Presentation by Elena Marks, JD, MPH for the Third Annual Policy Prescriptions® Symposium Elena M. Marks is the president and chief executive officer of the Episcopal Health Foundation and a nonresident fellow in Health Policy at Rice University’s Baker Institute for Public Policy. Marks previously served as the director of Health and Environmental Policy for the City of Houston. Prior to joining the mayor’s staff, Marks practiced trial and appellate law with major law firms, started and directed a successful legal placement firm, and developed strategic, long-range, and operating plans for service lines and system centers at a major health system. The symposium is designed for clinicians, healthcare workers, and healthcare executives interested in exploring the major themes that will emerge in health policy throughout the year. This year, the symposium will emphasize value in healthcare, health information technology, gun violence, insurance choices, the Affordable Care Act, and the viewpoints of the Presidential candidates on health care.

1. Health Policy Symposium
Elena Marks
Episcopal Health Foundation
June 11, 2016

2. Time for a Reality Check on Health Insurance
• Learn the basics of the coverage provisions of
the Affordable Care Act
• Learn about the impact of the coverage
provisions in Texas
• Learn about particular features of ACA
marketplace plans of concern to consumers and
physicians

3. Health Insurance Coverage Provisions of
the ACA

4. History of Health Insurance in US
Source: PBS available at http://www.pbs.org/healthcarecrisis/history.htm
1910’s
Railroads
provide
employee
medical care
1930’s
Social Security
Act; Blue Cross
offers hospital
care insurance
1940’s
Employer
sponsored plans
arise
1960’s
Medicaid and
Medicare
enacted
1980’s
Managed Care
1990’s
Costs rise at 2X
inflation; Clinton
plan dies
2000’s
Unsustainable
cost curve;
poor outcomes
2010
Affordable Care
Act

5. ACA’s Initial Objective: Access
A Core Objective of the ACA was
to Expand Access to Health Care
In the US, Access to Health Care
= Access to Health Insurance
50 Million Americans Lacked
Health Insurance in 2010

6. Coverage Provisions in ACA:
Publicly Funded Plans
Medicaid
expansion to
138% FPL
($16K/year for
one; $34K/year
for 3)
Marketplace with
subsidized plans for
100% to 400% FPL
(400%= $47K for
one; $97K for 3)

7. Coverage Provisions in the ACA:
None Out—All In
No pre-existing
condition exclusions
but
(almost) everyone
must have coverage
and
large employers must
offer affordable
coverage

8. Coverage Provisions in the ACA:
New Health Plan Regulations
Changes to Private
Insurance
• Kids on parents’ plans til 26
• Premium rate bands limited to
3:1 based on age, tobacco,
location
• 80% medical loss ratio
• Some preventive services
covered without co-pays
• Premium increases subject to
review

9. Texas and the ACA’s Coverage Provisions

10. Texas on the Eve of the ACA
Insured
19,564,000
76%
Undocumented
15%
ACA
Marketplace
Subsidy
Eligible
36%
No
Subsidy
11%
Uninsured
5,591,000
24%
Medicaid
Eligible but
Unenrolled
14%
Medicaid
Expansion
Adults
24%
Note: Due to rounding, percents may not total 100%
Sources: U.S. Census Bureau. March 2011 Current Population Survey (CPS), Texas Health and Human Services Commission, July 2012.

11. Texas on the Eve of the ACA:
Demographics of Uninsured Texans
Source: Current Population Survey, Annual Social and Economic Supplement, 2012
U.S. Census Bureau
*Personal Income
1,606,000
25%
610,000
9% 14,000
0%
190,000
3%
3,956,000
62%
50,000
1%
Uninsured by
Race/Ethnicity
White alone
Black or African American alone
American Indian and Alaska Native alone
Asian alone
Hispanic
Two or more races
1,073,000
18%
4,925,000
81%
81,000
1%
Uninsured by Age
00 to 17 18 to 64 65 to 80+
2,584,000
40%
1,817,000
28%
1,334,000
21%
427,000
7%
135,135
2%53,000
1%
75,000
1%
Uninsured by Income*
below$2,499 $2,500 to $19,999
$20,000 to $39,999 $40,000 to $59,999
$60,500 to $79,999 $80,000 to $99,999
$100,000+

