Vision
Vital Presence
Healthcare That Leaves No
One Behind
Inspired People
Trusted Partnerships
Empowering Knowledge
Healthcare That Is Safe
Healthcare That Works
Our outward
promise to those
we serve
Enabled by focused
inner strengths

10. Provider-Centered:
transactional model
Person-Centered:
relationship model
Focus  Providers’ delivery of medical
services to patients to address a
healthcare episode
 Trust-based relationship that promotes a
spiritually centered, holistic approach to
supporting a person’s health and well-being
Locus of
Control
 Primarily providers  Primarily the person and family supported by a
trusted ecology of resources
Nature of
Choices
 Healthcare choices are mostly
reactive
 Health choices are well-understood and frequently
proactive
Primary
Locations
 Hospitals and clinics  More care and support in the community, in the
home and by virtual means
Health
Information
 Provider-based, episodic,
transactional
 Coordinated, transparent data managed by well-
informed individuals
Duration  Episode of care  Lifetime relationships
Transformational Path to Realizing our Vision
Person-
Centered
Approach
Fostering
Continuous,
Dynamic
Relationships
With Those
We Serve
Moving from Provider-Centered
to Person-Centered

11. Update on Legislation to Repeal and
Replace Physician SGR

12. Medicare SGR Reform
• Annual threat of significant reductions in the conversion
factor under the Medicare Physician Fee Schedule (PFS)
 Estimated 24.4 percent reduction effective January 1, 2014.
• Challenges in achieving consensus on a permanent
replacement
• Challenges in achieving consensus on offsetting savings
 CBO estimate of SGR reform 10-year costs at $138 billion BUT
this assumes freezing the conversion factor for 10 years, which
is not currently what is on the table; costs likely to be much
higher
12

13. SGR Reform Proposals in Congress
• House Energy and Commerce Bill, H.R. 2810
– Approved by vote of 51-0 on July 31, 2013
– Repeals SGR and provides for an annual 0.5 percent update to PFS
conversion factor for 2014 through 2018
– Beginning in 2019, updates to conversion factor for each physician or
physician group would depend upon their performance on certain
quality measures and, if applicable, clinical practice improvement
activities
• House Ways and Means and Senate Finance Committees still need to
weigh in
• Offsetting savings proposals must be identified and approved
• House and Senate must both approve the same reform plan…or
approve another short-term fix
13

14. The ACA: An Overview
of Implications for Physician
Practices as Small Businesses
Beth Fuchs, Ph.D.

15. Health Care Reform: What Is It?
Health Care Reform
Quality
Enhancement
Insurance
Coverage
Expansion
Health
Insurance
Reforms
Patient Protection and
Affordable Care Act (ACA)
signed on March 23, 2010
Constitutionality Affirmed by
Supreme Court on June 28, 2012.
The health care reform law makes
sweeping changes to our nation’s
healthcare system with a vision to provide
health coverage to all Americans and
promote more efficient care delivery.
15

16. 16
Overview: Implications for
Physicians as Clinicians
• Fewer uninsured patients
• Insured patients have better coverage, including
100% coverage for recommended preventive services
• Insurers can‘t cancel coverage when a patient gets sick,
and they can‘t set lifetime benefit limits that leave
patients without coverage
• Insurers that don‘t spend at least 80% of premium dollars
on patient care have to provide rebates to consumers
• Medicaid reimbursements increased to match Medicare rates for
primary care services (effective January 1, 2013)

17. 17
Overview: Implications for Physician
Practices as Small Businesses
• Small physician private practices will be able to
join together with other small businesses to purchase
health insurance in a new competitive marketplace
(SHOP Exchange)
– Greater bargaining power when shopping for
health insurance for their employees
• Small business tax credits may be available
to help pay for health insurance for employees

18. Key Terms
• Affordable Care Act = ObamaCare
• Health Insurance Exchange = Health Insurance
Marketplace
– In Kansas – The Health Insurance Marketplace
• insure.KS.org
18

