October 18, 2018 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE UNIVERSAL ACCESS TO CARE WORK GROUP 2018
1 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE AGENDA Welcome, Opening Remarks ……………………..……………………………………………..8:00—8:05am • Representative Salinas, Chair, Work Group
Rhode Island Market Stability Workgroup – Shared Responsibility………………8:05—9:00am • Zachary Sherman, Director, HealthSource, Rhode Island
Work Group Discussion – Shared Responsibility…….…………………………………..9:00—9:20am • Representative Salinas, Chair, Work Group
Medicaid Buy-in: Oregon Policy Goals and Approaches………………………...... 9:20—10:00am • Tim Sweeney & Zachary Goldman, OHA Jesse O’Brien, DCBS, Oliver Droppers, LPRO
Work Group Proposals – Review and Refinement…….………………………………10:15—10:45am • Representative Salinas, Chair, Work Group
Public Comment …………………………………………………………………………….....10:45—11:00am Adjourn……………………………………………………………………………………………………....11:00 am
2 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Today’s Objectives
➢Learn about Rhode Island’s Shared Responsibility Proposal
➢Consider Medicaid Buy-in options A-C • Discuss member feedback and program proposals • Clarify and potentially refine proposals • Summarize key considerations for policy makers ➢ Review and discuss preliminary list of policy concepts and topics identified by work group
3 THE RHODE ISLAND PRESPECTIVE: A PRESENTATION TO THE OREGON UNIVERSAL ACCESS TO CARE WORKGROUP
By HealthSource RI Director Zach Sherman AGENDA
• The Rhode Island Market Stability Workgroup • Why a state Shared Responsibility Payment? • Anticipated Shared Responsibility Payment revenue impact • Q&A
5 RHODE ISLAND MARKET STABILITY WORKGROUP CHARGE
Guiding Principles: Goal: Identify and propose sensible, state-based policy options for 1. Sustain a balanced risk Rhode Island that will be in service pool; to those Principles. 2. Maintain a market that is attractive to carriers, Membership: A diverse group of consumers and providers; stakeholders including all Rhode Island payers, providers, hospital and and medical societies, legislators, 3. Protect coverage gains consumer advocates, nonprofit achieved under the leaders and brokers. Affordable Care Act.
6 WORKGROUP RECOMMENDATIONS
Near-term recommendations: • To secure a 1332 waiver under the ACA to implement a reinsurance program • Garner state authority to regulate Short-Term Limited Duration (STLD) and other limited benefit health plans • Implement a state-based shared responsibility requirement Further work remains, including: • Action to determine how to fund a state reinsurance program and how to best design and implement a shared responsibility requirement
7 REASONS TO CONSIDER A STATE SHARED RESPONSIBILITY PROVISION
A state-level Shared Responsibility Payment would: • Incentivize people to get and stay insured • Help stabilize the risk pool, protect against adverse selection • Generate revenue for affordability programs • Provide data on the uninsured, create outreach opportunities
8 ANTICIPATED SHARED RESPONSIBILITY PAYMENT REVENUE
The Shared Responsibility Payment, as currently structured could generate ~$10.6 M in 2020.
Rhode Island Uninsured Rate RI Shared Responsibility Payment Revenue ($M)
$10.6 $8.6 11.6% $4.3
7.4%
5.7% 2014 2015 2016 4.6% 4.3% Amount is $95/person or $325/person or $695/person or Larger of: 1% of income 2% of income 2.5% of income # RI returns with 23,540 21,320 16,320 penalty 2013 2014 2015 2016 2017 % of RI returns 4.5% 4.0% 3.1% Note: Assumes enrollment/uninsured rate stays at current levels.
