Health Reform 101 the Road Ahead for Healthcare in Utah

Health Reform 101 The Road Ahead for Healthcare in Utah

A presentation by the Utah Health Policy Project (UHPP) Who is UHPP?

Utah Health Policy Project is a non-profit, non-partisan organization advancing sustainable health care solutions for underserved Utahns, through better access, education, and public policy

www.healthpolicyproject.org

@UHPP

www.facebook.com/uthpp What we’ll talk about…

• About the Affordable Care Act (U.S. and Utah) • Inside Utah’s insurance marketplaces • How ACA premium subsidies work • How to access enrollment assistance • Looking ahead to 2015 Key Terms State/Federal health insurance for low-income kids, pregnant Medicaid women, seniors, and people with disabilities

State/Federal health CHIP insurance for kids

Federal health insurance for Medicare senior citizens (ages 65+)

Photo Source: jaime22; Albuquerque Public Schools Key Terms

ACA or Private insurance plans Obamacare sold on healthcare.gov Insurance with monthly premiums subsidized for some people

A few more terms…

Premium Monthly payments for health insurance Point-of-service cost for an office visit or a Co-pays prescription drug

Co-insurance / Share of costs (usually a percentage, like Cost-sharing 20%) for an office visit or procedure Deductible Medical expenses paid out-of-pocket before an insurer will pay any costs

Out-of-pocket Max payments you make during a year maximum before your insurance pays 100% of covered benefits Insurance is sold in three markets

Private An individual or family policy purchases a policy directly from a private insurance company

Small group Employer-based insurance often subsidized by the company for employees and their dependents

Self-insured / Self-funded A group health plan in which the employer assumes risk for providing health care benefits to employees The Affordable Care Act (ACA) Also called Obamacare • Initial enrollment period: October 1, 2013 – March 31, 2014 • Special enrollment period (SEP) lasts from April 1, 2014 to November 14, 2014

Next Enrollment Period (for 2015): November 15 2014 – February 15, 2015 How the ACA changed healthcare

29.0% Utah Adults Uninsured under age 26 Rate Ages 18-26: can stay on No lifetime caps on their parents 18.4% insurance payments insurance plan 2010 2013

Insurance offers free preventative care like blood pressure checks, flu shots, and health screenings

No one can be denied or Men and women pay priced out of coverage for a the same for coverage pre-existing condition How the marketplaces work in Utah

Utah’s Split Model

Federal State

Individual & Families Small Business Marketplace Marketplace ACA across the nation

State Decisions1 18: State-run 7: Partnership 26: Federal

[1] http://kff.org/health-reform/state-indicator/health-insurance-exchanges/#map ; accessed 5/16/13) 84,601 Utahns signed up for coverage on healthcare.gov October 1, 2013 – April 19, 2014

84,601

by October 31 by November 30 by December 28 by February 1 by March 1 39,902 by April 19

Source: HHS/CMS Health Insurance Marketplace – March Enrollment Report For the period: October 1, 2013 – April 19, 2014 How does the ACA affect you?

Large company No changes to coverage Self-insured

Small company Policies must cover 10 Carrier insurance 85% essential health benefits

Senior citizen Prescription drug “donut hole” On Medicare gone by 2020

Lost job / Part-time job Uninsured Eligible to use the new insurance marketplaces to: Small business / Self employed 15% 1) Shop for coverage No or bad insurance 2) Qualify for Medicaid Young people 3) Receive tax credits Uninsured Utah has a higher percentage of employer- based coverage than the national average Coverage status for all residents

49% Employer-based 59% Employer-based

Source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2012 and 2013 Current Population Survey (CPS: Annual Social and Economic Supplements (http://kff.org/other/state-indicator/total-population/) www.healthcare.gov What is the marketplace like?

Shopping for breakfast cereal… All plans will have essential benefits

1. Ambulatory (ie. out-patient) services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including dental and vision care Adult dental and vision can be purchased as extras

Source: http://cciio.cms.gov/resources/factsheets/ehb-2-20-2013.html How can premium prices vary?

