THE COMMONWEALTH FUND Women and the Affordable Care

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THE COMMONWEALTH FUND Women and the Affordable Care Act of 2010 Sara R. Collins,

THE COMMONWEALTH FUND Women and the Affordable Care Act of 2010 Sara R. Collins, Ph. D. Vice President, Affordable Health Insurance The Commonwealth Fund Grantmakers In Health Audioconference What Effect Will the Affordable Care Act Have on Women’s Health? December 8, 2010

Exhibit 1. 18. 8 Million Uninsured Women Ages 19 -64 in 2009, Up by

Exhibit 1. 18. 8 Million Uninsured Women Ages 19 -64 in 2009, Up by 2 Million in Last Year Millions uninsured, women ages 19 -64 Source: Analysis of the 2001– 2010 Current Population Surveys by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund.

Exhibit 2. Timeline for ACA Implementation • Small business tax credit • Prohibitions against

Exhibit 2. Timeline for ACA Implementation • Small business tax credit • Prohibitions against lifetime benefit caps & rescissions • Phased-in ban on annual limits • Annual review of premium • States adopt exchange legislation increases and begin implementing exchanges • Public reporting by insurers on share of premiums spent • Insurers must • HHS must on non-medical spend at least determine if costs 85% of premiums states will have • Preventive (large group) or operational services 80% (small group exchanges by coverage / individual) on 2014; if not, without costmedical costs or HHS will sharing provide rebates to operate them enrollees • Young adults on parents’ plans • State insurance exchanges • Medicaid expansion up to 133% FPL • Small business tax credit increases • Insurance market reforms including no rating on health • Essential benefit standard • Penalty for • Premium and cost individual sharing credits for requirement to exchange plans have insurance • Premium increases phases in (2014 a criteria for carrier 2016) exchange • Option for state participation waiver to design • Individual alternative requirement to have coverage programs insurance (2017) • Employer shared responsibility penalties Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law 111 -148 and 111 -152), www. commonwealthfund. org/Health-Reform-Resource. aspx. THE COMMONWEALTH FUND

Exhibit 3. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2019 24

Exhibit 3. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2019 24 M (9%) Exchanges (Private Plans) 54 M (19%) Uninsured 16 M (6%) Other 15 M (5%) Nongroup 162 M (57%) ESI 35 M (12%) Medicaid 23 M (8%) Uninsured 16 M (6%) Other 159 M (56%) ESI 10 M (4%) Nongroup 51 M (18%) Medicaid Pre-Reform Affordable Care Act Among 282 million people under age 65 * Employees whose employers provide coverage through the exchange are shown as covered by their employers (5 million), thus about 29 million people would be enrolled through plans in the exchange. Note: ESI is Employer-Sponsored Insurance. Source: Congressional Budget Office, Letter to Honorable Nancy Pelosi, March 20, 2010 http: //cbo. gov/doc. cfm? index=11379. THE COMMONWEALTH FUND

Exhibit 4. Early Provisions of the ACA That Will Benefit Women, 2010 -13 •

Exhibit 4. Early Provisions of the ACA That Will Benefit Women, 2010 -13 • Employers/insurers must allow adult children to remain on or join their parent’s health plans (Sept. 2010): 1 million uninsured adult children to gain coverage. • Ban on lifetime coverage limits (Sept 2010): About 102 million people have health plans with lifetime limits, 20, 400 exceed limits and lose coverage each year, assuming women comprise half of population, 10, 000 women would gain coverage. • Phased-in restrictions on annual benefit limits (Sept. 2010): about 18 million people have plans with annual limits, 3500 people exceed limits each year, about 1750 women. • Bans on rescissions of coverage (Sept 2010): Rescissions most common in the individual market where about 5. 5 million women covered. About 10, 700 people lose their coverage as a result each year, assume about half are women or 5, 000. • Preexisting condition insurance plans (PCIPs)(July-Aug 2010): Enrollment underway in 50 states/DC for people with health problems who have been uninsured for 6 months; 27 states running their own, 23 state plans run by HHS, eligibility is transferrable. • Insurers must cover recommended preventive services without cost-sharing (Sept. 2010): Includes mammograms for women age 40+, cervical cancer screening, genetic counseling and testing for the breast cancer (BRCA) gene. • $250 rebates to Medicare beneficiaries in the Rx doughnut hole (2010): About 16 percent of Medicare beneficiaries enter doughnut hole annually, women are among THE those most likely to. COMMONWEALTH FUND Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law 111 -148 and 111 -152), www. commonwealthfund. org/Health-Reform-Resource. aspx.

Exhibit 5. Provisions of the ACA That Will Benefit Women, 2014+ • Expansion in

Exhibit 5. Provisions of the ACA That Will Benefit Women, 2014+ • Expansion in Medicaid eligibility to cover adults with incomes under 133% poverty ($14, 000 individual; $29, 000 for family of four) • New state insurance exchanges with premium and cost-sharing subsidies up to 400% poverty ($43, 000 individual, $88, 000 family of four): Premiums capped at 2%-9. 5% of income between 100 -400% poverty; spending capped at 6%-27% of total spending between 133250% poverty • Essential health benefit standards that include maternity and newborn care and limits on cost-sharing for plans sold in insurance exchanges and the individual and small group markets: Four different levels of benefits – bronze, silver, gold, platinum – that will vary only by cost sharing, benefits are the same at each level • Prohibitions on insurance carriers from denying coverage or charging higher premiums on the basis of health or gender Source: Commonwealth Fund Health Reform Resource Center: What’s In the Affordable Care Act? (Public Law 111148 and 111 -152), www. commonwealthfund. org/Health-Reform-Resource. aspx. THE COMMONWEALTH FUND

