1. Brian Colby Policy Director

2. Who Am I? Policy Director Lobbyist Analyst Communicator/Reporter Former Small Business Owner

3. What do we call it? Patient Protection and Affordable Care Act PPACA ACA Obamacare Health Reform Whatever you call it, it is what it is.

4. What is the Status of the Law On March 23, 2010, President Obama signed into law the Patient Protection and Affordable Care Act. In a June 28, 2012 decision, the U.S. Supreme Court upheld much of the ACA, but struck down a requirement that states expand their Medicaid program or face financial penalties. The Medicaid expansion will now be optional for the states. Medicaid is a joint federal and state program that provides health coverage for certain low-income individuals and families.

5. November Elections Changes in leadership in the Senate and at the White House could see the repeal of the law or major changes. For now, it is what it is until it changes.

6. Decisions for the MO Legislature 1. Should Missouri establish a “state based” health insurance exchange or allow the federal government create one for Missourians to use? 2. Should Missouri expand its Medicaid program?

7. What About Abortion in a possible Medicaid Expansion? The Medicaid expansion is governed by the same abortion restrictions as provided in the regular Medicaid program. For many years Medicaid has been subject to the Hyde Amendment, which prohibits the use of Medicaid monies for abortions or abortion coverage, except when necessary to save the life of the mother or in cases of rape and incest. The Hyde Amendment, however, is an annual rider to the Medicaid appropriation. – MO Catholic Conference Medicaid Fact Sheet 2012

8. Mandated Benefits, SB 749 and Religious Liberty SB 749 passed, was vetoed and the veto was overridden A lawsuit has been filed to challenge the regulations. No more action in front of the state on this issue for now.

9. What was Congress Thinking? Employers drop coverage Fewer payers in the market Causes increases in cost More employers drop coverage Cost go up Self Reinforcing Negative Feedback Loop

10. Cost Rising Faster than Income Health Care Cost have been going up 4 times our National Income - GDP Since 1980 it has doubled every 10 years. The government pays a large share of over all health care spending. Rising costs of health care is taking up a larger and larger share of the budget

11. Really Smart People Jonathan Gruber, PhD at MIT – adverse selection and the self reinforcing negative feedback loop Len Nichols, PhD at George Washington U -”If we can control the rising cost of health care, we can’t pay back the Chinese.”

12. Why are Cost Rising? Good question: -if you ask a health care economist he or she will likely tell you that we do not have a Global Budget. “If you don’t have a global budget, you might as well be squeezing a balloon. If you try and squeeze cost at one end it just pops out the other.” -Uwe Reinhardt, PhD, Professor at Princeton

13. Health Insurance Coverage of the Nonelderly Population, 2010 266.0 Million SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS. Private Non- group 5.5%

14. Nonelderly Uninsured by Poverty Levels and Age, 2010 Total = 49.1 million uninsured Note: Federal Poverty Level (FPL) for a family of four in 2010 is $22,050/year. Children includes all individuals under age 19. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS. <138% FPL 139-399% FPL 400%+ FPL Children 10% Adults 44% Children 5% Adults 32% Children 1% Adults 8%

15. Access to Insurance through the Workplace by Income, 2005 Source: Urban Institute analysis of the February and March 2005 CPS Supplements, 2006, for the Kaiser Commission on Medicaid and the Uninsured. Percent of employees not offered insurance through own or spouse’s employer Percent of Federal Poverty Level

16. The Correlation between Income and Employer Sponsored Insurance The higher the income the more likely you will be offered insurance at work. The lower the income the least likely you will be offered insurance at work. There is an inverse correlation between your ability to pay and your need to pay for your own insurance. In our system, if you need insurance chances are you can’t afford it and if you can afford it, chances are you don’t need it.

17. The Market is Broken at the Low Income Scale If your customer has no money, you have no market. The private marketplace is becoming out of reach for low income workers.