19. 19
The ACA and Small Business
• Three major provisions in the
Affordable Care Act (ACA) for Small
Business (small business = fewer than
50 full-time employees)
– Exchanges (including SHOP Exchanges)
• Premium and cost-sharing subsidies
– Insurance Reforms
– Small Business Health Insurance
Tax Credits

20. 20
ACA Basics for Small Employers
• Small employers (fewer than 50 FTEs) are not required
to offer health coverage or pay for coverage for
their employees.
• Larger employers (50 and more full-time workers) are
not required to offer health coverage to their employees.
– But if a larger employer does not offer coverage or offers
inadequate coverage, and one or more of their employees
obtains federally subsidized Exchange insurance, then the
employer must pay a penalty.
– But, penalty will not be imposed for 2014.

21. 21
Small Business: Cost of Coverage
is a Major Deterrent for Many
• Between 1999 and 2012, health insurance premiums
increased over 170%*
• Because of smaller scale and thinner margins,
less able than larger employers to absorb these
increasing costs
• Small businesses less likely to offer coverage than
larger employers
*Kaiser Family Foundation and Health Research and Educational Trust, Employer Sponsored Health Coverage 2012,
http://kff.org/private-insurance/report/employer-health-benefits-2012-annual-survey/

22. 22
Cost Equation for
Business Owners is Unsustainable
Source: Kaiser Family Foundation, 2012
Inflation
Health Insurance Premium Increases Over 10 Years
Compared to Other Variables
Workers‘ Earnings
Premiums
Worker Contribution to Premiums

23. 23
Barriers: The Hassle Factor
Can‘t be Underestimated
Finding insurance, comparing options, and
making decisions on renewals can pose a barrier
• Searching for affordable options, if any
• Comparing them when information is
not comparable
• Choosing among options
• Dealing with renewals
• Responding to employee complaints

24. 24
For Identical Coverage,
Small Employers Pay More
• Smaller risk pools over which to spread costs
• State rating and underwriting rules that permit
insurers to price premiums in order to avoid bad risks
– In Kansas, insurers have used health status and other factors to vary
premiums. Thus, premiums for the same benefits vary widely.
• Higher administrative costs
• Unlike self-insured employer plans, bear costs of state
mandated benefits and insurer premium taxes

25. Small Group Rating Rules:
Premiums Can Vary Significantly
25Source: National Association of Insurance Commissioners and the Center for Insurance Policy and Research
http://www.naic.org/documents/topics_health_insurance_rate_regulation_brief.pdf

26. 26
For Identical Coverage, Smaller Employers
Pay Higher Costs than Larger Employers
for Administration/Overhead
Data: Estimates by The Lewin Group for The Commonwealth Fund.
Source: Commonwealth Fund Commission on a High Performance
Health System, The Path to a High Performance U.S. Health System:
A 2020 Vision and the Policies to Pave the Way
(New York: The Commonwealth Fund, Feb. 2009).
Cost of Administering Health Insurance as a % of Claims, by Group Size

27. ACA Reforms for
Physician Practices
as Small Businesses

28. 28
ACA Insurance Reforms Now In Place
• No lifetime limits; limits on use of annual dollar limits on benefits
• Insurance companies can‘t renege on promised coverage
• No pre-existing conditions exclusions for children under 19
• Children up to age 26 can be covered on their parent‘s plan
• Patient cost sharing eliminated for recommended
preventive services

29. 29
More ACA Insurance Reforms
Now In Place
• Medical Loss Ratio
– 80% of insurance premiums must be spent on health care delivery
– Insurers must rebate excess premiums
• Enhanced rate (premium) review by state regulators
• Uniform explanation of coverage documents;
standardized definitions

30. 30
Insurance Reforms as of 2014
• Insurers have to charge small firms in same area for
identical coverage more similar premiums regardless
of health status of their employees
– Within area premiums can only vary for:
family size, age, tobacco use
• No one can be turned down or cancelled because of
health status, pre-existing condition or use of healthcare;
no pre-existing condition exclusions
– These apply at annual and special enrollment periods