12. Pre-2014 Experiences:
Affordability of Care by Insurance Status
7.2%
27.9%
17.9%
21.3%
13.4%
13.1%
14.4%
13.2%
40.6%
25.2%
27.5%
21.2%
32.3%
29.7%
Mental health care or counseling
Dental care
Medical tests and treatment
Prescription drugs
Specialist care
General primary care
Medical Care
Skipped Care, September 2013 By Household Income as a Percent of the
Federal Poverty Level (FPL)
Uninsured Insured

13. Pre-2014 Experiences:
Affordability of Care by Income
11.3%
40.6%
25.9%
30.1%
19.8%
31.5%
30.8%
11.5%
37.8%
23.5%
28.1%
19.0%
17.0%
20.4%
2.6%
14.3%
9.7%
10.6%
7.2%
5.4%
4.4%
Mental health care or counseling
Dental care
Medical tests and treatment
Prescription drugs
Specialist care
General primary care
Medical Care
Skipped Care, September 2013 By Household Income
as a Percent of the Federal Poverty Level (FPL)
400+% FPL 139-399% FPL <=138% FPL

14. 10.9% 9.0%
13.4%
13.4% 15.1%
17.7%
32.5% 30.6%
21.5%
16.6%
14.5%
11.8%
26.5%
30.2% 24.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Age 18-24 Age 35-49 Age 50-64
General Opinion of the ACA in TX by
Age, Sept 2013
14.3%
8.3% 11.2%
16.2%
15.7%
13.9%
37.9%
29.9%
19.6%
8.2%
12.8%
21.7%
23.1%
33.0% 33.4%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
<=138% 139-399% >=400%
General Opinion of the ACA in TX by
Income, Sept 2013
7.6%
18.0%
13.6%
9.8%
38.2%
15.3%
19.3%
20.8%
42.7%
18.4%
7.9%
11.2%44.1%
14.7% 17.1%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
White Black Hispanic
General Opinion of the ACA in TX by
Race/Ethnicity, Sept 2013
Pre-2014 Experiences:
Opinion of the ACA by Age, Income, Race

15. Pre-2014 Experiences:
Expectations about ACA

16. Texas Post-ACA Implementation

17. 8.0
10.0
12.0
14.0
16.0
18.0
20.0
22.0
24.0
26.0
Q3 2013 Q1 2014 Q2 2014 Q1 2015 Q3 2015 Q1 2016
Percentage
U.S.
Texas
Source: Health Reform Monitoring Survey and HRMS TX. Estimates are regression adjusted.
Uninsured by Race/ethnicity and Age
Texans ages 18-64, 2013 to 2016
Trends in Uninsurance for
Texas Adults Ages 18-24

18. Uninsured by Race/ethnicity and Age
Texans ages 18-64, 2013 to 2016
14.3
18.7
42.6
9.9
14.2
30.7
0 5 10 15 20 25 30 35 40 45
White, non-Hispanic
Black/other, non-Hispanic
Hispanic
Uninsured by Race/Ethnicity
26.4
28.1
21.1
20.7
21.6
10.3
0 5 10 15 20 25 30
18-30
31-49
50-64
Uninsured by Age Mar 2016 (%) Sep 2013 (%)

19. Uninsured by Income and Gender
Texans ages 18-64, 2013 to 2016
54.1
46
22.7
13.1
0 10 20 30 40 50 60
1
2
Uninsured by Family Income
Between 139% and 399% of FPL At or below 138% or FPL
22.3
14.9
28.4
20.7
0 5 10 15 20 25 30
1
2
Uninsured by Gender
Female Male

20. Texans Covered by ACA Marketplace Plans during
Open Enrollment Periods
733,757
918,890
1,306,208
0
200,000
400,000
600,000
800,000
1,000,000
1,200,000
1,400,000
Oct 2013-Mar 2014 Nov 2014-Jan 2015 Nov 2015-Jan 2016
Texas Enrollees from Open Enrollment

21. Texas Enrollment in Marketplace Plans by Income,
January 2016
48,279
4%
531,073
44%
277,606
23%
168,978
14%
84,489
7%
72,419
6%
24,140
2%
-
100,000
200,000
300,000
400,000
500,000
600,000
<100% of FPL >100% to <150% of FPL >150% to <200% of FPL >200% to <250 %of FPL >250% to <300% of FPL >300% to <400% of FPL > 400% of FPL
Fig. 8: Enrollment by Household Income

