What’s Next for the ACA and Health Reform? Nancy Turnbull Regis College March 2019

Massachusetts: Lowest Rate of Uninsurance in US since 2008 Percent of Population With No Health Insurance ACA U.S. MASSACHUSETTS 2010 Source: Massachusetts Division of Health Care Finance and Policy, 2008-2014 Household Insurance survey; US Census Bureau CPS, Urban Institute 2007 study for BCBSMAF 2 2

Comparison of Major Coverage Components of Massachusetts Law and the ACA Medicaid Expansions √ Subsidized Coverage Insurance Market Rules Health Insurance Exchange/Marketplace Individual Mandate Employer Responsibilities

Percent of Non-Elderly Adults In Massachusetts: More People Covered But Little Progress on Financial Security Overall Percent of Non-Elderly Adults Source: MHRS, 2018, BCBSMA Foundation

Percent of Non-Elderly Adults In Massachusetts, Difficulties Obtaining Health Care Are Common, Worse for Lower Income Individuals Percent of Non-Elderly Adults Source: MHRS, 2018, BCBSMA Foundation

November 2016

After 2016 Election Republicans Tried and Failed to Repeal ACA March 2017 American Health Care Act -24 million No Vote May Revised American Health Care Act -23 million Passed House 217-213 June Senate Better Care Reconciliation Act Repeal, No Replace -22 million -32 million July BCRA Rejected Health Care Freedom Act -16 million Rejected 49-51 Sept Graham-Cassidy -21 million No vote

Where are we now? Congressional stalemate Trump Administration still trying to sabotage ACA Courts a real threat Action moves to the states

Trump Administrative Actions to Weaken/Sabotage the Law Weaken individual mandate Reduce subsidies Discourage enrollment/reenrollment Disinformation Encourage states to weaken Medicaid Public charge proposed rule Allow insurers to sell products with fewer benefits and protections Weaken standards for coverage

Action in the States: Medicaid 14 states have not yet expanded Medicaid

Expand Medicaid

What States Are Doing for Now Expand Medicaid State Level Individual Mandates Mass, NJ, DC, Vermont

Improve the ACA Subsidies ACA subsidies too low to make good coverage affordable for many So Massachusetts “tops off” the subsidies with state funds Comes from tobacco tax and employer assessments State Enrollment Assistance

Massachusetts Subsidies are Larger and Coverage Is Better Than in ACA Individual FPL Income (2017) Federal Maximum Enrollee Annual Premium Contribution after APTC* Mass Enrollee Annual Premium for ConnectorCare 100-133% $11,770-$15,654 $235-313 $0 133%-150% $15,655-$17,655 $471-710 150-200% $17,656-$23,540 $710-1,492 $512 200-250% $23,541-$29,425 $1,492-2,392 $989 250-300% $29,426-$35,310 $2,392-3,376 $1,471 Note: Actuarial value of APTC silver plan ~70% ; with cost-sharing subsidy for <250% FPL is 73% to 94%; actuarial value of ConnectorCare plans ~94-99%.

What States Are Doing for Now Expand Medicaid State Level Individual Mandates Improve ACA subsidies at state level Weaken Medicaid

Work Requirements in the states Weaken Medicaid Work Requirements in the states Source: https://www.commonwealthfund.org/publications (work requirements)

What States Are Doing for Now Expand Medicaid State Level Individual Mandates Improve ACA subsidies at state level Protect insurance market reforms Weaken Medicaid Lower Drug Prices Social Determinants of Health

What’s in the Future? Court decisions in lawsuits that challenge certain administrative actions? The Presidential Elections in 2020? Medicare for All? Can the U.S. ever control its health care costs? ?