31. Insurance Reforms in Kansas
as of 2014
• For Kansas small businesses--
– Age adjusted community rating (3:1 limits on age
variation)
– No 90 day pre-existing condition waiting periods for
timely enrollment
– Insurers must offer Essential Health Benefits
• Comparable to largest small business policy in the state
• May be more comprehensive than current policy
31

32. 32
Essential Health Benefits (EHB)
• States selected among certain existing option(s)
for their EHB benchmark plan. Default is largest small group policy
in the state
• KS – BCBS Comprehensive Major Medical-Blue Choice
luCross Blue Shield of Kansas Comprehensive Plan
• EHBs must cover 10 categories of required services:
– Ambulatory care, emergency services, hospitalization,
maternity/newborn care, mental health and substance use
disorder services, including behavioral health treatment,
prescription drugs, rehabilitative and habilitative services
and devices, laboratory services, preventive and wellness
services and chronic disease management

33. 33
Actuarial Value (AV) and Cost Sharing
Plans offering EHB have to meet certain
cost-sharing standards:
• Limits on maximum out-of-pocket (MOOP)
costs for EHB: $6,400 for an individual,
$12,800 for a family for 2014
• Certain AV levels (the so-called ―metals‖ levels)
– Bronze: 60% AV
– Silver: 70% AV
– Gold: 80% AV
– Platinum: 90% AV
Note: The cost-sharing is reduced on sliding scale basis under affordability programs

34. 34
Actuarial Value (AV) and Cost Sharing
Plans offering EHB have to meet certain
cost-sharing standards:
• Plans in the small group market also
have limits on deductibles
• Cost-sharing for non-network providers
are not taken into account
Note: The cost-sharing is reduced on sliding scale basis under affordability programs

35. 35
Help to Buy Individual Insurance
• Self-employed individuals may no longer be
denied coverage based on health status
• New premium/cost-sharing subsidies for workers
in firms that elect not to provide coverage
– About 60% of small business owners now buying in
individual market have incomes up to 400% of FPL and
thus eligible for tax credits in Exchanges or Medicaid
– 83% of small business owners who are now uninsured
will be eligible for subsidized coverage (split about
equally between tax credits and Medicaid)*
*Kaiser Family Foundation, How Small Business Owners Get Health Insurance, September 28, 2012.
www.healthreform.kff.org

36. 36
Health Coverage Options
For Individuals In 2014
Source: CCIIO, Insuring America, Presentation, NIHCM Webinar, May 7, 2013
133% FPL for family of 3 -- $25,975
400% FPL for family of 3 -- $78,120
Sliding
Scale

37. 37
Establishment of State Exchanges
• Small Business Health Option Program (SHOP) Exchanges
− Give small employers some advantages that
large employers have in buying private insurance
• Exchange for individuals without employer coverage
to buy private insurance
• States given flexibility in designing and building SHOP
and individual market Exchanges, along with federal funding
– If a state opts not to create an Exchange, a
Federally-Facilitated Exchange/Marketplace is being established

38. 38
Functions of Exchanges
• Approve health plans for participation; ensure
adequacy of plan provider networks
• Operate annual open enrollment and special
enrollment periods
• Facilitate plan comparisons (website, call center;
standardized comparative info; plan ratings)
• Eligibility (including subsidies) and enrollment in plans

39. 39
Why State Exchanges?
• Premiums are reduced by pooling small-business
buying power, structure of competition, and
economies of scale
• More choice of insurance options for small
employers and their employees
• Comparing and making choices among insurance
options is easier
• Ultimate goal: drive innovation and improvements
in affordability, quality and customer service

40. 40
Status of the States‘ Exchange
Decisions for 2014
State-based Exchange:
16 states + DC have declared
Partnership Exchange:
7 states are planning for a Partnership
Exchange
Federally-Facilitated Exchange:
26 states currently default to the
Federally-Facilitated Exchange
Kaiser Family Foundation, Statehealthfacts.org;
http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#