9 Sources: U.S. Census; Rhode Island Market Stability Workgroup (10/16/18); Faulkner Consulting Group QUESTIONS?
10 Have questions? Email me at [email protected] or visit www.HealthSourceRI.com/market-stability- workgroup
11 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
STATE-BASED INSURANCE MANDATES:
OREGON CONSIDERATIONS
12 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Data Considerations and Informational Needs - Discussion
13 Source: Oregon Health Insurance Survey 2017 – Summary and Results LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
State-Based Insurance Mandates
Oregon
14 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
State-Based Insurance Mandates
On average, the state mandates would reduce marketplace premiums by 11.8 percent if all states adopted the ACA’s federal individual mandate structure.
15 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Work Group Discussion: State-Based Insurance Mandates 1. Initial reactions to Rhode Island’s state-based shared responsibility proposal? 2. What is your overall impression of state-based insurance mandates? 3. What questions do you have about a state-based insurance mandate in Oregon? ◦ Additional information or analysis to further explore this concept in Oregon? ◦ Penalties and enforcement? 4. Initial thoughts on potential advantages or disadvantages around an ACA-like state-based insurance mandate in Oregon?
16 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
MEDICAID BUY-IN: OREGON CONSIDERATIONS
17 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Oregon Design Considerations • Staff requested non-legislative members respond to a set of questions about their perspectives on Medicaid Buy-in • Members had two weeks to review and submit responses • Eight of the 12 non-legislative members submitted responses • Staff compiled and summarized member responses • Member feedback used to revise initial proposal ‘A,’ (September 20th proposals) • Result: three different buy-in options for a Medicaid Buy-in program offered off the Marketplace without pursuit of a federal 1332 waiver (see Table 1, pgs. 8-9).
18 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Design Proposals
Proposal A Proposal B Improve Access and Affordability: Increase Access and Competition: Contract with CCOs to provide CCOs offer commercial insurance consumers outside of Medicaid product on Marketplace in counties eligibility to purchase insurance with limited carriers (fewer than two product with similar design carriers). consideration to CCO plans. Expand affordable coverage in Oregon Stabilize/Strengthen Individual Market • Reduce monthly premiums, or • Carrier of last resort • Reduce out-of-pocket costs, or • More plans on the marketplace • Enhance benefits or value for given • Increased plan offerings premium (potentially)
19 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Design Proposals
Proposal C Proposal D Strengthen Alignment Between Medicaid Spread coordinated care model: establish and Marketplace: ensure the same provider quality reporting and incentive structures networks are offered in Medicaid and modeled after those in Medicaid and CCOs Marketplace; enhance care continuity. for QHP offerings in Marketplace.
Streamline transitions for consumers Spread Oregon’s Health Care between Medicaid and commercial coverage Transformation (coordinated care model) • CCOs offer plans on the Marketplace • CCO-type plans on the marketplace (individual market) (individual market) • CCOs offer plans to small group market • CCO-like financial incentives on the • Accountability and quality (Triple Aim) marketplace (individual market)
20 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Design Considerations Delivery Model Managed care or fee-for-service Marketplace, Stand Alone, other On or off the Marketplace Determine eligibly by income (FPL), ineligibility for Target population(s) federal coverage, other categories Benefit Coverage More or less generous coverage of benefits More or less consumer out-of-pocket costs including Cost-Sharing monthly premiums, deductibles, and co-pays for services Provider Reimbursement Level of provider reimbursement
Scalability and Financial Model Pilot or statewide Identify federal waiver authorities and impact to Federal and State Considerations current coverage environment Feasibility and Implementation Risk pools, provider and/or carrier participation Considerations 21 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Oregon Design Considerations 1. Policy Goal: Medicaid Buy-in potentially moves Oregon closer to the goal of bringing more Oregonians into a coverage program. 2. Target Population(s): individuals who do not qualify for Medicaid or federal subsidies on the Marketplace. 3. Program Administration: CCOs enroll and administer the program, manage member premiums and provider reimbursement and networks. 4. Benefits: Oregon Health Plan (OHP) for adults including dental and vision.
