1. Affordable Care Act: An Overview
Karen Pollitz, Senior Fellow Kaiser Family Foundation March 1, 2019

2. Sources of Health Insurance Coverage for Non-Elderly, 2012-2017
SOURCE: KFF analysis of the 2013, 2018 American Community Survey, US Census Bureau.

3. ACA Made Specific Changes to Employer-Sponsored Coverage and Expanded Medicaid
Specific provisions affected employer-sponsored coverage
Pre-existing condition exclusion periods prohibited, all plans
Other specific changes for all plans include:
Cover dependents to age 26
Cover preventive services without cost-sharing
No annual, lifetime dollar limits
Out-of-pocket maximum for in-network cost sharing ($7,900 in 2019)
Large employer mandate
Share of population covered by ESI has remained relatively stable
Significant eligibility expansion for Medicaid
Pre-ACA, eligibility was categorical (children, parents, disabled, or elderly)
ACA expanded eligibility to 138% FPL, federal government pays 90% of cost in 2020
Supreme Court ruled in 2012 that expansion is a state option
In 2017, 12.7 million Medicaid enrollees were eligible because of the expansion
In 2017, 2.2 million poor adults in non-expansion states, in the “coverage gap”

4. Status of State Medicaid Expansion DecisionsWY 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 (37 States including DC)
Not Adopting At This Time (14 States)
NOTES: Current status for each state is based on KFF tracking and analysis of state activity.
◊Expansion is adopted but not yet implemented in ID, ME, NE, and UT. (See link below for additional state-specific notes).
SOURCE: “Status of State Action on the Medicaid Expansion Decision,” KFF State Health Facts, updated January 4, 2019.

5. ACA Substantially Changed Non-Group Coverage
Standards for ACA-compliant policies
No medical underwriting
Pre-existing condition exclusion periods prohibited; Guaranteed-issue and renewability
Modified community rating; rates vary by age (3:1), family size, geography, tobacco (1.5:1)
Benefit and cost sharing standards
10 essential health benefits (EHB) categories required
Metal tiers define cost-sharing levels; out-of-pocket maximum for in-network cost sharing
Subsidies
Premium tax credits for eligible individuals 100% to 400% FPL
Cost sharing reductions (CSR) for eligible individuals 100% to 250% FPL
Marketplaces administer subsidies, conduct annual open enrollment, facilitate plan comparison and choice, provide consumer assistance
State flexibility waivers authorized (Section 1332)
Individual Mandate
Congress reduced penalty to zero, effective in 2019
Non-compliant policies still exist
Grandfathered, “grandmothered” plans don’t comply; cannot sell to new policyholders
Short-term limited duration insurance doesn’t comply; can sell to new policyholders

6. Average combined annual deductible, medical and Rx, self-only
Many Marketplace Plans Have High Deductibles, Cost-Sharing Subsidies (CSR) Apply In Silver Plans
Average combined annual deductible, medical and Rx, self-only
SOURCE: Healthcare.gov data for 39 states with Federally Facilitated or Partnership exchanges.
FPL refers to Federal Poverty Level.

7. Marketplace Benchmark Plan Premiums Have Increased, but Stable For Those With Subsidies
National average monthly premiums, tax credit amounts, and individual contributions for the benchmark Silver plan for a 40-year old consumer with income at 200% FPL,
SOURCE: Kaiser Family Foundation Health Insurance Marketplace Calculator

8. Factors Contributing to Premium Increases in Benchmark Plans
Issuers adopt one-time price correction in response to under-pricing, losses in early years (2017)
Termination of CSR payments to issuers leads to “silver loading” (2018 and 2019)
Pricing for expected adverse selection due to repeal of mandate penalty, expansion of short-term plans (2019)
Lack of competition in areas with single issuer
Uncertainty

9. Individual market enrollment first quarter 2015-2018
Most Individual Market Participants Buy Through the Marketplace and are Eligible for Subsidies
Individual market enrollment first quarter
18.8 M
Source: Kaiser Family Foundation analysis of data from Mark Farrah Associates Health Coverage Portal TM and Centers for Medicare and Medicaid Services (CMS)
Notes: Data on the share of off-exchange enrollment in compliant vs. noncompliant plans in 2018 are not available, so this assumes the share to be the same as in For 2015 through 2017, we assume the share of off-exchange enrollment in non-compliant plans in Q1 is the same as share of annual enrollment in non-compliant coverage.
Enrollment is measured as average members per month.

