Women's Health and the Affordable Care Act: Impact and Benefits

1. 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

2. Exhibit 1. 18.8 Million Uninsured Women Ages 19-64 in 2009,Up by 2Million in Last Year Millions uninsured, women ages 19-64 Source: Analysis of the 2001–2010 Current Population Surveys by N. Tilipman and B. Sampatof Columbia University for The Commonwealth Fund.

3. Small business tax credit • Prohibitions against lifetime benefit caps & rescissions • Phased-in ban on annual limits • Annual review of premium increases • Public reporting by insurers on share of premiums spent on non-medical costs • Preventive services coverage without cost-sharing • Young adults on parents’ plans Exhibit 2. Timeline for ACA Implementation • 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 • Premium and cost sharing credits for exchange plans • Premium increases a criteria for carrier exchange participation • Individual requirement to have insurance • Employer shared responsibility penalties • Phased-in ban on annual limits • States adopt exchange legislation and begin implementing exchanges • Penalty for individual requirement to have insurance phases in (2014-2016) • Option for state waiver to design alternative coverage programs (2017) • Insurers must spend at least 85% of premiums (large group) or 80% (small group / individual) on medical costs or provide rebates to enrollees • HHS must determine if states will have operational exchanges by 2014; if not, HHS will operate them 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/Health-Reform-Resource.aspx.

4. Exhibit 3. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2019 23 M (8%) Uninsured 24 M (9%) Exchanges (Private Plans) 54 M (19%) Uninsured 16 M (6%) Other 16 M (6%) Other 162 M (57%) ESI 159 M (56%) ESI 10 M (4%) Nongroup 15 M (5%) Nongroup 35 M (12%) Medicaid 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.

5. 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 those most likely to. 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/Health-Reform-Resource.aspx.

6. 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 133-250% poverty • Essential health benefit standards that include maternity and newborn care and limits on cost-sharing for plans sold in insurance exchanges and the in 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 111-148 and 111-152), www.commonwealthfund.org/Health-Reform/Health-Reform-Resource.aspx.

7. 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

8. 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.

9. 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.

10. 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 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; Commonwealth Fund analysis of Affordable Care Act (Public Law 111-148 and 111-152).

11. Exhibit 10. Most of the 18.8 Million Currently Uninsured Women Ages 19-64 Will Gain Coverage Beginning in 2014 Subsidized Private Insurance with Consumer Protections 7.5 million 40% Medicaid 9.5 million 51% 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

12. 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 ME MT ND MN OR NY ID 20.2% WI MA SD WY MI RI PA CT IA NJ NE OH DE NV 22.9% IL IN WV 21.0% MD UT VA CO DC CA 22.7% MO KS KY 21.0% NC 20.2% TN OK 20.7% AR 24.9% SC AZ 21.3% NM 27.6% MS 21.7% GA 22.7% AL HI LA 23.7% TX 30.8% FL 26.0% States with uninsured rate higher than national average of 20%, women ages 19-64, 2008-2009 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