1. 1 The Road to Affordable Care: Opportunities, Challenges and Successes in a post-ACA Market

2. Disclaimer The comments here represent my opinion alone, and are not intended to be representative of the Washington State Health Exchange Board. I am speaking today as a consumer and working families advocate, and not as a Board member. 2

3. 3 Cover the Uninsured Medicaid Enrollment Exchange Enrollment Improve Quality Ensure Affordability & Access Consumer’s Voice Protect Existing Coverage Watch Employer Behavior Impact on Market Identify Threats Monitor Costs Evaluate Access Hours and Pay Cuts Dual Role for Consumer Advocates

4. Type of Employer Penalty$$$ Penalty Employer fails to offer ANY Coverage and at least 1 FTE enrolls and is eligible for premium tax credit or cost sharing subsidy $2,000 on all FTEs (minus 30 FTEs) Employer offers UNAFFORDABLE Coverage and 1 or more FTEs enrolls and gets premium tax credit or cost sharing subsidy $3,000 per employee receiving coverage 4 FTE = 30+ hours or more per week “Unaffordable” = coverage costs more than 9.5% of individual’s income Employer Penalties in the ACA

5. Possible scenario: Employers drop group plan, pay penalty only instead TimelineIncome (4 at 250% FPL) Annual Plan Premium Employer Annual Cost Individual Cost Estimated Govt Cost Pre ACA$57,625$14,196$11,357$2,839$0 Post ACA$57,625$14,196$2,000$4,644$7,552 Difference - $9,357+ 1,805+ $7,552 5 Source: Calculation example borrowed from Gene Mechanic Law, 503.384.2070 Unanticipated Possible Market Changes

6. Unanticipated Market Changes Nationally Example: Employer penalty only applies to employees who work more than 30hrs/week and qualify for the exchange. Penalty does not apply to employers whose workers qualify for Medicaid. 6 Source: See handout from the Healthy WA Coalition.

7. Changing Market Behavior

8. Experienced Market Behavior in WA, 2012 Source: HCA Report to the Legislature, Employment status of HCA medical assistance clients & persons with dependents, Nov 2013. (excerpt, top 18)

9. The Affordable Care Act (ACA) was designed to ensure that employers, individuals, and the government share the responsibility for health care coverage and cost :  The ACA requires large employers to pay a penalty to offset the costs of public subsidies for their workers' healthcare if their full time employees receive health coverage through Exchanges.  Big corporations who shift costs to taxpayers by exploiting a loophole in the ACA, by cutting hours, pay or benefits, move more low-wage workers to Medicaid, should also have a penalty.  The assessment could cover the state’s portion of Medicaid, enhance provider reimbursement rates and invest in Washington’s safety net programs.  State-level policy can close this loophole in the ACA. Shared Responsibility was the ACA’s intent

10. Other employer policies that impact health and health outcomes for working families:  Lower income workers more likely to face shift changes, mandatory overtime, and non-standard hours.  Despite increased workload for families, no major federal initiatives have passed to help family/work dynamics.  Other nations with comparable resources have passed “work-family reconciliation” acts; The US ranks dead last.  Of 200 nations studied by UCLA, 180 nations offer guaranteed paid leave to new parents, 175 of them mandate paid annual leave, 162 limit the maximum length of the workweek; The US offers none of these protections. Other Market Policies that Impact Health Source: New York Times, Stephanie Coontz, Why Gender Equality Stalled, Feb 3, 2013.

11. 11 Teresa Mosqueda, MPA Government Affairs Director WA State Labor Council, AFL-CIO tmosqueda@wslc.org tmosqueda@wslc.org 206-353-5276

12. Source: Mirror, Mirror on the Wall, How the Performance of the US Healthcare System Compares Internationally, Commonwealth Fund, June 2014