22 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Oregon Design Considerations 5. Out-of-pocket Costs: no deductibles or co-pays at the point of care with members paying a portion, or all the monthly premiums for coverage. 6. Enrollee Premiums: premiums based on Medicaid per-member, per- month rates paid to CCOs (e.g., ACA adult population with regional adjustments). 7. Provider Reimbursement: rates in Medicaid utilizing existing payment models by CCOs with the goal of deploying value-based payment methodologies.
23 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Data Considerations and Informational Needs - Discussion
24 Source: Oregon Health Insurance Survey 2017 – Summary and Results LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE Comparative PMPM – Illustrative Purposes ONLY 2018 Payment Rate: ACA Monthly PMPM Annual Premium Oregon Health Plan $ 503 $6,031 (*no cost-sharing in OHP) (2018) 1) Rates summarized above are weighted using calendar year 2017 enrollment (using the paid COA) and average maternity cases 2) Rates above do not include the Hospital Reimbursement Adjustment or "pass-through" to hospitals 3) Rates above do not include the 1.5% MCO tax • Benefit package differences between Medicaid and commercial insurance • Provider reimbursement rate differences between CCOs and commercial carriers • Profit/administrative cost differences between CCOs and commercial carriers • Population differences (risks factors, socioeconomic factors, and other differences between ACA Medicaid expansion population and marketplace enrollees) • Utilization differences (primary care utilization vs. specialty care, behavioral health utilization, etc.) • Financial barriers to care / incentives for patients in commercial coverage • Other barriers to access to care in Medicaid population (time, transportation barriers in spite of NEMT benefit, etc)
25 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Comparative PMPM – Illustrative Purposes ONLY
Monthly PMPM Annual Premium
Premiums $390 $4,680 Total Cost: Individual Market Premium + Cost- $550 $6,600 (2017) 1 Sharing Estimated Total Cost for Premiums with $594--$632 $7,128-$7,584 no Cost-Sharing 3 1. Rates are estimated based on 2017 PMPMs for the individual commercial market 2. “Total cost with cost-sharing” includes estimated consumer out-of-pocket spending on covered services. 3. $0 or no cost-sharing is expected to increase utilization which is estimated to increase average costs by 8-15% 4. Individual market estimates with cost-sharing are based on an average actuarial value of approximately 70%, compared to Medicaid which is 100% AV.
26 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Comparative PMPM – Illustrative Purposes ONLY
Monthly PMPM Annual Premium
Oregon Health Plan $ 503 $6,031 (*no cost-sharing in OHP) (2018) Premiums $390 $4,680 Total Cost: Individual Market Premium + Cost- $550 $6,600 (2017) Sharing Estimated Total Cost for Premiums with $594--$632 $7,128-$7,584 no Cost-Sharing 3
27 Medicaid Buy-in Program Offered Off Exchange to provide consumers not eligible for federal and state health LPRO: LEGISLATIVEcoverage toP purchaseOLICY AND directlyR ESEARCHan insuranceO productFFICE administered by CCOs. Option A: Targeted Buy-in Option B: Targeted Buy-in Option C: Broad Buy-in Limited Medicaid Buy-in Limited Medicaid Buy-in Offer Medicaid Buy-in program option targeted to individuals option targeted for individuals off the exchange and allow Overview not eligible for Medicaid or unable to obtain affordable anyone to participate (more federal marketplace subsidies coverage in the individual and Public Option). based on geographic region, small group markets. age, or health status. • Expand coverage to finite • Reduce the number of • Expand coverage by set of groups currently uninsured by creating a promoting enrollment into uninsured (e.g., fill in the new coverage option for plans by potentially gaps) specified set of groups creating an affordable • Improve affordable access currently uninsured (e.g., coverage option to quality care fill in the gaps) • Pay for value and quality • Avoid creating new • Allow potentially healthier using value-based payment products to compete with individuals purchase model(s) Policy Goals plans on Marketplace coverage; improve risk pool • Potentially creates a • Administrative • Improve affordable access pathway to universal simplification by leveraging to quality care coverage by building on key existing insurance design, • Address family-glitch in elements of Oregon’s organizations, providers Oregon coordinated care model networks and payment models available in Medicaid 28 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Oregon Design Considerations 1. Policy Goal: changes, clarifications, other?
