Jonathan Keisling November 15, 2019
While enacted in 2010, the Affordable Care Act
(ACA) has never been fully implemented. The Health Insurance Marketplaces and
partial Medicaid expansion were implemented in 2014, but under the Obama
Administration full implementation was prevented by states that were slow to
take up the federal money for Medicaid expansion. Under the Trump
Administration, the penalty for the individual mandate has been set to $0, and
Cost-Sharing Reduction (CSR) payments to insurers have been discontinued, among
other things.
This report details the findings of the Center
for Health and Economy (H&E) analysis – relying on its Under-65
Microsimulation Model – of a scenario where every state expands Medicaid and
the individual market policies of the ACA are fully implemented. All impacts
projected in this report are relative to H&E’s July 2019 Baseline.[1] As with all projections, the estimates
are associated with some degree of uncertainty.
KEY FINDINGS:
·
Premium
Impact: Driven by the return of
the CSR payments, premiums are expected to fall by 2 to 11 percent by the year
2029 for qualified health plans (QHPs) in the individual market. Silver plans
are expected to see the largest reduction.
·
Coverage
Impact: A fully implemented ACA
would lead to a decrease in the number of uninsured, primarily because of the
Medicaid expansion but also because of lower premiums. Initially, there would
be a decrease in the uninsured of roughly 4 million people. By 2029, the
decrease the uninsured would be around 3 million relative to the baseline.
·
Medical
Productivity: The scenario would lead
to a 1 percent decrease in medical productivity by 2029.
·
Provider
Access: The scenario would lead
to a 16 percent increase in provider access by 2029.
·
Budget
Impact: The scenario is expected
to increase spending by $170 billion between 2020 and 2029. The reintroduction
of the individual mandate penalty is expected to increase revenues by $36
billion. The net budgetary impact of the fully implemented ACA is an increased
deficit of $136 billion.
ANALYSIS
This analysis uses a microsimulation model
developed for use by H&E. The model employs micro-data available through
the Medical Expenditure Panel Survey to analyze the effects of health policies
on the health insurance plan choices of the under-65 population, and it
interprets the resulting impact on national coverage, average insurance
premiums, the federal budget, and the accessibility and efficiency of health
care. The following provisions and subsequent assumptions are included in this
score.
·
Full implementation
would take effect on January 1, 2020.
·
Every state would expand
Medicaid to include adults up to 133 percent of the Federal Poverty Level
(FPL).
·
The individual mandate
penalty is restored to the level it was before the Tax Cuts and Jobs Act of
2017. In 2018, the individual mandate penalty was the greater of $695 for each
uninsured adult or 2.5 percent of yearly household income. For each successive
year after 2018, the penalty was the greater of $695 indexed to an inflation
rate of CPI-U plus 1 (a factor of roughly 1.02) or 2.5 percent of yearly
household income.
o
For 2020, it was assumed
the individual mandate penalty was the greater of $723 per household adult or
2.5 percent of household income.
o
Those subject to the
penalty are those who are not enrolled in a QHP.
·
Congress appropriates
the funds for CSR payments to insurers.[2]
Premium Impact
H&E health insurance premium estimates are
based on five plan design categories offered in the Individual Market:
Platinum, Gold, Silver, Bronze, and Catastrophic. Under current law, the
cost-sharing designs of the four metallic categories correspond to approximate
actuarial values: 90 percent, 80 percent, 70 percent, and 60 percent,
respectively. Catastrophic coverage plans refer to two different kinds of
health insurance plans. First, Catastrophic coverage can mean plans that
reimburse medical expenses only after members meet a high deductible—a maximum
of $7,900 for an individual under current law. Second, Catastrophic coverage
includes Short-Term Limited Duration plans. All premium estimates reflect
health insurance prices without any federal subsidies and reflect the average
premiums of plans actually purchased in the marketplace. They do not represent
an average of all the offerings in the marketplace.
Table 1 below presents the average premiums for
the purchased plans in each category between 2020 and 2029.
There are two main sources of downward pressure
on premiums: the reintroduction of CSR payments to insurers and the individual
mandate penalty. H&E estimates that the reintroduction of CSR payments to
insurers would allow insurers to decrease premiums for Silver plans, as the
Silver metal level includes plans with increased cost sharing.H&E estimates
that a fully implemented ACA would lower insurance premiums in every category,
especially premiums for Silver and Catastrophic plans.
Another policy change that would lead to
decreases in premiums is the individual mandate. The mandate would place
downward pressure on premiums as people who are otherwise healthy purchase
insurance in the individual market to avoid the penalty. The mandate penalty
would also have a profound effect on the market for Catastrophic plans. Anyone
who purchases a Short-Term Limited Duration Insurance (STLDI) plan would be
subject to the penalty. Likewise, anyone above the age of 30 would be subject
to the penalty as the ACA stipulates that Catastrophic plans are only available
for those under the age of 30. As a result, many people above the age of 30
would purchase other QHPs. Therefore, under a fully implemented ACA, the group
of people purchasing Catastrophic coverage would be overwhelmingly younger than
it is currently, leading to a decrease of 25 to 27 percent in the premiums of
purchased Catastrophic plans by the year 2029.