41. SHOP: Employer Coverage Options
• Select among Qualified Health Plans (QHPs)
offered by specific insurer for employees
• Select a metal tier of Essential Health Benefit
coverage
– bronze, silver, gold or platinum
• Choose plan effective date: enroll for coverage
beginning 1/1/2014 or the first of any month
thereafter
41Source: HealthBenefitExchange.ny.gov. In 2014-15, eligible small employers are groups of 2 to 50 employees
(increases to 100 by 2016)

42. 42
SHOP: The Role of the Employer
• SHOP is open to firms with up to 50 or fewer full-time employees
• The employer must have an office or employee work site within the
SHOP's state to use that particular SHOP
• Using one online application, employer can (or with help of
an agent, broker or assister) compare price, coverage, and quality
of plans in a way that's easy to understand the differences
• The employer decides how much to pay toward employee premiums
• Employees can then enroll in the plan selected by the employer
– In 2015, employees will have choice of plans within a tier
picked by employer
Source: HealthBenefitExchange.ny.gov

43. Which Insurers in Kansas will be
Selling through the Individual Exchange?
• As of late August
– Blue Cross and Blue Shield of Kansas
– Blue Cross of Kansas City
• Also Multistate Plan Program option in same 103 counties
– Coventry Life and Health, and Coventry Health Care
of Kansas
• PPO and an HMO
Source: Wichita Eagle, How will the Affordable Care Act Work? August 28,
2013, www.kansas.com/2013/08/28/2969649/how-will-the-affordable-care-
act.html
43

44. Federally Facilitated SHOP--
www.Healthcare.gov
44

45. InsureKS.org
45
Sponsored by Kansas Department of Insurance

46. Outreach Efforts for 2014 for Kansas
Exchange (Marketplace)
• Help for consumers as they apply for and choose new insurance
options
– Navigators
• Kansas Association for the Medically Underserved, $524,846
– (Consortium of Kansas Hospital Association, the Kansas Association of Local
Health Departments, the Association of Community Mental Health Centers of
Kansas, the Kansas Area Agencies on Aging Association, and the Kansas Insurance
Department). Aim to assist about 48,000 people
• Advanced Patient Advocacy, $195,556
• Via Christi Health, Ascension Health, $165,683
– Certified application counselors (e.g., community health
centers, hospitals, social service agencies)
– Agents and brokers
• HHS Call Center; www.healthcare.gov
46

47. 47
• Many key design decisions left to states, so what
exchanges do and how well they do it will vary by state
• Exchanges must compete with insurance offered in the
outside market, so will need to offer plans that are
cost competitive and high quality
• Exchanges need to maximize participation
to gain scale, avoid adverse selection
Will Exchanges Succeed?

48. Exchanges Projected to Start at 7 million
and Reach About 25 million
• Exchange enrollment
estimated to be about
7 million in 2014,
increasing to about 22
million by 2016 and 25
million in 2018
• More than 80 percent
of enrollees estimated
to be eligible for
sliding-scale tax-credits
• About 3 million
estimated to be in
small business (SHOP)
Exchange
48

49. Implications for Physicians
and Hospitals
• Patients covered under Exchange plans may have better coverage
with lower out of pocket maximums than currently
• More insured patients but many uninsured likely to be unaware of
the Exchanges and subsidies in 2014, so effects of ACA may be
limited at first
• Plans have to meet network adequacy requirements but Exchange
plans may have narrower networks than non-Exchange plans
• To keep premiums competitive, insurers may try to negotiate
deeper discounts from hospitals; physicians may have to accept
lower reimbursement rates to participate in plan networks
• In the large group market, some employers may offer ―skinny‖
health plans that lack hospital coverage
49

50. Small Business
Health Insurance
Tax Credit

51. 51
Who Qualifies for the
Health Insurance Tax Credit?
• Coverage: Do you cover at least 50% of the cost of health care
coverage for some of your workers based on the single rate?
• Size: Do you have less than the equivalent of
25 full-time workers? (An employer with fewer
than 50 half-time workers may be eligible.)
– Owner of sole proprietorship is not counted as an employee
– Neither is a partner in a partnership
• Average annual wage: Do you pay average annual wages
below $50,000?
• Tax status: Both taxable (for-profit) and
tax-exempt firms qualify

