ACA Implementation in CA Some Implications

Transcription

1 ACA Implementation in CA Some Implications Albert Lowey-Ball Health Economics and Medicaid Advisor, California Program on Access to Care, UC Berkeley School of Public Health President, Albert Lowey-Ball Associates, Inc. (ALBA) Health Economics Consultants (916) (510) Presentation, NoCA HIMSS Court-Yard Marriott, Sacramento, CA February 3, 2014

2 ACA Implementation:Topic Overview ACA Implementation in US: Shaky, Weak HIT, Challenges with the Single Portal Underenrollment Many States Without Medicaid Expansion Enrollment Growing Now ACA Implementation in CA: Ragged Start, But Getting Much Better. Relatively Stronger HIT and Functional Single Portal Considered a Success: Good on Enrollment, Best in US Both CoveredCA and Medicaid (Medi-Cal) Growing Fast Still Some Glitches Impacts on Health Plan, Provider and Hospital-Health System Markets Some HIT Implications

3 Personal Background Experience as Health Economist and Managed Care Consultant Public Agencies, Health Plans, Medical Groups, Hospital Systems, Start-Up ACOs, TelehealthFirms, Health Economics Consulting Firms Economic Analyses, Forecasts, Rate Development, Regulatory Compliance, Administrative Support, California Health Care Marketplace As Health Economics and Medicaid Advisor at CPAC/SPH/UC Berkeley Focus on Economics of ACA Implementation and Medicaid Expansion Access to Care, Medi-Cal Managed Care and Insurance Coverage Former Managed Care Consultant to CSC, EDS-HP, and ACS-Xerox Helped Establish Several Health Plans, Medicaid Managed Care Plans and Medical Groups, Including the Santa Barbara Health Initiative (CenCalHealth) and Care 1st

4 What ACA Is Supposed to Do-I Overall Goal: Near Universal Coverage Protect Consumers: MLR, Guarantee Issue, No Adverse Selection Reduce Personal Costs to Consumers Enhance Population Health CA: Full Speed Ahead

5 What ACA is Supposed to Do-II Possible Rate Review and (Maybe) Rate Regulation Expand Coverage: Individuals, Medicaid (Medi-Cal), Small Business Increase Access and Efficiency: HIT, Delivery System Reform, and (Maybe) Innovation Prevention: Improve Health Status of the Population Over Medium-Term, Contain Costs to Individuals, Businesses and Governments Maybe Preserves Private Market in Health Care, Maintains Consumer Choice, Employer Choice, Maybe {Does not Cover Undocumented Immigrants}

6 Covered California (CoveredCA) Organizational Features Strong Executive Leadership Support From Administration and Legislature Engaged and Knowledgeable Board of Directors Established Linkages With State Agencies Determined Essential Health Benefits (EHB) and Optional Benefits Packages Set Up the Data System (CalHEERS) and the Single Portal Designated Qualified Health Plans (QHPs), Terms and Conditions, Negotiated Rates Expanded Infrastructure and Staff (Over 1,000 Staff), Service Centers and County Links Setting Up and Training Assisters, Navigators, CECs, CIAs Established Outreach Networks Started Media Campaigns

7 Eligibility and Market Structures Covered CA s Products: Individual and SHOP Market Two Separate Risk Pools Four Levels: Bronze, Silver, Gold, Platinum, Determined by Coverage Percentages Eligibility for Subsidies Depend on Income Subsidies Vary From 138% FPL to 400% FPL EHBs Establish Minimum Levels of Coverage by Service, To Be Met By All Health Plans Including SI-ERISA QHPs Provide All Services: All Are Managed Care, Prepayment Plans Loose IPA, Tightknit PMG, Staff Models