10. Number of Uninsured and Uninsured Rate Among the Non-elderly Population, 2008-2017
NOTE: Includes nonelderly individuals ages 0 to 64.
SOURCE: Kaiser Family Foundation analysis of American Community Survey (ACS), 1-Year Estimates.

11. Eligibility for ACA Coverage Among Nonelderly Uninsured, 2017
Eligible for Financial Assistance
55%
Total = 27.4 Million Nonelderly Uninsured
NOTES: Numbers may not sum to totals due to rounding. Tax Credit Eligible share includes adults in MN and NY who are eligible for coverage through the Basic Health Plan. Medicaid/Other Public also includes CHIP and some state-funded programs for immigrants otherwise ineligible for Medicaid.
SOURCE: Kaiser Family Foundation analysis of 2017 American Community Survey (ACS), 1-Year Estimates.

12. Texas v. US Lawsuit Challenges Constitutionality of ACA
Republican state attorneys general are arguing that the ACA in its entirety is unconstitutional because the individual mandate (without a tax penalty) is unconstitutional.
The Trump administration is not defending the ACA in court, instead arguing that only the ACA’s pre-existing condition protections should be invalidated.
A district court judge has sided with the Republican state AGs, ruling that the ACA is unconstitutional, though the ruling has been stayed.
Democratic state attorneys general have intervened in the case to defend the ACA and have appealed the decision to the 5th Circuit.

13. KFF Resources
ACA/Marketplace Frequently Asked Questions questions/
Marketplace Subsidy Calculator calculator/
ACA Analyses and Data
Private Insurance Analyses and Data insurance/
Employer Health Benefits Survey costs/report/2018-employer-health-benefits-survey/
Uninsured
State Health Facts

14. Contact Information
Karen Pollitz Senior Fellow
Phone:

15. Freshman Member Briefing on the Affordable Care Act
Recent & Potential Legislative and Administrative Changes
March 1, 2019
Sabrina Corlette, J.D.

16. Based at Georgetown University’s McCourt School of Public Policy
About CHIR
A team of nationally recognized experts on private health insurance and health reform
Conduct research on issues related to health policy and health services
Based at Georgetown University’s McCourt School of Public Policy

17. Individual mandate penalty repeal Texas lawsuit to strike down ACA
The ACA in 2019
Individual mandate penalty repeal
Texas lawsuit to strike down ACA
Short-term health plans
Association plans
Marketplace cuts
Navigators
Outreach
Elimination of CSRs
1332 Waivers
Proposed: subsidy reductions, higher OOP costs, HRAs
Law has taken a number of body blows, some pretty serious.
Marketplace cuts:
Navigators - $10M for 2019 (80% drop in funding over 2 years)
Outreach - $10M – same as last year but 85% cut from 2016
Elimination of CSRs – ironically costing feds estimated $29B over 10 years in extra PTC funding.
1332 – relaxing the ACA’s guardrails, making it easier for states to design programs encouraging enrollment in skimpier health insurance products, such as short-term plans
Premium indexing proposal (in NBPP) – change in methodology = higher premiums for subsidized MP enrollees (~$200/annually for family of 4). Increases MOOP by $200 for individual, $400 per family (applies to IM, GM, including self-funded)

18. Premiums relatively stable (-1.5%) Insurer participation stable
ACA’s Present:
Premiums relatively stable (-1.5%)
Insurer participation stable
Majority public support
~87% receive premium subsidies
BUT:
3.7% decline in enrollment
8.8% still uninsured
Off-exchange enrollment declining (-38%, )
Surprising resiliency
Polling data: half of the public holds a favorable view of the Affordable Care Act while four in ten hold an unfavorable view. (Sept. 2018); compare to 2014, when it was 53% unfavorable, 37% favorable
Enrollment data – 8.3M in OE5
8.0M in OE6
87% get APTCs, up from 85% last year
Where there are problems – unsubsidized enrollment declining – off-exchange dropped 38% last year.

19. ACA: What’s Going on in the States?
Codifying pre-existing condition protections
Rejecting – or embracing – Trump administration actions
Individual mandate
1332s: Reinsurance
Marketplace conversions
ACA improvements
Subsidy wraps
Public option/Medicaid buy-in

20. ACA: Future Legislative Action?
Reversing Trump administrative actions
1332, Short-term plans, AHPs
Marketplace support
Navigators
Outreach
Reinsurance?
Cost-sharing reduction subsidies?
Affordability improvements?

21. Sabrina Corlette, J.D. Questions? Research Professor (202) 687-0880
@SabrinaCorlette