(in billions) 1) Age (new ratio of 3 to 1) 2) Tobacco use (ratio of 1.5 to 1) 3) Geography (by counties)

Area 1: Cache and Rich Area 2: Box Elder, Morgan, and Weber Area 3: Davis, Salt Lake, Summit, Tooele, and Wasatch Area 4: Utah Area 5: Iron and Washington Area 6: Beaver, Carbon, Daggett, Duchesne, Emery, Garfield, Grand, Juab, Kane, Millard, Piute, San Juan, Sanpete, Sevier, Uintah, and Wayne Insurance costs will differ by “metal tier”

80% 90% 70% 60% <60%

Catastrophic Bronze Silver Gold Platinum

Lower Premiums Higher Premiums

Higher cost-sharing Lower cost-sharing Salt Lake County’s marketplace Medical Altius Health Plans Arches BridgeSpan 91 plans Humana Molina Healthcare Select Health

1 plan 24 plans 34 plans 26 plans 6 plans

Source: https://https://insurance.utah.gov/health/Health%20Refrom/ACA_Rate_Individual_20131007_OnExchange.pdf Utah Individual on Exchange Rates - Medical Plans - Non-smoker Rates for plans currently approved (10/072013) Utah’s 2014 premiums were among the lowest in the country $ Lowest-cost silver premium for a 40-year-old person

$171 $154 $166 $164 $173 $181 $167 $180

Source: “The 10 Least Expensive Health Insurance Markets In The U.S. “ Kaiser Health News, February 13, 2014 Note: Results based on lowest-cost silver premium for a 40-year-old person Salt Lake County Premiums on Healthcare.gov

Lowest monthly premiums by age and plan level

Rates apply to:

• Single person • Salt Lake County resident • Non-smoker $248 $162

Age in years

Source: https://insurance.utah.gov/health/Health%20Refrom/ACA_Rate_Individual_20131007_OnExchange.pdf Utah Individual on Exchange Rates - Medical Plans - Non-smoker Rates for plans currently approved (10/7/2013) These are the 2014 premiums…

Most expensive monthly premiums by age and plan level

Rates apply to: • Single person • Salt Lake County resident • Non-smoker $389 $254

Age in years

$400

$350

$300

$250

$200

$150

$100

Beaver, Duschene, Carbon, Davis, Cache, Summit, Box Elder, Iron, Weber Utah Millard, Garfield, Daggett, Salt Lake Rich Tooele, Morgan Washing Piute, San Juab, Emery, Wasatch -ton Juan, Sevier Sanpete, Grand, Uintah Kane Cost for Benchmark Silver-level Plan 20-years old 30-years old 40-years old 55-years old

(in billions)

After 2014, 270,000 Utahns will be eligible for premium subsidies

[1] “Help is at Hand: Health Insurance Tax Credits for Utah,” Families USA, based on analysis by the Lewin Group, April 2013 Who is eligible for premium subsidies?

Income as % of the Federal Poverty Level (FPL) 0% 100% 101% 400%

57,000 Utahns NO in the Gap YES 2015: Who is eligible for premium subsidies?

+$180 +$720

+$300 +$1200

For 2015, a family of four can earn up to $95,400 a year and receive a premium subsidy

Source: For Lower 48 States; 2014 Health and Human Services, http://www.placerwest.com/2014-FPL-chart.pdf Joe Ute Income: $18,000 Residence: Salt Lake City, Utah Age: 25

Annual income: $18,000 % of poverty level: 157% Expected contribution: 4.31% of income

Monthly premium: $184 Benchmark Subsidy pays: $119 per month Silver Plan Joe Ute pays: $65 per month

Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: Kaplan International The Hernandez Family Income: $26,000 Residence: Salt Lake City, Utah Ages: Dad : 33 Mom: 29 Kids: 5, 3

Annual income: $26,000 % of poverty level: 110% Expected contribution: 2% of income

Monthly premium (for 2): $393 Benchmark Subsidy pays: $350 per month Silver Plan The Hernandez's pay: $43 per month

Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: CBPP The Shumways Income: $44,000 Residence: Draper, Utah Ages: Dad : 24 Mom: 23 Kid: On the way

Annual income: $44,000 % of poverty level: 225% Expected contribution: 7.18% of income

Monthly premium: $438 Benchmark Silver Plan Subsidy pays: $175 per month The Shumway’s pay: $264 per month

Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: JohnCropper Mr. and Mrs. Smith Income: $42,000 Residence: Sandy, Utah Ages: 60, 62

Annual income: $42,000 % of poverty level: 271% Expected contribution: 8.65% of income

Monthly premium: $849 Benchmark Subsidy pays: $546 per month Silver Plan The Smith’s pay: $303 per month

Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: Creative Commons Find out how much you would pay…

Healthcare.gov

www.healthcare.gov/find-premium-estimates

Kaiser Family Foundation kff.org/interactive/subsidy-calculator/ 87% of Utahns qualified for premium subsidies October 1, 2013 – April 19, 2014

Source: HHS/CMS Health Insurance Marketplace – March Enrollment Report For the period: October 1, 2013 – April 19, 2014 64% of Utahns received $50 or more in monthly subsidies to purchase insurance

Source: ASPE Premium Affordability, Competition, and Choice In the Health Insurance Marketplace, 2014 (6/18/14) The new enrollment calendar

We Are Here 2014 Open Special Open Enrollment Enrollment Enrollment

JANUARY 1 APRIL 1 NOVEMBER 15

2015

Open Special Open Enrollment Enrollment Enrollment

JANUARY 1 FEBRUARY 16 NOVEMBER 15 What happens if you need coverage now?

Qualify for a • Sign up for ACA insurance on Special healthcare.gov Enrollment • Could be eligible for subsidies Period (SEP)

• Apply for Medicaid (if eligible) • Apply for Utah’s Primary Care No Special Network (PCN) (if eligible) Enrollment • Purchase non-ACA coverage direct Period (SEP) from insurer • Wait for November 15, 2014 • Pay tax fine (if required)

What is a Qualifying Life Event? It triggers a Special Enrollment Period • Marriage • Having a baby • Adopting a child or placing a child for adoption or foster care • Moving outside your insurer’s coverage area • Losing other insurance due to loss of job, divorce, the end of an individual policy, COBRA expiration • Aging off a parent’s plan (at age 26), losing eligibility for Medicaid or CHIP, and similar circumstances. • Gaining citizenship • Leaving incarceration • Gaining status as member of an Indian tribe.

Source: healthcare.gov ; https://www.healthcare.gov/sep-list/ What is a Qualifying Life Event?

• Getting sick • Forgetting to sign up for insurance before March 31, 2014 • Voluntarily ending insurance coverage • Losing coverage that doesn’t qualify as minimum essential coverage under the ACA What ACA enrollment looks like Who are the navigators?

Navigators are…

…people trained to help others evaluate their insurance options on the new insurance marketplaces… Who are the helpers? Navigator

Certified Application Counselor Experts trained to help others evaluate their insurance options on the new insurance marketplace. Anti- Health poverty Clinics groups Salt Lake County: Outreach to other counties, grants AUCH UHPP Administration, Outreach, Legal enrollment, education, policy primary care service interface, hub access support groups points 2-1-1 / UWSL Office of Health Call center, point of Disparities (engage entry, enrollment CBOs serving Library communities of color) Networks Refugee Other Assistance statewide networks networks Where can Utahns find help?

www.takecareutah.org Where can Utahns find help?

Dial 2-1-1 Where can Utahns find help?

Community Health Clinics

www.auch.org Association of Utah Community Health Where can I get help? Insurance brokers

www.utah.gov/agent- search/search.html www.utah.gov

Brokers are trained and certified to help individuals and businesses with enrollment Getting the message out: Get Covered Looking ahead to 2015 Challenges in 2015

• Shorter (3-month) enrollment period • Potential ACA consumers didn’t sign up the first time • No solution for coverage gap population • Utah’s uninsured rate above national average • Heathcare.gov glitches will continue • Auto-renewal process is complicated 2015 Enrollment Targets

Utahns who need to renew their ACA insurance

Utahns who are under- insured or uninsured

Branding Take Care Utah and Enrollment Medicaid Expansion in Utah 383,000 Utahns received Medicaid in 2013

• Medicaid in Utah provides health insurance primarily to children, pregnant women, and disabled adults • Utah adults without children aren’t eligible for Medicaid at any income level

Source: Utah Dept. of Health 2013 Medicaid Report; http://health.utah.gov/medicaid/stplan/LegReports/MedicaidAnnualReport_2013.pdf

Why we are here…

ACA in 2010 ACA in 2012

0% 133% 400% 0% 100% 101% 400%

Income as % of the Federal Poverty Level Income as % of the Federal Poverty Level In June 2012, the Supreme Court declared Medicaid expansion optional for states. Utah is among 24 states that have not expanded coverage Who falls in the coverage gap?

