Federal Landscape: Defending the ACA

Cary Sanders, Director Policy Analysis, November 1, 2017

CPEHN: Together We’re Stronger

Eliminating Health Disparities

www.cpehn.org

AGENDA

• Federal Landscape • What’s at Stake?• Year in Review, ACA Repeal Proposals,

Administrative Actions, Other Proposals• What’s Next?

Rate of Uninsured Dropped Under ACA

Source: California Budget & Policy Center, November 2016

Medi-Cal – What’s at stake?California’s Medi-Cal population has almost doubled since implementation of the ACA in 2013

Medi-Cal Population• Close to 14 million Californians are covered by

Medi-Cal, one-third of the state’s population, 60% of all children

• CA receives $67 billion in federal Medi-Cal funds

White20% American

Indian/Alaskan Native

>1%

Asian/Pacific Islander

13%

African American8%

Latino48%

Not Reported11%

Medi-Cal Population by Race/Ethnicity 2016

White American Indian/Alaskan Native Asian/Pacific Islander African American Latino Not Reported

13,570,391

3.7 Million Newly Enrolled Adults in Medi-Cal Expansion

Asian/Pacific Islander631,181

17%

African-American289,299

8%

Latino1,378,809

37%American Indian/Alaskan Native

18,4171%

White 951,737

26%

Other/Not Reported419,421

11%

Percent of Adults Who Gained Access to Medi-Cal under the Expansion by Race/Ethnicity 2016

Total3,688,864

Source: CPEHN Fact Sheet, “Efforts to Repeal the ACA will Hurt Low-income and Communities of Color,” December 2016

Medi-Cal is the largest insurer in some parts of the stateCounty % of Population in Medi-Cal

Fresno 50%

Imperial 51%

Kern 45%

Los Angeles 40%

Madera 45%

Merced 51%

San Bernardino 41%

San Joaquin 41%

Tulare 55%

Source: California Budget & Policy Center, November 2016

Mental Health Benefits at Risk!

• 30% of Medi-Cal eligible (MCE) population in CA have a mental illness and/or substance use disorder.

• Nationally, Medicaid expansion has resulted in a reduction in the unmet need for mental health and substance use disorder treatment.

• In the first 6 months of ACA implementation, nearly 70,000 MCE beneficiaries received Medi-Cal specialty mental health services.

• 9 in 10 people incarcerated in CA were uninsured prior to the ACA; now 30% are eligible for MCE and 20% are eligible for financial assistance through Covered CA.

Substance Use Benefits at Risk!

• Substance use disorder treatment is also an Essential Health Benefit.

• The Drug Medi-Cal Organized Delivery System (DMC-ODS) was authorized as part of the Sec. 1115 waiver and is a significant expansion of SUD benefits.

• Counties must opt-in to participate. 40 counties covering the vast majority of California’s population have opted in to the demonstration.

• This provides a comprehensive array of SUD services for all Medi-Cal enrollees.

California will have to make hard choices about remaining state dollars

California went above and beyond other states using state dollars to expand Medi-Cal in 2014 to:

• Lawfully-residing immigrant children and pregnant women here less than five years (including DACA – see immigrantguide.ca.gov)

• Pregnant women with incomes up to $38,254 (322% FPL) regardless of immigration status

• Health4All Kids: Children age 19 and under regardless of immigration status

• Health4All?

Covered California Population• Close to 1.4 million Californians are currently enrolled in

Covered California• 90%, more than 1.2 million receive financial assistance

(tax credit subsidies) to help pay for their care• 570,000 people of color benefit from these subsidies

American Indian/Alaska

Native2,9500.3%

Asian/Pacific Islander213,080

23%

African American21,050

2%

Latino269,270

30%

Other62,580

7%

White342,500

38%

Covered California Subsidy Enrollment - Race/Ethnicity 2016

Total911,420

What’s on the GOP ACA Repeal Hit List?– Block grants to Medicaid, resulting in massive cuts– Elimination of Medicaid expansion– Elimination of the individual mandate and financial

assistance for marketplace coverage– Defunding Planned Parenthood – Prohibiting tax credits for plans that cover abortions– Allowing states to weaken insurance market rules for

those with pre-existing conditions– Defunding the prevention and public health fund– Repealing a number of ACA taxes

Earlier ACA Repeal Proposals Failed!• American Health Care Act (AHCA) - Failed!• Better Care Reconciliation Act (BCRA) – Failed!• Graham-Cassidy proposal – Failed!

