The Affordable Care Act: An Evidence-Based Update

1. Seth Trueger MD MPH University of Chicago @MDaware ACA: Evidence-Based Update

2. DISCLOSURES Emergency Physicians Monthly

3. (bias?)

8. Plan ENROLLMENT stats, uninsured PLANS premiums, deductibles narrow networks, balance billing SCOTUS Zubik, House v Burwell PAY/QUALITY readmits v obs, MACRA

9. ENROLLMENT stolen mostly from Charles Gaba

15. Kaiser Family Foundation. Health Insurance Coverage in the US, 2011. Kaiser Slides. 19 October 2012. Medicaid, 13% VA/Other, 5% Medicare, 13% Private, Non- group, 5% Employer- Sponsored Insurance, 48% Uninsured 16% 2011

16. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart Medicaid, 19% VA/other, 6% Medicare, 17% Private, Non- group, 6% Employer- Sponsored Insurance, 43% Uninsured 9% 2016

17. Medicaid, 1319% VA/other, 6% Medicare, 1317%Private, Non- group, 56% Employer- Sponsored Insurance, 4843% Uninsured, 169%2011 2016

18. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart Medicaid, 19% VA/other, 6% Medicare, 17% Private, Non- group, 6% Employer- Sponsored Insurance, 43% Uninsured 9% 2016

19. Gaba C. SHOW YOUR WORK. ACA Signups. 2016 Mar 28. http://acasignups.net/16/04/18/show-your-work-healthcare-coverage-breakout-entire-us-population-1-chart

26. http://ccf.georgetown.edu/ccf- resources/medicaid_expansion_positive_impact_safety_net_hospitals_clinics/

31. Household 138% FPL 400% FPL 1 $16,242 $47,080 2 $21,983 $63,720 3 $27,724 $80,360 4 $33,465 $97,000 5 $39,205 $113,640

32. 2016 Enrollment Marketplaces Medicaid

36. 2015 Enrollment 11 million paid QHP 9 million off-Exchange QHP

37. 2015 Enrollment 11 million paid QHP 9 million off-Exchange QHP 2016 Enrollment 11 million Exchange QHP 6 million off-Exchange QHP 2 million off-Exchange grandfathered

38. 2015 Medicaid 9 million Medicaid expansion 3.4 million Medicaid woodworkers

39. 2015 Medicaid 9 million Medicaid expansion 3.4 million Medicaid woodworkers 2016 Medicaid 11 million Medicaid expansion 3.8 million Medicaid woodworkers 0.5 million Basic Health Plan

41. “Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured.

42. “Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured. Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period.

43. “Despite concerns about plan cancellations, only 600,000 people starting out with nongroup coverage became uninsured. Of the 155.8 million people with insurance in September 2013, 80 percent experienced no changes in the source of their insurance during the study period. Among those who were uninsured at baseline, 47 percent remained uninsured at follow-up.”

46. UNINSURED

52. MEDICAID EXPANSION

53. http://kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/ Medicaid Expansion WY 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* KYKS IA* IN*IL ID HI GA FL DC DE CT CO CA AR*AZ AK AL Adopted (32 States including DC) Not Adopting AtThisTime (19 States)

60. http://cahc.net/wp-content/uploads/2016/06/CAHC-IssueBrief-FinalWeb-06161.pdf Exchange enrollment by income

63. 12% 38% 70% 83% 56% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% 2014 http://kff.org/slideshow/employer-sponsored-insurance-offer-and-coverage-rates/ <100FPL 100- 250% 250- 400% >400% <65yo ESI by income

64. PMID 27076474

65. vs no ACA? 18.1 million reduction in uninsured 46% reduction (nonelderly)

66. PLANS premiums deductibles narrow networks oh my

70. my take 2014 rates were low “subsidy equilibrium” rate increase requests ≠ rate increases deductibles??

71. lower premiums?

75. “Under the law, no one can be denied coverage because of a pre-existing medical condition.”

82. BAD THING OTHER BAD THING NOT BECAUSE OF OBAMACARE BECAUSE OBAMACARE MAGNITUDE TIME OBAMACARE BEGAN

103. narrow networks

108. balance billing

109. balance billing out of network ED

110. balance billing out of network ED insurance has to pay

111. balance billing out of network ED insurance has to pay how much?

112. balance billing out of network ED insurance has to pay how much? ED bill balance

122. SCOTUS Zubik v Burwell & House v Burwell

123. Zubik v Burwell

124. Zubik v Burwell Little Sisters

125. Zubik v Burwell Little Sisters OCPs

126. Zubik v Burwell Little Sisters OCPs 2 page form

127. Zubik v Burwell Little Sisters OCPs 2 page form duck

128. House v Burwell

129. CSRs Cost Sharing Reductions “the other subsidies” (pork/chicken of the sea)

130. above: premium subsidies monthly bill 400% FPL CSR: deductibles, copays, coinsurance out of pocket, based on use 250% FPL only Silver+ (not cheaper Bronze) CSRs

131. CSR uptake

132. CSR uptake

149. ¯_(ツ)_/¯

150. PAYING FOR QUALITY the card says MIPS

151. Readmissions

152. Readmissions outpatient network incentives

153. Readmissions outpatient network incentives 20%!

154. PMID: 26910198

157. Readmissions outpatient network incentives 21.5%  17.8% 15.3%  13.1%

158. penalties? 2015: 80% all 3: 57% (!) https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how- are-we-doing/

159. penalties? 2015: 80% all 3: 57% (!) https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how- are-we-doing/

160. penalties? average $100-300k 2013: teaching & safety-net hospitals 2015: more broadly distributed (still gap) https://blogs.sph.harvard.edu/ashish-jha/readmissions-penalty-at-year-3-how- are-we-doing/

161. Readmission penalties? risk adjustment socioeconomic status ¯_(ツ)_/¯

162. Readmission penalties? hiding in observation? ¯_(ツ)_/¯

163. PMID: 26910198

170. MIPS APM FFS + P4P ACO, CMMI bundles 2019 ±4% 5% bonus 2020 ±5% 5% bonus 2021 ±7% 5% bonus 2022 ±9% 5% bonus 2023 ±9% 5% bonus 2024 ±9% 5% bonus 2025 ±9% 5% bonus 2026+ 0.25%+ baseline annually 0.75%+ baseline annually

172. ¯_(ツ)_/¯

173. ntrueger@gmail.com @MDaware

The Affordable Care Act: An Evidence-Based Update

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The Affordable Care Act: An Evidence-Based Update

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