Parents Annual income for a family of three

50% 400% 0% FPL Medicaid Coverage Gap 100% ACA Tax Credits FPL FPL FPL

$0 Annual Income $9,765 $19,530 $78,120

Adults without kids Annual income for a single adult

100% 400% 0% FPL Coverage Gap FPL ACA Tax Credits FPL

$0 Annual Income $11,490 $45,960 Where states stand on Medicaid Expansion

Considering Expansion: Utah; Missouri; Indiana

Source: The Advisory Board Daily Briefing (8/28/14) ; http://www.advisory.com/daily-briefing/resources/primers/medicaidmap The latest news…

September 9, 2014 The latest analysis…

“[T]he best-case scenario is that the Healthy Utah Plan will be debated and voted on during a special legislative session, or more likely during the 2015 Legislative General Session that begins in late January.

But we all know that best-case- scenarios rarely happen. Especially in Utah. Especially in the state legislature.” Want to learn more?

Call or email UHPP to schedule a presentation just like this one Jason Stevenson Education and Communications Director cell. 617-290-8188 work. 801-433-2299 ext. 7 [email protected] Helpful Resources Where @sarahkliff http://www.vox.com to learn more @JeffreyYoung_HC www.huffingtonpost.com/jeffrey-young

@JasonMillman http://www.washingtonpost.com/blogs/wonkblog/ @ddiamond http://www.forbes.com/sites/dandiamond/ www.kaiserhealthnews.org

www.takecareutah.org

www.heathcare.gov How the ACA is funded: Cuts (in billions) Total: $741 billion [2013-2022] Uncompensated care Other for hospitals (DSH) $114 $56 Medicare / Medicaid payment $415 $156 rates Medicare Advantage

[Chart] CBO / Washington Post Wonkblog http://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/30/how-congress-paid-for-obamacare-in-two-charts// How the ACA is funded: Taxes (in billions) Total: $893 billion [2013-2022]

Medical devices tax Penalties (individuals) $87 $55 Penalties (employers) $106 High-earners ‘Cadillac’ capital gains taxes $111 health plans $318 $216 Cost-savings

[Chart] CBO / Washington Post Wonkblog http://www.washingtonpost.com/blogs/wonkblog/wp/2012/08/30/how-congress-paid-for-obamacare-in-two-charts// What are the penalties for remaining uninsured in 2014?

$95/adult, $325/adult $695/adult $47.50/child $162.50/child $347.50/child

Max per family $285 $975 $2,085

[Chart] Kaiser Family Foundation 2014 Premiums* by Age: Salt Lake County

Age

Age Age

Age

(*) Before premium subsidies Source: [2014] https://insurance.utah.gov/health/Health%20Refrom/ACA_Rate_Individual_20131007_OnExchange.pdf Utah Individual on Exchange Rates - Medical Plans - Non-smoker Rates for plans currently approved (10/7/2013) Which post-tax income is counted as MAGI? Yes No • Wages, salaries, tips, etc. • Veterans’ disability payments, • Taxable interest (1099-INT) • Workers’ compensation • Ordinary dividends (1099-DIV) • Child support received • Taxable amount of pension, annuity or • Self-employed expenses IRA distribution (1099-R) and Social • Student loan interest Security benefits (SSDI but not SSI) • IRA deduction (trad. IRAs) • Business income, farm income, capital • Moving expenses gain or loss • Penalty on early withdrawal of • Unemployment compensation savings • Alimony • Health savings account ded. • Rental real estate, royalties, • Alimony paid partnerships, S corporations, trusts, • Domestic prod. activities ded. Taxable refunds • Certain business expenses of • Other miscellaneous income reservists, performing artists, and fee-basis gov’t officials

Source: http://laborcenter.berkeley.edu/pdf/2013/MAGI_summary13.pdf How do I calculate my MAGI? (in billions) Step #1) Start with gross income (GI) Your adjusted gross income is the money you earned through wages, interests, dividends, rental and royalty income, capital gains, business income, farm income, unemployment and alimony.

Step #2) Calculate Adjusted Gross Income (AGI) by subtracting qualified deductions from gross income. AGI is used to determine your tax liability Adjustments can include items like some contributions to IRAs, moving expenses, alimony paid, self-employment taxes, and student loan interest.