22. Texas Enrollment in Marketplace Plans By
Race/Ethnicity, January 2016
0
0
8,531
1%
75,156
9%
125,261
15%
308,977
37%
317,327
38%
0 50,000 100,000 150,000 200,000 250,000 300,000 350,000
Native Hawaiian/Pacific Islander
American Indian/Alaska Native
Multiracial
African-American
Asian
Latino
White

23. The Impact of Texas’ Refusal to Expand
Medicaid

24. Texas: Public Insurance pre-ACA

25. ACA’s Public Insurance Schema

26. Texas: Public Insurance post-ACA
~1 million
Texans

27. Trends in Uninsured Rates
2013 to 2016, Texas and US

28. Post-2014 Experiences:
Reasons for Remaining Uninsured, September 2015

29. Post-2014 Experiences:
Perceptions of Tax Penalties
22%
31%
26%
21%
Importance of the Possibility of a Fine to Uninsured
Adult Texans, March 2015
Very important
Somewhat important
Not too important
Not at all important

30. Thorny Issues for Consumers, Providers,
and Payers

31. Consumer Concerns
Cost
Provider selection
Surprise bills

32. Provider Concerns
Panels Reimbursement rates What’s next?

33. Payer Concerns
Change
It takes two to tango
Cost control

34. Life Expectancy
Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015
9 10
12 11 12
9 9
12 11
8
16
11 10
21
18 15
11
16
21
20
15
9
82.2
81.5
82.3
80.9
81.4
81.4
81.8
82.0
82.9
81.1
78.8
75
76
77
78
79
80
81
82
83
84
85
0
5
10
15
20
25
30
35
40
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK USA
LifeExpectancyatBirthinYears
HealthandSocialCareSpendingasaPercentageofGDP
Health Care Social Care Life Expectancy

35. Infant Mortality
Source: D. Squires and C. Anderson, U.S. Health Care from a Global Perspective: Spending, Use of Services, Prices, and Health in 13 Countries, The Commonwealth Fund, October 2015
9 10 12 11 12 9 9 12 11 8 16
11
10
21
18
15
11
16
21
20
15
9
3.6
4.8
3.6
3.3
3.8
5.2
2.4
2.7
3.9
3.8
6.1
2
3
4
5
6
7
8
0
5
10
15
20
25
30
35
40
AUS CAN FR GER NETH NZ NOR SWE SWIZ UK USA
InfantMortalityper1,000LiveBirth
HealthandSocialCareSpendingasaPercentageofGDP
Health Care Social Care Infant Mortality

36. Social Determinants of Health

37. Where We Invest
Social and Economic
Factors
- Education
- Employment
- Income
- Family and Social
Support
- Community Safety
Health Behaviors
- Tobacco Use
- Diet and Exercise
- Alcohol and Drug Use
- Sexual Activity
Physical Environment
Clinical Care
- Access to Care
- Quality of Care
- Hospital Care
- Physician and Clinical
Services
- Dental Services
- Home Health Care
- Nursing Care Facilities,
Continuing Care
Communities
- Prescription Drugs
- Durable Medical
Equipment
- Government
Administration
- Net Cost of Health
Insurance
- Research
- Structures and
Equipment
40%
30%
10%
20%
98%
Determinants of Health 2014 National Health Expenditures
Public
Health
2%
$79
billion
$2.9
trillion
Medical
Services

38. The Following Presenters Have Disclosed Relevant Financial Relationships:
Cedric Dark, MD MPH FAAEM FACEP
Community Health Choice, Event Sponsorship; Schumacher Clinical Partners, Event Sponsorship
Seth Trueger, MD MPH
Emergency Physicians Monthly, Employee, Salary
The Following Presenters Have Disclosed No Financial Relationships:
Megan Douglas, JD
Elena M. Marks, JD MPH
Laura Medford-Davis, MD
Bich-May Nguyen, MD MPH
The Following Planners Have Disclosed Relevant Financial Relationships:
Cedric Dark, MD MPH FAAEM FACEP
Community Health Choice, Event Sponsorship; Schumacher Clinical Partners,
Event Sponsorship
The Following Planning Committee Members and Staff Have Disclosed No
Relevant Financial Relationships:
Emily DeVillers, CAE
Kay Whalen, MBA CAE
Janet Wilson, CAE
Disclosure