THE COMMONWEALTH FUND Women and the Affordable Care Act of 2010 Sara R. Collins, Ph.D. Vice President, Affordable Health Insurance The Commonwealth Fund Grantmakers In Health Audioconference What Effect Will the Affordable Care Act Have on Women’s Health? December 8, 2010

Exhibit Million Uninsured Women Ages in 2009, Up by 2 Million in Last Year Millions uninsured, women ages Source: Analysis of the 2001–2010 Current Population Surveys by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund.

THE COMMONWEALTH FUND Exhibit 2. Timeline for ACA Implementation Small business tax credit Prohibitions against lifetime benefit caps & rescissions Phased-in ban on annual limits Annual review of premium increases Public reporting by insurers on share of premiums spent on non-medical costs Preventive services coverage without cost- sharing Young adults on parents’ plans Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law and ), Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them State insurance exchanges Medicaid expansion up to 133% FPL Small business tax credit increases Insurance market reforms including no rating on health Essential benefit standard Premium and cost sharing credits for exchange plans Premium increases a criteria for carrier exchange participation Individual requirement to have insurance Employer shared responsibility penalties Penalty for individual requirement to have insurance phases in ( ) Option for state waiver to design alternative coverage programs (2017) States adopt exchange legislation and begin implementing exchanges Phased-in ban on annual limits

THE COMMONWEALTH FUND Exhibit 3. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2019 * Employees whose employers provide coverage through the exchange are shown as covered by their employers (5 million), thus about 29 million people would be enrolled through plans in the exchange. Note: ESI is Employer-Sponsored Insurance. Source: Congressional Budget Office, Letter to Honorable Nancy Pelosi, March 20, Among 282 million people under age 65 Pre-Reform 162 M (57%) ESI 35 M (12%) Medicaid 54 M (19%) Uninsured 16 M (6%) Other 15 M (5%) Nongroup 159 M (56%) ESI 51 M (18%) Medicaid 24 M (9%) Exchanges (Private Plans) 16 M (6%) Other 10 M (4%) Nongroup 23 M (8%) Uninsured Affordable Care Act

THE COMMONWEALTH FUND Exhibit 4. Early Provisions of the ACA That Will Benefit Women, Employers/insurers must allow adult children to remain on or join their parent’s health plans (Sept. 2010): 1 million uninsured adult children to gain coverage. Ban on lifetime coverage limits (Sept 2010): About 102 million people have health plans with lifetime limits, 20,400 exceed limits and lose coverage each year, assuming women comprise half of population, 10,000 women would gain coverage. Phased-in restrictions on annual benefit limits (Sept. 2010): about 18 million people have plans with annual limits, 3500 people exceed limits each year, about 1750 women. Bans on rescissions of coverage (Sept 2010): Rescissions most common in the individual market where about 5.5 million women covered. About 10,700 people lose their coverage as a result each year, assume about half are women or 5,000. Preexisting condition insurance plans (PCIPs)(July-Aug 2010): Enrollment underway in 50 states/DC for people with health problems who have been uninsured for 6 months; 27 states running their own, 23 state plans run by HHS, eligibility is transferrable. Insurers must cover recommended preventive services without cost-sharing (Sept. 2010): Includes mammograms for women age 40+, cervical cancer screening, genetic counseling and testing for the breast cancer (BRCA) gene. $250 rebates to Medicare beneficiaries in the Rx doughnut hole (2010): About 16 percent of Medicare beneficiaries enter doughnut hole annually, women are among those most likely to. Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law and ),

THE COMMONWEALTH FUND Exhibit 5. Provisions of the ACA That Will Benefit Women, Expansion in Medicaid eligibility to cover adults with incomes under 133% poverty ($14,000 individual; $29,000 for family of four) New state insurance exchanges with premium and cost-sharing subsidies up to 400% poverty ($43,000 individual, $88,000 family of four): Premiums capped at 2%-9.5% of income between % poverty; spending capped at 6%-27% of total spending between % poverty Essential health benefit standards that include maternity and newborn care and limits on cost-sharing for plans sold in insurance exchanges and the in the individual and small group markets: Four different levels of benefits – bronze, silver, gold, platinum – that will vary only by cost sharing, benefits are the same at each level Prohibitions on insurance carriers from denying coverage or charging higher premiums on the basis of health or gender Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law and ),