Source: Zane Benefits - http://www.zanebenefits.com/blog/bid/271272/How-Do-I-Calculate-My-Health-Insurance-Tax-...2 How do I calculate my MAGI? (in billions) Step #3) Add back items excluded from AGI • Deductions for IRA contributions. • Deductions for student loan interest or tuition. • Excluded foreign income. • Interest from EE (employee) savings bonds used to pay higher education expenses. • Employer-paid adoption expenses.

Step #4) The result is your Modified Adjusted Gross Income (MAGI) – used to calculate eligibility for premium subsidies on the new insurance marketplaces For most people, MAGI is the same as AGI.

Source: Zane Benefits - http://www.zanebenefits.com/blog/bid/271272/How-Do-I-Calculate-My-Health-Insurance-Tax-...2 Small Business Focus for Utah Which Utah firms offer insurance?

# Employees: % Offer insurance <10 employees 31.2% 10-24 employees 56.5% >50 employees 92.9%

42% of Utah’s 67,000 small businesses are in SL County

Agency for Healthcare Research and Quality, Center for Financing Access, and Cost Trends. 2008 What worries small businesses?

Cost is the #1 reason they don’t offer coverage

UHPP/SBM Utah Small Business Healthcare Survey, 2009 What ACA does for small businesses • Tax credits • Shared risk allows more stable premiums and lower costs • More level playing field (hiring, cost, entrepreneurship) with large businesses • Employees at firms <50 FTE can get coverage on the individual marketplace—or Medicaid How does the ACA affect me?

Less than No mandate or penalties 50 employees Eligible for tax credits (FTEs)

More than Mandate or penalties if 50 employees firm offers no insurance or (FTEs) inadequate insurance (starting in 2015)

76% of Utah firms employ 50 or fewer employees

Agency for Healthcare Research and Quality, Center for Financing Access, and Cost Trends. 2008 How do I calculate 50 FTE?

• FTEs are calculated by summing the hours of full, part- time, and seasonal workers. For example, two PT employees are equivalent to one FT employee • Example: 40 full-time employees (30h/week = 40 FTE 20 half-time employees (15h/week = 10 FTE Total = 50 FTE

• A full-time employee is defined as working an average of at least 30 hours a week or 130 hours in a month. What timeframe do I use?

• Employers have a choice of calculating FTE by averaging the full twelve (12) months of the year, or by looking at a six (6) consecutive month period during the year (starting in 2013) • To calculate FTE in a given month, employers must add all the hours worked (up to 120 hours per employee) and divide the total by 120 • If an employer has at least 50 FTEs for 2013, it will be considered a large employer for 2014 What are the employer penalties?

Businesses with 51 or more FTE $2,000 employees who do not offer coverage to full-time workers (penalty excludes first 30 employees) Businesses with 51 or more FTE $3,000 employees who offer coverage but have at least one FTE get a subsidy in the individual marketplace

Note: For an insured employee to access the Utah marketplace, the employee’s contribution to the lowest-cost single-person plan must be 1) more than 9.5 percent of family income, or 2) the actuarial value of the plan must be below 60 percent What are the employer penalties?

Businesses with 51 or more FTE $2,000 employees who do not offer coverage to full-time workers (penalty excludes first 30 employees)

Example A firm with 61 workers that does not offer coverage would pay an amount equal to 61 minus 30, or 31, times the applicable per- employee payment amount What are the employer penalties?

Businesses with 51 or more FTE $3,000 employees who offer coverage but have at least one FTE get a subsidy in the individual exchange

Note For an employee to receive a subsidy on the individual exchange, the employee’s contribution to the lowest-cost single plan must be more than 9.5 percent of family income or the actuarial value of the plan must be below 60 percent The ACA and Employer Penalties

(in billions)

[Chart] http://www.thebenefitsfirm.com/healthcare-reform-resources/ Health Reform and Utah Senior Citizens What the ACA does for Medicare • Closes the “doughnut hole” in Medicare prescription drug coverage by 2020 • Adds annual “wellness visits” plus free screenings for diabetes and cancer • No cuts to benefits or changes guaranteed by Medicare • Puts Medicare on a more solid financial footing • Reins in Medicare Advantage plans while protecting plan members What is the Medicare doughnut hole? • Before the ACA, seniors paid 100% of drug costs while in the “Doughnut Hole” between Initial

Coverage and Catastrophic Coverage

2010 100% 25% 100% 5% What seniors pay…

Deductible Doughnut hole

Initial Catastrophic What is the Medicare doughnut hole?