52. 52
How Much Tax Credit Can I Get?
Maximum Amount
• Up to 35% of a small business' premium costs in 2010-2013
(25% for tax-exempt employers)
On January 1, 2014
• Rate increases to 50% (35% for tax-exempt employers)

53. 53
How Much Tax Credit Can I Get?
Phase-out
• Credit phases out gradually for firms with average wages between
$25,000 and $50,000 and for firms with the equivalent
of between 10 and 25 full-time workers
Impact of Budget Sequester: Refundable portion of credit
is reduced by 8.7 percent (ends 9-30-2013)

54. 54
Small Business Tax Credit:
Two Illustrations
Sophie’s Day Care (Non-Profit) Main Street Auto Mechanics
Employees: 9 Employees: 10
Wages: $198,000 total
or $22,000 per worker
Wages: $250,000 total
or $25,000 per worker
HI costs: $72,000 HI costs: $70,000
2011 Tax Credit:
$18,000 (25% credit)
2011 Tax Credit:
$24,500 (35% credit)
2014 Tax Credit:
$25,200 (35% credit)
2014 Tax Credit:
$35,000 (50% credit)

55. 55
Where Can I Learn More?
• Consult your tax preparer or check IRS website at:
– www.irs.gov/pub/irs-pdf/p4862.pdf
• Obtain IRS Form 8941 Small Business Health Insurance Tax Credit
and IRS Form 8941 Instructions
– http://www.irs.gov/pub/irs-pdf/f8941.pdf
– http://www.irs.gov/pub/irs-pdf/i8941.pdf

56. 56
Medicaid Primary Care
Rate Increase for 2013 and 2014
• States required to reimburse qualified Medicaid
(including Medicaid CHIP) primary care providers at rate
that would be paid for primary care service under Medicare
– MD must attest to practicing in Family, General Internal
or Pediatric Medicine and also to either being
• Board certified in designated specialties/subspecialties or
• Having a 60% paid claims history of both certain E&M codes
and vaccine administrative codes
• Physicians need to complete the attestation form at https://www.kmap-
state-ks.us/Documents/Content/Forms/Certification_Attestation_PCP.pdf
• For forms received after 3/31/2013, the effective date of the rate
increase will be the date of the physician's application for attestation
https://www.emedny.org/info/ProviderEnrollment/ProviderMaintForms/PrimaryCareRateIncrease_FAQs.pdf

57. 57
• Now: Tax credit may help some small physician
practices that opt to provide coverage to their employees
– Can carry the credit back or forward to other tax years
– Can claim a business expense deduction for any premium
in excess of the credit
• 2014: SHOP Exchange, with continuation of outside SHOP
market; Exchange for individuals who do not otherwise
have access to coverage; small businesses (under 50 FTEs)
will not be subject to penalties under shared responsibility
requirements
Bottom Line for Physician Practices

58. 58
• Because healthcare costs trends are steadily upwards,
even those small physician practices who benefit
from new insurance rules may not perceive improvement
• Temporary bump up in Medicaid reimbursement for
primary care physicians
Bottom Line for Physician Practices

59. ACA‘s Shared
Responsibility
Requirements

60. 60
Employer Requirements:
―Shared Responsibility‖ Penalties
Applies to employers averaging 50+ full-time employees
beginning in 2015
• If employer does not offer minimum essential coverage
to FTEs and dependents and at least 1 employee obtains
a premium assistance tax credit in an exchange, penalty
of $2,000 per full-time employee, with first 30 employees
not counted
Minimum essential coverage is typical public and private health
insurance (excludes accident-only, dental-only, vision-only coverage).

61. 61
Employer Requirements:
―Shared Responsibility‖ Penalties
Applies to employers averaging 50+ full-time employees
beginning in 2015
• If employer offers minimum essential coverage and
at least 1 employee obtains a premium assistance credit,
penalty of $3,000 per subsidized employee (capped at
amount of penalty for not offering coverage)
– Employees only eligible for premium credit if employer
coverage is < 60% actuarial value or employee contribution
is at least 9.5% of income
Minimum essential coverage is typical public and private health
insurance (excludes accident-only, dental-only, vision-only coverage).