2. Target Population(s): changes, clarifications, other?
3. Program Administration: changes, clarifications, other?
4. Benefits: changes, clarifications, other?
29 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Medicaid Buy-in Oregon Design Considerations 5. Out-of-pocket Costs: changes, clarifications, other?
6. Enrollee Premiums: changes, clarifications, other?
7. Provider Reimbursement: changes, clarifications, other?
30 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
UNIVERSAL ACCESS TO CARE WORK GROUP
REPORT—TOPICS AND MEMBER PRIORITIES
31 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Potential List of Topics for Report A. Identify incremental state-level policy changes to make it easier for individuals to access and maintain coverage, whether through their employer or through existing or new publicly funded programs.
• Premium Assistance Program • Primary Care Trust Fund to • Enrollment Assistance and Support Universal Primary Care Outreach • Shared Responsibility Mandate • Consumer Coverage Simplification • Medicaid Buy-in • Administrative Billing • Pharmaceutical Costs Simplification • Price Transparency • Plan Uniformity • Public Opinion
32 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Potential List of Topics for Report (cont.) B. Describe potential changes to employer-sponsored coverage and commercial plans, including the extent to which existing coverage mechanisms are compatible with a universal coverage system. Determine what mechanisms, if any, are needed to minimize disruption to the current health care system.
1. Expansion of the coordinated care model: expand the state’s reform model beyond Medicaid and coordinated care organizations (CCOs) to all commercial health carriers and health plans offered in Oregon based on the six key elements
33 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Potential List of Topics for Report (cont.) C. Explore whether new governance models are needed to achieve universal access, including major components and functions of any such model. Information below is largely drawn from international perspectives on universal coverage models that provide comprehensive, affordable, high-quality health care coverage for all residents.
1. Simplify and standardize consumer cost-sharing 2. Ownership models 3. Provider reimbursement 4. Propose new governance models for a state-based coverage system
34 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Potential List of Topics for Report (cont.) D. Explore long-term sustainable funding sources to raise sufficient revenue to finance universal health access, including local, state, and federal funding. (RAND 2017 Study)
1. Single payer (RAND Study): use public financing to provide privately delivered health care for all Oregon residents, 2. Health Care Ingenuity Plan: create a public financing pool for coverage in commercial health plans for all Oregon residents 3. Public Option: establish a state-run public plan that would compete with private Marketplace plans
35 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Potential List of Topics for Report (cont.) E. Investigate the federal waivers and permissions that would be required for Oregon to maximize federal funding for the provision of health care services.
1. House Resolution (HR) 6097—State-based Universal Health Care Act: expands the current Affordable Care Act (ACA) section 1332 waiver to include waivers from multiple federal laws currently preventing state- based universal care.
36 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Potential List of Topics for Report (cont.) • Anything missing from the list (Jan. thru Oct. discussions)?
• What are critical issues, considerations, or key messages members want shared with legislators about universal access to care in Oregon?
• Additional information staff should provide in advance of the Nov. 15 meeting?
• Process questions?
37 LPRO: LEGISLATIVE POLICY AND RESEARCH OFFICE
Next Steps
Review draft report in advance of Nov. 15 meeting TBD: offline exercise, survey, or homework for members? Finalize report at Nov. 15 meeting Submit final report to the House Committee on Health Care no later than Nov. 30th
December Legislative Days (Dec. 12-14th): present comprehensive report that identifies barriers to and incremental steps for moving Oregon towards creating a financially sustainable, universal, and affordable health care system (December 2017 charter)
38