• After 2020, seniors will be responsible for only 25% of drug costs before Catastrophic

Coverage kicks in

2020 100% 25% 5%

What seniors pay…

Deductible Doughnut hole

Initial Catastrophic Life after the doughnut hole…

• The ACA will eliminate the “doughnut hole” by the year 2020. • After 2020, seniors will be responsible for only 25% of drug costs before Catastrophic Coverage kicks in • After a senior qualifies for Catastrophic Coverage, they are responsible for 5% of their prescription drug costs for the rest of the year

AARP’s Doughnut Hole Calculator www.aarp.org/doughnuthole Why cut Medicare Advantage rates?

• By 2010, Medicare Advantage per-patient costs were 117% more than traditional Medicare

• Federal subsidies for Medicare Advantage plans ($14 billion in 2011) will gradually be reduced until payments are in line with traditional Medicare Health Reform for Refugees and Immigrants What the ACA does for refugees

“Refugees, as lawfully present immigrants, are eligible for the same protections and benefits under the Affordable Care Act as U.S. citizens…”

Office of Refugee Resettlement, U.S. Dept. of Health and Human Services, 10/15/10) Refugees will be able to…

• Remain exempt from the 5-year waiting period for Medicaid and Children’s Health Insurance Program (CHIP) • Eligible to purchase health insurance on Utah’s Insurance marketplaces beginning in October 2013 • Able to qualify for premium tax credits to purchase insurance • Keep their current private health insurance plan and doctor if they are satisfied with their current care Who is eligible for premium subsidies?

Income as % of the Federal Poverty Level (FPL) 0% 100% 101% 400%

NO YES Who are the exceptions? Legal Permanent Residents (LPRs) in U.S. less than 5 years

0% 100% 101% 400% LPRs

LPRs income is “bumped up” to 101% FPL to receive premium subsidies YES Income Boost for LPRs in U.S. less than 5 Years

U.S. Citizens and Refugees 0% 100% 101% 400% No Subsidies Receive Premium Subsidies Income as % of the Federal Poverty Level (FPL)

Legal Permanent Residents (< 5 years) 101% 0% 100% Receive Premium Subsidies 400%

LPRs income gets “bumped” to 101% FPL to qualify for premium subsidies on marketplace The Nga Family Income: $23,000 Residence: West Valley City, Utah Ages: Dad : 29 Mom: 27 Kid: 5

Annual income: $23,000 % of poverty level: 118% Expected contribution: 2% of income

Monthly premium (for 2): $393 Benchmark Subsidy pays: $318 per month Silver Plan The Nga’s pay: $74 per month

Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: Danny Guy The Pradhans Income: $28,000 Residence: South Salt Lake, Utah Ages: Dad : 35 Mom: 31 Kids: 5, 1

Annual income: $19,000 % of poverty level: 81% “Bumped up” to 101% 101%

Monthly premium: $617 Benchmark Silver Plan Subsidy pays: $577 per month The Pradhan’s pay: $40 per month

Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: CWS Greensboro The Sulemans Income: $12,000 Residence: South Salt Lake, Utah Ages: Dad : 32 Mom: 32 Child: 11

Annual income: $12,000 % of poverty level: 61%

Monthly premium: $393 The Suleman’s are in the Medicaid “coverage gap” and are ineligible for premium subsidies to buy insurance on healthcare.gov Source: Kaiser Family Foundation Subsidy Calculator; http://kff.org/interactive/subsidy-calculator; Image source: UNHCR Who is affected by the insurance mandate? • All “lawfully-present” immigrants – including refugees, green card-holders, lawful permanent residents, and recipients of valid student and temporary work visas will be able to purchase insurance on the new insurance marketplaces and receive subsidies • Anyone “lawfully-present” will also be subject to the mandate to have insurance (with exceptions for people with low incomes)

• Undocumented immigrants cannot purchase insurance through the marketplaces. Plus, they are not eligible for any tax credits, or for Medicaid and CHIP in most cases