Exhibit 6. Interim Final Regulations and Requests for Comments Issued by HHS, DOL, Treasury

Exhibit 6. Interim Final Regulations and Requests for Comments Issued by HHS, DOL, Treasury as of December 2010 INTERIM FINAL REGULATIONS ISSUED: • Dependent coverage of children to age 26 – May 2010 • Early retiree reinsurance program – May 2010 • Preexisting condition exclusions for children, lifetime and annual limits, rescissions, patient protections – June 2010 • Grandfathered plans - June 2010 • Coverage of preventive services without cost-sharing - July 2010 • Preexisting Condition Insurance Plans (PCIPs) – July 2010 • Medical loss ratio reporting and rebates - November 2010 REQUEST FOR COMMENTS: • Premium review – April 2010 • Insurance exchanges – August 2010 See Office of Consumer Information and Insurance Oversight http: //www. hhs. gov/ociio/index. html THE COMMONWEALTH FUND

Exhibit 7. Estimated Change in Medicaid Enrollment, Uninsured Adults <133% FPL and Spending Over

Exhibit 7. Estimated Change in Medicaid Enrollment, Uninsured Adults <133% FPL and Spending Over 2014 -2019 as a Result of ACA Medicaid Expansion* Percent 44. 5% 27. 4% 22. 1% 13. 2% 1. 4% *Projections based on a 57% participation rate among newly eligible uninsured and lower rates across other coverage groups. Scenario assumes moderate levels of participation similar to current experience among those newly eligible and little additional participation among currently eligible individuals. Source: J. Holahan, I. Headen, Medicaid Coverage and Spending in Health Reform. Kaiser Family Foundation. May 2010. THE COMMONWEALTH FUND

Exhibit 8. Changes in Spending from Medicaid Expansion in the ACA, 2014 -2019 $21.

Exhibit 8. Changes in Spending from Medicaid Expansion in the ACA, 2014 -2019 $21. 2 Billion (5%) State $443. 5 Billion (95%) Federal Total Change in Medicaid Spending $464. 7 Billion Source: J Holahan, I Headen. Medicaid Coverage and Spending in Health Reform: National and State-by-State Results for Adults at or Below 133% FPL. May 2010. Kaiser Family Foundation. *Projections based a 57% participation rate among newly eligible uninsured and lower rates across other coverage groups. Scenario assumes moderate levels of participation similar to current experience among those newly eligible and little additional participation among currently eligible individuals. THE COMMONWEALTH FUND

Exhibit 9. Distribution of 18. 8 Million Uninsured Women by Federal Poverty Level and

Exhibit 9. Distribution of 18. 8 Million Uninsured Women by Federal Poverty Level and Provisions of the Affordable Care Act Uninsured Women ages 19 -64 Federal Poverty Level Percent Number Uninsured Premium Cap As A Share of Income Cost Sharing Cap <133% FPL 51% 9, 480, 576 Medicaid 133%– 149% FPL 5% 1, 009, 244 3. 0%– 4. 0% 6% 150%– 199% FPL 12% 2, 331, 821 4. 0%– 6. 3% 13% 200%– 249% FPL 9% 1, 701, 066 6. 3%– 8. 05% 27% 250%– 299% FPL 6% 1, 141, 312 8. 05%– 9. 5% 300%– 399% FPL 7% 1, 282, 853 9. 5% 30% Subtotal (133%-400%FPL) 40% 7, 466, 296 3. 0%– 9. 5% 6%– 30% >400% FPL 10% 1, 812, 800 -- -- Total 100% 18, 759, 672 -- -THE COMMONWEALTH Note: Percentages may not sum to 100 due to rounding. FUND Source: Analysis of the March 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund; Commonwealth Fund analysis of Affordable Care Act (Public Law 111 -148 and 111 -152).

Exhibit 10. Most of the 18. 8 Million Currently Uninsured Women Ages 19 -64

Exhibit 10. Most of the 18. 8 Million Currently Uninsured Women Ages 19 -64 Will Gain Coverage Beginning in 2014 Medicaid 9. 5 million 51% Subsidized Private Insurance with Consumer Protections 7. 5 million 40% Non-Subsidized Private Insurance with Consumer Protections 1. 8 million 10% 18. 8 Million Uninsured Women Ages 19 -64 in 2009 Note: Percentages may not sum to 100 due to rounding. Source: Analysis of the March 2010 Current Population Survey by N. Tilipman and B. Sampat of Columbia University for The Commonwealth Fund THE COMMONWEALTH FUND

Exhibit 11. Women Ages 19 -64 in 16 States With Uninsured Rates Higher Than

Exhibit 11. Women Ages 19 -64 in 16 States With Uninsured Rates Higher Than the National Average Will Particularly Benefit From the Health Reform Law AK 21. 7% NH WA VT MT ND MN OR ID 20. 2% NY WI SD WY MI PA IA NE NV 22. 9% OH IL UT CO CA MO KS IN WV 21. 0% VA NJ MA RI CT DE MD DC KY 21. 0% 22. 7% NC 20. 2% OK AZ 21. 3% HI ME NM 20. 7% TN AR 24. 9% 27. 6% SC MS 21. 7% TX 30. 8% LA 23. 7% AL GA 22. 7% FL 26. 0% States with uninsured rate higher than national average of 20%, women ages 19 -64, 2008 -2009 THE COMMONWEALTH FUND Note: Uninsured rates are two-year averages, 2008 -2009. Source: Health Insurance Coverage of Women 19– 64, states (2008– 2009), Kaiser Family Foundation, statehealthfacts. org. Estimates based on the Census Bureau's March 2009 and 2010 Current Population Survey