62. 62
Individual Responsibility (―Mandate‖)
• Individuals without ―minimum essential coverage‖
pay penalty beginning with tax year 2014
• Exemption for certain religious sects, incarcerated
individuals and illegal immigrants
• No penalty applies if: income below the tax filing threshold;
for hardship; coverage gaps less than 3 months; or if coverage
unaffordable (> 8% of income, indexed after 2014)
Minimum essential coverage is typical public and private health insurance
(excludes accident-only, dental-only, vision-only coverage).

63. 63
Individual Mandate — Penalty
• For 2014, penalty higher of $95 per person
(up to 3 per household) or 1% of income above
filing threshold (e.g., $9,350 for singles in 2009)
• By 2016, penalty increases to $695 or 2.5% of income
above threshold ($695 indexed for later years)
• Penalty payable on income tax return; pro-rated
on monthly basis
• No IRS enforcement teeth

64. More ACA Information

65. 65
Current Sources of Coverage for
Non-Elderly in US and Kansas (2011-2012)
Kansas U.S.
Employer-Sponsored 60% 56%
Individual Insurance 6% 6%
Medicaid 14% 18%
Other public 4% 3%
Uninsured 15% 18%
Total 100% 100%
Source: Kaiser Family Foundation, http://kff.org/other/state-indicator/nonelderly-0-64/
Close to 327,000 Kansans are uninsured

66. Over Time, Number of Uninsured is
Projected to Decline by About Half
Medicaid and Exchange
coverage increases, and the
net number of uninsured
declines by about 25 million.
That still leaves about 30
million uninsured.
• The undocumented (cannot
get coverage in Exchange or
through Medicaid)
• Those in States that have not
expanded Medicaid
• Those can get coverage and
opt not to enroll, including
those exempt from tax
penalty
Sources of Coverage, Non-Elderly in Millions
Congressional Budget Office, May, 2013 Baseline 66

67. Medicaid Expansion Decision
as of September 3, 2013
67
Kaiser Family Foundation, Status of State Action on the Medicaid Expansion
Decision, as of September 3, 2013, www.statehealthfacts.org

68. Illustrative Monthly QHP Premiums
Cynthia Cox et al., An Early Look at Premiums and Insurer Participation in
Health Insurance Marketplaces, 2014, Kaiser Family Foundation, September 2013.
http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-
participation-in-marketplaces.pdf
State Lowest Cost Silver
Plan*
Lowest Cost Bronze Plan
Age 25 Age 40 Age 60 Age 25 Age 40 Age 60
Los Angeles,
CA
$176 $224 $475 $147 $188 $398
Indianapolis,
IN
$229 $291 $618 $196 $250 $531
NY, NY $359 $359 $359 $308 $308 $308
Richmond,
VA
$181 $230 $488 $134 $170 $361
*Lowest cost plan for person age 25. Other insurers may offer lowest cost plans for other age cohorts.

69. Illustrative QHP Premiums With and
Without Subsidies
2014 Monthly Premium for a Single 25-Year-Old at 250% of
Poverty ($28,725 per year)
Second
Lowest Cost
Silver plan
before
subsidies
Second Lowest
Cost Silver
Plan After
Subsidies
Lowest Cost
Bronze Plan
Before
Subsidies
Lowest Cost
Bronze Plan
After Subsidies
Los Angeles,
CA
$200 $193 $147 $140
Indianapolis, IN $232 $193 $196 $157
NY, NY $390 $193 $308 $111
Richmond, VA $199 $193 $134 $127
Note: Premiums are capped at 8.05% of income for an individual at 250% of poverty.
Source: Cynthia Cox et al., An Early Look at Premiums and Insurer Participation in
Health Insurance Marketplaces, 2014, Kaiser Family Foundation, September 2013.
http://kaiserfamilyfoundation.files.wordpress.com/2013/09/early-look-at-premiums-and-
participation-in-marketplaces.pdf