1. The Impact of the Patient Protection and Affordable Care Act (ACA) on Low-Income Enrollees of the Minnesota Comprehensive Health Association (MCHA) Kerry Landry MPH Candidate: Public Health Administration & Policy Minnesota Health Services Research Conference St. Paul, Minnesota March 1st, 2011
2. Acknowledgements Minnesota Comprehensive Health Association (MCHA) HallelandHabicht Consulting State Health Access Data Assistance Center (SHADAC) University of Minnesota School of Public Health 2
3.
4. The new coverage options will be based on income eligibility with no asset test
5. Assuming that health reform is fully implemented, what coverage options will be available for current MCHA enrollees?3
6. Overview of Presentation Affordable Care Act coverage expansions Overview of MCHA and the Low-Income Subsidy Program What we know about Low-Income Subsidy recipients Estimate of MCHA enrollees eligible for new coverage options Policy Implications 4
10. High-Risk Pools State health coverage mechanism for: Medically uninsurable HIPAA eligible Health Care Tax Credit (HCTC) eligible 35 states Financing Mostly through enrollee premiums and insurer assessments CMS grants 8
11. Minnesota Comprehensive Health Association (MCHA) MCHA Largest high-risk pool in the country (~27,000 enrollees) 2nd oldest – in operation since 1976 Currently administered by Medica ‘Presumptive conditions’ also eligible 9
12. Low-Income Subsidy Programs Approximately 15 states offer a subsidy Financing through CMS grants Annual application for federal grant money; some years not offered Most states distribute as monthly premium discount High variation across programs 10
23. Estimating income for all MCHA enrollees Income information not available for all enrollees – only those who applied for the subsidy program Do have zip code information for all enrollees Use zip code to determine community level income Estimate MCHA enrollee income using community level income 20
24. American Community Survey (ACS) Annual survey conducted by the US Census Bureau Information on demographics, income, education, employment, health insurance, etc. Sub-state (community-level) analysis possible Public use file available 21
25. Estimating income for all MCHA enrollees Find the % of people in different income categories for each community from the ACS 0-138%FPL 139-200%FPL 201-400%FPL 401%+FPL Imputation of income for MCHA enrollees based on community level income 22
28. Policy Implications 58% of MCHA enrollees potentially eligible for some form of subsidized health insurance (n = 14,179) There are likely more low-income enrollees than what we estimate from the subsidy program 25
29. Policy Implications (2) Potential for many individuals with chronic conditions moving to Medicaid and the individual market Increase in risk profile of these groups Added costs Potential increase in premiums for private coverage Risk adjustment in the exchange and individual market 26
30. Limitations These results are estimates Could improve estimate through: Income information on all MCHA members through an enrollee survey Further research needed to assess affordability of new options compared with MCHA coverage 27
I would like to thank the Minnesota Comprehensive Health Association and HallelandHabicht Consulting for their contributions and allowing me to use enrollee data. I would also like to thank my fellow research assistants and staff at SHADAC for their help and support as well as the School of Public Health at the University of Minnesota.
The Affordable Care Act provides for health insurance coverage expansions for low-income individuals, required to be implemented by states in 2014. We know that these new coverage options will be based on new income eligibility determinations without an asset test. This is a significant change from the current methodology and likely the reason that low-income high risk pool enrollees do not qualify for public coverage. Assuming that these coverage expansions are implemented, I tried to identify what options would be available to MCHA enrollees.
What I will talk about today will include background information on the Affordable Care Act coverage provisions, Minnesota’s high risk pool and the Low Income Subsidy program administered by MCHA. From the subsidy data, I will describe what we know about low-income subsidy recipients followed by an estimation of low-income MCHA enrollees eligible for new coverage options in 2014. Finally, I will discuss the policy implications of my findings.
The three coverage expansions included in the ACA are:The expansion of Medicaid up to 138%FPL – the law actually establishes a 133%FPL benchmark with a 5% income disregard, totaling 138%FPLAn option for states to cover populations not eligible for Medicaid but who have family incomes between 139 and 200%FPLAnd premium assistance for people purchasing plans on the exchange whose incomes are between 201 and 400%FPL. The premium subsidy will actually be administered through a tax credit.
Presumptive conditions = leukemia, AIDS/HIV, organ transplant, cystic fibrosis, etc.
High variation in:-income eligibility limits-number of enrollees or percent of membership receiving subsidy-amount of subsidy received; variation in amount each member gets
Subsidy is equal to $50.86 per month
This figure describes the MCHA enrollee population. Of the 27,000 enrollees in MCHA, most hold deductible plans. There are a small number of enrollees who purchase Medicare Supplement plans – only 819 enrollees. These enrollees were not eligible for the subsidy.As you can see in this figure, about 2800 enrollees received the low-income subsidy in 2010. The blue area highlights the individuals which Income data was available for – these were policyholders receiving the subsidy - about 86% of all subsidy recipients.
This chart describes low-income subsidy recipients as compared with the entire MCHA population.As you can see, most enrollees are between the ages of 45 and 64 – this is a group with increasing incidence of health issues making it difficult for them to purchase insurance on the private market.Anecdotally, we know that MCHA enrollees are self-employed, small business owners or farmers who have difficulty purchasing coverage if they or a member of their family has a chronic health condition.
Looking at deductible level for enrollees and subsidy recipients, we see that the most common plan has a $2,000 deductible.The high-deductible plan is a $3,000 deductible plan that is also a federally qualified plan for a health savings account. The plan does not require enrollees to establish an HSA but allows them the option. (also is the only plan with a family deductible that applies to dependents - $6,000/family)We can see that the plan choice for low-income subsidy recipients is very to the entire MCHA population. But to put it into perspective a little bit - a low-income subsidy recipient with a $10,000 deductible has an average income of $11,306 for a one-person household. For that person to have the means to spend $10,000 on health care seems quite unlikely and extremely burdensome.
From the low-income subsidy program data we identified that about half of subsidy recipients would be eligible for Medicaid in 2014 as their incomes are at or below 138%FPL.About 950 enrollees would be eligible for the basic health plan with incomes between 139 and 200%FPL.Because the income eligibility cutoff for the subsidy was 220%FPL we aren’t able to estimate the number that would receive premium assistance in the exchange.
What we can infer from the subsidy program is a minimum estimate of the proportion of all MCHA enrollees that might be eligible for the new coverage expansions.We know this is a minimum estimate since there are likely low-income enrollees who did not apply for the subsidy, but would still fit the income criteria. Since we only have income information for subsidy recipients, the estimates are very limited.
In order to get a better idea for how many low-income enrollees would fit the income eligibility for the new expansions, we needed to estimate income based on information available for all enrollees which was zip code.Using zip code, we estimated the income for all MCHA enrollees, including subsidy recipients.
Strategy was to estimate MCHA enrollee income using community level income.
Community level was PUMA – public use microdata areas – smallest geographic unitUsed the 2009 ACS because it reflects most current income estimates available.Family income, HHS poverty guidelines
What we did was identify the proportion of people in each community with family incomes in our categories of interest.Using these proportions, we were able to estimate the proportion of MCHA enrollees in that community that have similar incomes.There was variation in income across communities (PUMAs)0-138%FPL min=8% max=44.74%139-200% min=3.13% max=14.60%201-400% min=15.21% max=42.65%
Using these community level estimates we find that 16.7% of MCHA enrollees have incomes at or below 138% making them eligible for Medicaid in 2014.9.3% would be eligible for the state’s basic health plan32% would be eligible for premium subsidies in the exchange