THE COMMONWEALTH FUND Exhibit 6. Interim Final Regulations and Requests for Comments Issued by HHS, DOL, Treasury as of December 2010 INTERIM FINAL REGULATIONS ISSUED: Dependent coverage of children to age 26 – May 2010 Early retiree reinsurance program – May 2010 Preexisting condition exclusions for children, lifetime and annual limits, rescissions, patient protections – June 2010 Grandfathered plans - June 2010 Coverage of preventive services without cost-sharing - July 2010 Preexisting Condition Insurance Plans (PCIPs) – July 2010 Medical loss ratio reporting and rebates - November 2010 REQUEST FOR COMMENTS: Premium review – April 2010 Insurance exchanges – August 2010 See Office of Consumer Information and Insurance Oversight

THE COMMONWEALTH FUND Exhibit 7. Estimated Change in Medicaid Enrollment, Uninsured Adults <133% FPL and Spending Over as a Result of ACA Medicaid Expansion* 27.4% 1.4% 22.1% 13.2% *Projections based on a 57% participation rate among newly eligible uninsured and lower rates across other coverage groups. Scenario assumes moderate levels of participation similar to current experience among those newly eligible and little additional participation among currently eligible individuals. Source: J. Holahan, I. Headen, Medicaid Coverage and Spending in Health Reform. Kaiser Family Foundation. May % Percent

THE COMMONWEALTH FUND Exhibit 8. Changes in Spending from Medicaid Expansion in the ACA, $21.2 Billion (5%) State $443.5 Billion (95%) Federal Total Change in Medicaid Spending $464.7 Billion Source: J Holahan, I Headen. Medicaid Coverage and Spending in Health Reform: National and State-by-State Results for Adults at or Below 133% FPL. May Kaiser Family Foundation. *Projections based a 57% participation rate among newly eligible uninsured and lower rates across other coverage groups. Scenario assumes moderate levels of participation similar to current experience among those newly eligible and little additional participation among currently eligible individuals.

THE COMMONWEALTH FUND Federal Poverty Level Percent Number Uninsured Premium Cap As A Share of Income Cost Sharing Cap <133% FPL51%9,480,576Medicaid 133%–149% FPL5%1,009,2443.0%–4.0%6% 150%–199% FPL12%2,331,8214.0%–6.3%13% 200%–249% FPL9%1,701,0666.3%–8.05%27% 250%–299% FPL6%1,141, %–9.5%30% 300%–399% FPL7%1,282,8539.5%30% Subtotal (133%-400%FPL) 40%7,466,2963.0%–9.5%6%–30% >400% FPL10%1,812,800-- Total100%18,759,672-- Exhibit 9. Distribution of 18.8 Million Uninsured Women by Federal Poverty Level and Provisions of the Affordable Care Act Note: Percentages may not sum to 100 due to rounding. Source: Analysis of the March 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund; Commonwealth Fund analysis of Affordable Care Act (Public Law and ). Uninsured Women ages 19-64

THE COMMONWEALTH FUND Exhibit 10. Most of the 18.8 Million Currently Uninsured Women Ages Will Gain Coverage Beginning in 2014 Note: Percentages may not sum to 100 due to rounding. Source: Analysis of the March 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund Medicaid 9.5 million 51% Subsidized Private Insurance with Consumer Protections 7.5 million 40% Non-Subsidized Private Insurance with Consumer Protections 1.8 million 10% 18.8 Million Uninsured Women Ages in 2009

THE COMMONWEALTH FUND TX 30.8% FL 26.0% NM 27.6% GA 22.7% AZ 21.3% CA 22.7% WY NV 22.9% AK OK 20.7% MS 21.7% LA 23.7% MT TN Exhibit 11. Women Ages in 16 States With Uninsured Rates Higher Than the National Average Will Particularly Benefit From the Health Reform Law Note: Uninsured rates are two-year averages, Source: Health Insurance Coverage of Women 19–64, states (2008–2009), Kaiser Family Foundation, statehealthfacts.org. Estimates based on the Census Bureau's March 2009 and 2010 Current Population Survey WA OR ID 20.2% UT CO KS NE SD ND MN WI MI IA MO AR 24.9% ILIN OH KY 21.0% WV 21.0% VA NC 20.2% SC AL PA NY ME DC MD DE NJ CT RI MA NH VT HI States with uninsured rate higher than national average of 20%, women ages 19-64, %