The Fight to Defend the ACA is Still On!

Other avenues exist to repeal or weaken the ACA including: • Administrative actions• Current Efforts• (Budget/Tax Reform)• Other issues

Administrative ActionsThe White House has taken various actions and signed Executive Orders to:

• Cut the budget for Marketing and Outreach• Shorten Open Enrollment Period for ACA• Eliminate Cost-Sharing Reductions (CSRs) used to

pay for the cost of care• Weaken the Birth Control Mandate• Authorize the Sale of Short term Insurance and

Association Health Plans

Administrative ActionsFortunately California was prepared!

• Marketing and Outreach• Covered CA is entirely state funded• The Board voted to increase spending on

marketing and outreach this year

• California’s Open Enrollment Period• Covered CA’s 2018 Open Enrollment Period is

the same as last year’s: Nov. 1, 2017 - Jan. 31,2018

• AB 156 signed into law, requires 3 month open enrollment period moving forward

Administrative Actions cont.• Elimination of CSRs

• Insurers will recoup the cost of CSRs through higher Premium Subsidy payments from the Federal Government!

• AGs of 18 states filed a separate action to compel payment of CSRs

• Birth Control Mandate• California held mainly harmless except for

individuals in self-insured plans (e.g. Hobby Lobby) see SB 1053 (Mitchell)

• 6.8 million individuals at risk• CA AG filed lawsuit

Administrative Actions• Authorize the Sale of Short term Insurance and

Association Health Plans• Directs federal agencies to draft rules that will:

• Expand the use of association health plans• Exempt small employer plans from the ACA’s

small group consumer protections and possibly state regulation

• Expand the length and renewability of short-term coverage

• Expand ability of employers to use health reimbursement accounts to shift coverage of employees to the individual market

Current Efforts to Reform, Repeal or Replace the ACALegislationBi-Partisan Alexander-Murray Market Stabilization proposal

• Restores Cost-Sharing Reduction (CSRs) for two years• Partially restores ACA marketplace outreach and

enrollment funding ($100 million)• Allows for sale of very high deductible plans to people

above 30• Loosens Standards around 1332 waivers

GOP Hatch-Brady proposal

• Funds CSRs• Suspends the individual mandate for 5 years• Waives the employer mandate for 2 years• Introduces new abortion-related restrictions on subsidy

money• Expands Health Savings Accounts

Medicare for All • Type of universal coverage proposal that allows for just one “Single Payer,” the federal government

• Comprehensive coverage• Eliminates other payers (insurers, employers)• Cost $32 trillion over 10 years

White House Wants Even More Cuts!

Other outstanding issues:Children’s Health Insurance Program: • Funding for CHIP expired Sept. 30th

• Senate bill: KIDS Act – bipartisan• House bill: CHAMPION Act similar to KIDS Act,

extends CHIP for 5 years, includes funds for community clinics for 2 years, but offsets funding by eliminating Prevention Fund

Community Clinics:• Fiscal cliff 70% reduction in federal clinic funding• HR 3770, CHIME Act• Bipartisan support

Next Steps: Keep the Pressure On!

• Join the statewide campaign to protect our care: #Fight4OurHealth

• CA Congressional leaders must be held accountable: Call 1-866-426-2631 to be automatically connected to your Representatives

• Join the Having Our Say (HOS) coalition

• Visit CPEHN’s www.cpehn.org website for remote phone banking to Congressional leaders

Thank you! For more info:www.cpehn.org(510) 832-1160

csanders@cpehn.org