1. Mission: To promote responsible and equitable fiscal policies through research and education Joy Smolnisky, Director 808 N. West Ave., Sioux Falls, SD 605-367-9667joys@sdbudgetandpolicyproject.orgjoys@sdbudgetandpolicyproject.org http://sdbpp.org Funded through a grant from the Northwest Area Foundation Medicaid Expansion – a South Dakota Decision

2. Federal Affordable Care Act includes: regardless of SD decision on Medicaid expansion 1.Coverage guarantees 2.Insurance exchanges 3.Federal tax credits to pay for insurance 4. Individual mandate 5. Funding provisions

3. 2012 Federal Poverty Level (FPL) by household size Household SizeAnnual Income 100% FPL Expanded Medicaid 138% FPL* 1$11,170$15,415 2$15,130$20,879 3$19,090$26,344 4$23,050$31,809 For each additional person, add$3,960$5,464 *138% minus 5% income disregard = 133% FPL

5. 2014 FEDERAL TAX CREDITS TO MAKE PREMIUM COSTS AFFORDABLE 92,800 South Dakotans eligible Premiums: The table below compares premiums* for subsidized families by income Family IncomePremiums IncomeAnnual SalaryPremiumsAnnual premiums (as % FPL)(for family of 3)(as % of income) (for a family of 3) 100%$19,0902%$381.80 133%$25,3903%$761.69 150%$28,6354%$1,145.40 200%$38,1806.30%$2,405.34 250%$47,7258.05%$3,841.86 300%$57,2709.50%$5,440.65 350%$66,8159.50%$6,347.43 400%$76,3609.50%$7,254.20 * based on 2012 Federal Poverty Levels Data source: http://www.kff.org/healthreform/upload/7962-02.pdf

6. FEDERAL TAX CREDITS – Cost Sharing 1/3 of out-of-pocket cap 1/2 of out-of-pocket cap 2/3 of out-of-pocket cap

7. *Based on income as a percentage of the Federal Poverty Level by household size

9. South Dakotans without access to affordable health insurance

10. South Dakotan health insurance in 2014 30,000 uninsured South Dakotans 92,800 116,000

12. SCENARIO #2 (without Medicaid expansion) Susan Frank Mary Willis Susan and Mary are both single parents. Susan’s daughter Sarah and Mary’s son Zeke are first grade classmates. These moms both work full time. Susan’s earnings Mary’s earnings $7.50/hour – 38 hrs/week$7.75/hour – 38 hrs/week 98% FPL (Federal Poverty Level) 102% FPL (Federal Poverty Level) Can these moms get affordable health insurance? NO YES Susan’s income is TOO LOW toMary’s HIGHER income is qualify for federal subsidies eligible for federal subsidies. (below 100% FPL) and too high Her insurance premium cost to qualify for SD Medicaidwill be less than $310 a year.

13. SCENARIO #3 (without Medicaid expansion) Bob & Cathy Nick & Deb Olsen Hansen The Olson Hansen families each have two children, ages 6 months and 3 years old. Each dad works full time while mom is home taking care of the children. Olson family earnings Hansen family earnings $10.90/hour$11.15/hour (98% FPL)(101% FPL) Can these parents get affordable health insurance? NO YES Bob’s income is TOO LOW toNick’s HIGHER income makes both qualify the parents for federal subsidies parents eligible for federal subsidies (below 100% FPL) and too high Their insurance premium cost to qualify the parents for SD Medicaid.will be less than $500 a year.

14. 138% FPL 100% FPL

16. Medicaid Expansion cost sharing between federal and SD state government In Millions Cost in Millions 6 months of SFY14SFY15SFY16SFY17SFY18SFY19SFY20Total thru SFY2020 Federal Share$58.3$273.4$321.9$333.1$342.4$359.3$373.$2,061.1 South Dakota State Share$1.50$1.90$2.1$10.6$22.1$27.2$36.9$102.1

17. Cost of increased state spending spread across SD population (in dollars per period) Total thru SFY2020 in dollars 6 months of SFY14SFY15SFY16SFY17SFY18SFY19SFY20 Total thru SFY2020 SD per person increase (2012 SD census 833,354)$1.80$2.28$2.52$12.72$26.52$32.64$44.28$122.52 SD per household increase (318,466 households)$4.71$5.97$6.59$33.28$69.40$85.41$115.87$320.60

18. November 2012 Kaiser Commission Estimates (million) 1 yr cost 1 yr cost10 yr cost 2016 2022 2013-2022 SD: $$1$ 36 $157 % 0.3% 5% 2.9% Fed: $$214$307$2,110 % 25.9% 25%22.8% *Table 6,7, & 8 Kaiser Commission on Medicaid and the uninsured. “Cost and Coverage implication of the ACA Medicaid Expansion National and State-by-state Analysis” November 2012

20. Which road does SD take? Medicaid expansion