8 Medi-Cal Component Medi-Cal Expansion Bigger Potentially Than CoveredCA Who: LIHP, CMSP, Almost All Childless Adults, Almost All Males; Healthy Families Transitioned in 2013 CMS Pays For Virtually All EligiblesWith Incomes Less Than 138% FPL Medi-Cal Almost Wholly Managed Care: COHS, LI Mainstream Services Are Capitated, Subcapitated

9 California Market Projections With ACA Implementation PAYER TYPE \ YEAR W/O ACA, 2014 W/ACA, 2014 W/ ACA, 2016 W/ACA, 2019 Employer-Sponsored Insurance Medi-Cal/Medicaid Healthy Families Other Public Covered CA W/ Subsidies Indiv Market W/O Subsidies Uninsured Eligible Uninsured Not Eligible Source: Gerald Kominski, Ken Jacobs, et al., Health Insurance Coverage in California Under the Affordable Care Act, Presentation to the California Health Benefit Exchange, March 22, 2012, Center for Health Policy Research, UCLA, and UC Berkeley Labor Center. CalSIM Model 1.7 Note 1: Population in mlns. Note 2: Over 64 Population excluded. Note 3: Healthy Families Merges with Medi-Cal in Note 4: Employer-Sponsored Insurance attrition is assumed to be modest.

10 Recent Enrollment Targets Market Projections Have Changed Since 2012 Greater Realism About Marketing and Outreach Slower Shift in Employer Health Care Markets Relative Weakness of Mandates and Penalties Recent Projections Individuals 800K-1Mln SHOP 30K-50K Medi-Cal, Mln Can Covered CA Make Those Targets?

11 Where Are We Today? Ragged, Halting Start, October 1, 2013 But Doing Well by December 2 Mln Applications Started CoveredCA Individual, 500K Subsidy, 425K, NonSubsidy, 75K Medi-Cal, 1.1 Mln LIHP, 630K, New Medi-Cal, 584K CoveredCA SHOP, 2155 Insureds, 289 Busineses But 900,000 + Californians Lost Insurance Coverage Some Hospitals, MDs, Clinics Not on Contract

12 Some Concerns Single Portal Often Too Slow, Inefficient, Still a Gap Between Application Starts and Sign-Ups Still a Gap Between Sign-Ups and Premium Payments Not Enough Young People (18-35) Enrolled Not Enough Latinos Enrolled, A Young Relatively Healthy Population Can CoveredCAGo ItAlone After January 2015 Are Networks Too Narrow? Enough MDs Willing to Participate? How Effective Are Links to Federal Systems, Hub? Can CoveredCA Cover Those Who Lost Individual and Employer Coverage? Do Financial Winners Exceed Financial Losers? How Interactive Are Links Between CalHEERSand Health Plan Data Systems? Counties Over-Enrolling Medi-Cal? Will CoveredCA Lead to Inreased Oligopolization of Health Care Markets?

13 Implications For ACO Development CoveredCAPlan Contracting Favors PMGs, IPAs and ACOs MD Entities That Meet System Standards and Quality Benchmarks Will Have Competitive Advantages Rate Structures Will Adjust Eventually For Quality QHPs Must Affirmatively Reach Out to ECPs CMS Sponsoring Innovations Linked to ACOs, Medical Homes

14 Some HIT Implications Great Need For Enhanced Links Among Large HealthCare Data Sets ( Big Data ) HIT at CoveredCA Be Made More Cost Effective and Efficient, The Single Portal Must be Made More Consumer Friendly Links to Federal Data Hub Need to Be Strengthened HIPAA Concerns Must Be Addressed Links Between Health Plan Quality and Enrollment Data and Those at CoveredCA Weak, As Well as Those With Counties EMR/EHR and TeleHealthApplications That Increase Physician/Medical Group Efficiency Will Have a Competitive Advantage

15 For Further Information Contact Albert Lowey-Ball at (916) , President, Albert Lowey-Ball Associates, Inc. (ALBA) Health Economics and Medicaid Advisor California Program on Access to Care UC Berkeley School of Public Health