Coverage Impact
H&E insurance coverage estimates reflect
health insurance choices for the under-65 population. H&E estimates that
the fully implemented ACA would result in increases in the insured population
of 4 million in 2020 and 3 million in 2029 relative to H&E’s 2019 baseline.
Table 3 below shows the overall projected insurance levels.
H&E expects enrollment to increase in the
Medicaid program (see Table 3, below). If every state expanded Medicaid, it is
expected that Medicaid enrollment would increase by 6 million relative to the
baseline. With Medicaid eligibility expanding to 133 percent of the FPL in every
state, expansion will be accompanied by a decrease in individual market
enrollment as people previously eligible for tax credits and cost-sharing
subsidies become newly eligible for Medicaid and sign up. Furthermore, H&E
expects some of this decrease to be offset as a result of the mandate penalty
imposed on those who choose to go uninsured or purchase a non-QHP.
As can be seen in Table 3, it is expected that the Medicaid expansion will also draw a small number of people currently enrolled in other forms of public insurance like the Veterans Health Administration and the Indian Health Service. It is expected that there will be a decrease of roughly 1 million enrolled in other public insurance by the year 2021.
Productivity and Access
In an attempt to evaluate access and
productivity in the health care system, H&E estimates the Medical
Productivity Index (MPI) and the Provider Access Index (PAI). Health insurance
plan designs are associated with varying degrees of access to desired
physicians and facilities, as well as incentives that promote or discourage
efficient use of resources. H&E estimates each index by attributing
productivity (i.e. efficiency) and access scores to the range of plan designs
available and uses the changes in plan choices to project the evolution of
health care quality. These scores are provided in Tables 4 and 5 below.
Provider access in the individual market is
expected to increase under the plan. This is largely a result of a shift of
consumers from Catastrophic coverage and STLDIs to QHPs because of the
individual mandate penalty. This interaction leads to a 16 percent increase in
provider access by the year 2029. H&E expects medical productivity to
decrease relative to the 2019 baseline projection as a result of the scenario,
as Table 6 below demonstrates. As the individual mandate precludes enrollment
in non-QHP plans, enrollment in Catastrophic coverage and STLDI plans would
decrease. Because of this decline, medical productivity decreases outside of
the exchanges as people enroll in higher actuarial value plans. Higher
actuarial value means lower medical productivity (or efficiency), as people are
more likely to pursue health care services. At the same time, the
reintroduction of CSR payments to insurers caused premiums for Silver plans to
decrease, creating more separation between Gold and Silver plans. As the
premiums of Silver plans decrease relative to Gold, a greater share of people
enroll in Silver plans leading to more medical productivity because of their
lower actuarial value. These offsetting shifts in the individual market interact
to decrease medical productivity by 1 percent in 2029 relative to the baseline.
Budgetary Impact
H&E projects that a fully implemented ACA
would lead to a net increase in the budget deficit of $134 billion, relative to
the current H&E baseline, over the next decade. H&E assumes an increase
of $36 billion in revenue due to the reintroduction of the individual mandate
penalty. Meanwhile, a fully implemented ACA would lead to an increase in
spending of $170 billion that results mainly from increased enrollment in
Medicaid from the expansion.
Though spending is expected to increase by $170
billion, there are various offsetting increases and reductions in spending. As
mentioned above, the Medicaid expansion would be the source of the largest
increase in spending, as Medicaid spending is expected to increase by $350
billion over the 10-year window. The reintroduction of CSR payments is expected
to increase spending also. H&E expects cumulative CSR spending to reach $39
billion by the year 2029.
There are various areas, however, where there
are reductions in spending. The expansion population will be made up of many
that are currently receiving premium tax credits in the individual market. As
individuals currently enrolled in private insurance through the individual
market shift to Medicaid coverage and the reintroduction of CSR payments, tax
credit spending is expected to decrease by $88 billion over 10 years. Moreover,
Medicaid is expected draw people out of other forms of public insurance,
resulting in another offsetting decrease in spending of $132 billion over the
budget window.
Uncertainty in Projections
H&E uses a peer-reviewed micro-simulation
model of the health insurance market to analyze various aspects of the health
care system.5 As with all economic forecasting, H&E estimates
are associated with substantial uncertainty. While the estimates provide a good
indication on the nation’s health care outlook, there are a wide range of
possible scenarios that can result from policy changes, and many current assumptions
are unlikely to remain accurate over the course of the next 10 years.
One
significant source of uncertainty is what effects the reintroduction of the
individual mandate penalty will have on the marketplace. The mandate’s purpose
is to force individuals and households to purchase insurance and reduce
premiums. After a 2-year increase in the mandate penalty, it is possible that
the updated mandate penalty has greater or smaller effects on the premium
decreases recorded in this report.
[2]
These were payments to insurers who offered Silver plans with reduced cost
sharing (required by the ACA) to help them absorb losses incurred. Congress
never appropriated the money for these payments, however, so the Trump
Administration discontinued them in 2017.
https://www.americanactionforum.org/research/fully-implementing-the-affordable-care-act/#ixzz65eEi1iqQ
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