Source: National Immigration Law Center; http://www.nilc.org/immigrantshcr.html#great/ ; Testimony of Gary Cohen (CCIIIO/CMS, 8/7/13) These statuses will qualify for marketplace coverage • Lawful Permanent Resident (LPR/Green Card holder) • Asylee • Refugee Find this list here: • Cuban/Haitian Entrant www.healthcare.gov/immigration- • Paroled into the U.S. status-and-the-marketplace/ • Battered Spouse, Child and Parent • Conditional Entrant Granted before 1980 • Victim of Trafficking and his/her Spouse, Child, Sibling or Parent • Granted Withholding of Deportation or Withholding of Removal, under the immigration laws or under the Convention against Torture (CAT) • Individual with Non-immigrant Status (includes worker visas, student visas, and citizens of Micronesia, the Marshall Islands, and Palau) • Temporary Protected Status (TPS) • Deferred Enforced Departure (DED) • Lawful Temporary Resident • Administrative order staying removal issued by the Dept. of Homeland Security • Member of a federally-recognized Indian tribe (or American Indian Born in Canada) • Resident of American Samoa Source: https://www.healthcare.gov/immigration-status-and-the-marketplace/ Documentation to prove immigration status Immigrants must -Permanent Resident Card, “Green Card” (I-551) -Reentry Permit (I-327) -Refugee Travel Document (I-571) verify their status -Employment Authorization Card (I-766) -Machine Readable Immigrant Visa (with temporary before using the I-551 language) -Temporary I-551 Stamp (on passport or I-94/I-94A) -Arrival/Departure Record (I-94/I-94A) marketplace -Arrival/Departure Record in foreign passport (I-94) -Foreign Passport -Certificate of Eligibility for Nonimmigrant Student Status (I-20) -Certificate of Eligibility for Exchange Visitor Status (DS2019) -Notice of Action (I-797) -Document indicating membership in a federally recognized Indian tribe or American Indian born in Canada -Certification from U.S. Department of Health and - Human Services (HHS) Office of Refugee Resettlement (ORR) -Office of Refugee Resettlement (ORR) eligibility letter (if under 18) -Document indicating withholding of removal -Administrative order staying removal issued by the Department of Homeland Security -Alien number or 1-94 number

Source: https://www.healthcare.gov/immigration-status-and-the-marketplace/ Deferred Action Status is not an eligible category

• Undocumented immigrants with Deferred Action Status (ie. Deferred Action for Childhood Arrivals (DACA) are not eligible to apply for health insurance on the marketplace, or receive premium subsidies

Sources: https://www.healthcare.gov/immigration-status-and-the-marketplace/; http://www.nilc.org/acadacafaq.html What’s inside Senate Bill 744 • Undocumented immigrants granted RPI (Registered Provisional Immigrant), blue-card (agricultural), or V-nonimmigrant-visa status can buy private health insurance at full cost through insurance marketplaces

• During 10 years of provisional status, they aren’t eligible for the ACA’s premium tax credits and cost-sharing reductions. They will also be excluded from the ACA’s mandate to have health insurance (as well as the penalty)

• Immigrants will remain eligible for employer-sponsored health insurance if it is offered by their employer

Source: National Immigration Law Center (http://nilc.org/irsenate2013.html) Thought Slides

(in billions) Support for the ACA has never exceeded 51%

September 2014: 35% Favorable

Source: Kaiser Family Foundation Health Tracking Polls; http://kff.org/health-reform/poll-finding/kaiser-health-tracking-poll-august-september-2014/ Employment Status and Coverage Status Are Linked in Utah

Utah Uninsured Rate Utah Unemployment Rate Great Recession

Sources: [Uninsured] Utah Healthcare Access Survey (UHAS) (2003-08); Utah Behavioral Risk Factor Surveillance System (BRFSS) (2009-13); http://health.utah.gov/opha/publications/2013brfss/Highlights_2013.pdf; [Unemployed] http://www.dlt.ri.gov/lmi/laus/us/annavg.htm; https://jobs.utah.gov/wi/pubs/em/annualreport/10annual/table31.pdf How much will Utah’s uninsured rate drop?

U.S. uninsured rate is down 21% since 4Q 2013

Sources: (1) Utah Healthcare Access Survey (UHAS) (2003-08); Utah Behavioral Risk Factor Surveillance System (BRFSS) (2009-13); (2) U.S. Census Bureau/SAHIE (2006-12); (3) Gallup-Healthways Well-Being Index (2008-14) The CBO forecasts the ACA will cost $104B less by FY 2024 (in billions)

Source: CBO/ Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April 2014; http://www.cbo.gov/publication/45231