The Affordable Care Act: An Evidence-Based Update

Seth Trueger MD MPHUniversity of Chicago @MDaware

ACA: Evidence-Based Update

DISCLOSURES

Emergency Physicians Monthly

(bias?)

PlanENROLLMENT stats, uninsured

PLANS premiums, deductiblesnarrow networks, balance

billing

SCOTUS Zubik, House v Burwell

PAY/QUALITY readmits v obs, MACRA

ENROLLMENTstolen mostly from Charles Gaba

Kaiser Family Foundation. Health Insurance Coverage in the US, 2011.Kaiser Slides. 19 October 2012.

Medicaid, 13%

VA/Other, 5%

Medicare, 13%

Private, Non-group, 5%

Employer-Sponsored Insurance,

49%

Uninsured, 16%2011

Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart

Medicaid, 19%

VA/other, 6%

Medicare, 17%



43%

Uninsured, 9%2016

Medicaid, 13%

Medicare, 13%



49%

Uninsured, 16%Medicaid, 1319% VA/other, 6%

Medicare, 1317%


Employer-Spon-sored Insurance,

4843%

Uninsured, 169%

20112016


Medicaid, 19%

VA/other, 6%

Medicare, 17%



43%

Uninsured, 9%2016








http://ccf.georgetown.edu/ccf-resources/medicaid_expansion_positive_impact_safety_net_hospitals_clinics/





Household 138% FPL 400% FPL1 $16,242 $47,080 2 $21,983 $63,720 3 $27,724 $80,360 4 $33,465 $97,000 5 $39,205 $113,640

2016 Enrollment

MarketplacesMedicaid



2015 Enrollment11 million paid QHP9 million off-Exchange QHP

2015 Enrollment11 million paid QHP9 million off-Exchange QHP

2016 Enrollment11 million Exchange QHP6 million off-Exchange QHP2 million off-Exchange grandfathered

2015 Medicaid9 million Medicaid expansion3.4 million Medicaid woodworkers

2015 Medicaid9 million Medicaid expansion3.4 million Medicaid woodworkers

2016 Medicaid11 million Medicaid expansion3.8 million Medicaid woodworkers0.5 million Basic Health Plan

“Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured.Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period.Among those who were uninsured at baseline, 47 percent remained uninsured at follow-up.”



EMPLOYER SPONSORED INSURANCE

UNINSURED

MEDICAID

MARKETPLACES & OFF EXCHANGE

UNINSURED





MEDICAID EXPANSION

http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/

Medicaid Expansion

WY

WI*

WV

WA

VA

VT

UT

TX

TN

SD

SC

RI PA*

OR

OK

OH

ND

NC

NY

NM

NJ

NH*

NV NE

MT*

MO

MS

MN

MI*MA

MD

ME

LA*

KY KS

IA* IN* IL

ID

HI

GA

FL

DC

DE

CT

CO CA

AR*AZ

AK

AL

Adopted (32 States including DC)

Not Adopting At This Time (19 States)



http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf

Exchange enrollment by income





20140%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

12%

38%

70%83%

56%

http://kff.org/slideshow/employer-sponsored-insurance-offer-and-coverage-rates/

<100FPL

100-250%

250-400%

>400%

<65yo

ESI by income

PMID 27076474

vs no ACA?18.1 million reduction in uninsured46% reduction (nonelderly)

PLANSpremiums deductibles narrow networks oh my

my take2014 rates were low

“subsidy equilibrium”rate increase requests ≠ rate increases

deductibles??

lower premiums?

“Under the law, no one can be denied coverage because of a pre-existing medical condition.”

BAD THING OTHER BAD THING

NOT BECAUSE OF OBAMACARE

BECAUSEOBAMACARE

MAG

NITU

DE

TIME

OBAMACAREBEGAN

narrow networks

balance billing

balance billingout of network ED

balance billingout of network EDinsurance has to pay

balance billingout of network EDinsurance has to payhow much?

balance billingout of network EDinsurance has to payhow much?ED bill balance

$?

$?

$?$

$?$

$

$?$

$

EMTALA

$?$

$

EMTALA

SCOTUSZubik v Burwell & House v Burwell

Zubik v Burwell

Zubik v BurwellLittle Sisters

Zubik v BurwellLittle SistersOCPs

Zubik v BurwellLittle SistersOCPs2 page form

Zubik v BurwellLittle SistersOCPs2 page formduck

House v Burwell

CSRsCost Sharing Reductions

“the other subsidies”

(pork/chicken of the sea)

above: premium subsidiesmonthly bill400% FPL

CSR: deductibles, copays, coinsurance

out of pocket, based on use250% FPLonly Silver+ (not cheaper

Bronze)

CSRs

CSR uptake

CSR uptake

X

X

X

X

X

¯\_(ツ )_/¯

PAYING FOR QUALITYthe card says MIPS

Readmissions

Readmissions

outpatient networkincentives

Readmissions


20%!

PMID: 26910198

Readmissions


21.5% 17.8%15.3% 13.1%

penalties?2015: 80%all 3: 57% (!)

https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/

penalties?2015: 80%all 3: 57% (!)

https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/

penalties?average $100-300k2013: teaching & safety-net hospitals 2015: more broadly distributed (still gap)

improving teaching & safety net?surgical?https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how-are-we-doing/

Readmission penalties?risk adjustment

socioeconomic status

¯\_(ツ )_/¯

Readmission penalties?hiding in observation?

¯\_(ツ )_/¯

PMID: 26910198

MIPS APMFFS + P4P

ACO, CMMIbundles

2019 ±4% 5% bonus2020 ±5% 5% bonus2021 ±7% 5% bonus2022 ±9% 5% bonus2023 ±9% 5% bonus2024 ±9% 5% bonus2025 ±9% 5% bonus2026+ 0.25%+ baseline

annually0.75%+ baseline

annually

¯\_(ツ )_/¯

[email protected]@MDaware

Health & Medicine

The Affordable Care Act: An Evidence-Based Update