18. Average Annual Premiums for Single and Family Coverage, 1999-2012 * Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2012. $15,745*

19. Establishment Offer Rates by Size and Average Worker Earnings, 2000-2005 Notes: Wages cutoffs are adjusted for inflation to 2005 dollars. Source: Kaiser Family Foundation calculations based on data from the National Compensation Survey, 2000-2005, conducted by the Bureau of Labor Statistics. Offer Rate Average Worker Earnings

20. Who Cares? Why does coverage matter?

21. Barriers to Health Care Among Nonelderly Adults, by Insurance Status, 2009 * In past 12 months. Respondents who said usual source of care was the emergency room were included among those not having a usual source of care. SOURCE: KCMU analysis of 2009 NHIS data. Percent of adults (age 18 – 64) reporting:

22. Diagnosis of Late-Stage Cancer Uninsured vs. Privately Insured NOTE: Odds ratios were adjusted for age, sex, race/ethnicity, facility type, region, and income and education on basis of postal code. They represent the odds of being diagnosed with stage III or state IV cancer vs. stage I cancer. Analysis based on cases occurring between 1998-2004. SOURCE: Kaiser Family Foundation, based on Halpern MT et al, Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis." The Lancet Oncology. March 2008. Equal likelihood between Uninsured and Insured Ratio of probability of diagnosis of late vs. early stage cancer, Uninsured/private insurance

23. EMTALA Emergency Medical Transportation and Active Labor Act – Passed 1986 signed into law by President Ronald Reagan – mandates that hospitals treat and stabilize patients with emergency medical conditions regardless of their ability to pay. – Hospitals agreed to take on this role in part because of a federal promise to pay disproportionate share hospital (DSH) payments to hospitals that saw the uninsured. These payments will phase down with the anticipation of health reform increasing coverage for more people. This will be important. Hospitals’ Role

24. Emergency Room Care is the Most Expensive $1000 versus $100 People without insurance utilizing this system puts burdens on hospitals that forces hospitals to raise prices for everybody. Health reform said we need to cover people to start to bring down cost.

25. How do we bring everyone into the System? Cover the very low income workers with publicly financed insurance via Medicaid. Cover the middle income folks not covered at work, including small businesses, family farmers and sole proprietors on to the exchange that provides affordable insurance.

26. New Requirements Everybody needs to find coverage somehow Medicare – disabled and over 65 Medicaid for lowest income Dependents – on parents until 26 Exchange – some small business, family farmers, sole proprietors of modest income Traditional Employer based coverage

27. Expanding Coverage Under the Affordable Care Act * Medicaid also includes other public programs: CHIP, other state programs, Medicare and military-related coverage. The federal poverty level for a family of three in 2012 is $19,090. Numbers may not add to 100 due to rounding. SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS. <139% (Medicaid) Federal Poverty Level 139-399% (Subsidies) 400%+ Private Non- Group Medicaid* Employer- Sponsored Insurance Uninsured 266 M Nonelderly

28. The new voluntary marketplace The Exchange Web-based shopping tool or store Compares coverage and price Set up by state or federal government Voluntary individuals and business can buy insurance inside and outside the Exchange Individuals will be provided tax credits only inside the exchange.

29. Question #1 1. Should Missouri establish a “state based” health insurance exchange or allow the federal government create one for Missourians to use?

30. Pro and Cons? Proponents say exchanges… – Pools risks inside the individual and small group markets making individual ins. more like group ins. – Brings down cost because of price transparency, competition and choice Opponents say exchanges… -are unnecessary -will drive up costs

31. Question #2 2. Should Missouri expand its Medicaid program?

32. What is Medicaid? President Lyndon Johnson signed Medicare and Medicaid into law on July 30, 1965, in Independence, Missouri in a ceremony attended by former President Harry Truman. Medicaid is a joint federal-state program offers health coverage for low-income people of specific populations – children up to age 19 – parents of very low income – pregnant women – disabled individuals – Long term care for seniors age 65 of low income and few assets

33. How the New Medicaid Program would change MO current program. Moves income eligibility from 17% to 138% FPL for families with dependent children. – Family of 3 at 17% of FPL has an income of $3504 – Family of 3 at 138% FPL has an income of $25,390 For the first time will include adults without dependent children. – Individual at 138% of FPL has an income of $15,415

34. Coverage and Cost 255,000 people would gain coverage The feds pay 100% of newly eligible cover for the first 3 years calendar years starting 2014- 2016 then fed share phases down 95% in 2017, 94% in 2018 and 90% in 2019 and beyond.

35. State Share of Cost Urban Institute and the Department of Social Services did some projections in 2010 that estimated the cost to the state in the first three years would be negligible but in 2017 the cost could be $50 million rising to $189 million in 2020 and $253 million in 2022. New analysis is being done so those numbers may change. Some folks believe a “woodwork” effect could cost the state more. No woodwork effect factored into DSS est. DSH payment begin to dramatically reduce in 2017, many argue that it could cause major disruption in our hospital system.

36. Estimates # of People Covered Health Insurance Exchange 305,000 Medicaid Expansion 255,000

37. Thank You Brian Colby bcolby@mohealthalliance.org