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US HC Final > ACA pt 1 > Flashcards

ACA pt 1 Flashcards

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1
Q

ACA 3 leg stool

A

ACA 3 leg stool

  • CR: no use of pre existing conditions for premiums in private insurance
  • Individual mandate
  • Low-income subsidies in indv marketplace
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2
Q

ACA’s 3 primary goals

  • Cover _
  • Increase _
  • Reduce _
A

ACA’s 3 primary goals

  • Cover the uninsured by subsidizing coverage
    • 2 mechanisms
      • Medicaid expansion
      • subsidized private coverage for people in exchanges
  • Increase regulation of private health insurers
    • CR + GI
  • Reduce healthcare spending “bending the curve”
    • healthcare spending as a percentage of GDP
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3
Q

heterogeneity of the uninsured

  • The Relationship Between the Uninsured and Income
    • high vs low-income insurance type
      *
A

heterogeneity of the uninsured

  • The Relationship Between the Uninsured and Income
    • Higher income= more likely to have private insurance
    • Lower income= more likely to have public insurance
    • There are uninsured people at all levels of income
    • most uninsured= working families
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4
Q

heterogeneity of the uninsured

  • The Relationship Between the Uninsured and Employment Setting
    • big vs small employer
A

heterogeneity of the uninsured

  • The Relationship Between the Uninsured and Employment Setting
    • strong relationship: uninsured and where one works, specifically focusing on the size of the employer
    • Big employer= more likely to be insured
      • (spread out admin cost/less underwriting/ bargaining)
    • Small firms and self employed had the most uninsured
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5
Q

ACA main insurance provisions (2014)

  • medicaid _
  • state _
  • Mandates
A

ACA main insurance provisions (2014)

  • medicaid expansion
  • state health insurance exchanges
  • individual mandate
  • employer mandate “play or pay”
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6
Q

Medicaid expansion

(as initially written) to all nonelderly under _ FPL

Coverage before ACA

Who lacked Medicaid coverage?

Who administers Medicaid?

A

Medicaid expansion

(as initially written) to all nonelderly under 133% FPL

Coverage before ACA

Who lacked Medicaid coverage?

  • childless adults, and to a lesser extent parents, lacked Medicaid coverage

Medicaid is administered by the states (have discretion)

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7
Q

State Health Insurance Exchanges/Marketplaces

What does it provide?

How do they help people get insurance?

Goal?

A

State Health Insurance Exchanges/Marketplaces

What does it provide?

  • Private insurance options for individuals and small businesses (SHOP)

How do they help people get insurance?

  • Tax credit varying by income for individuals between 100% and 400% FPL to offset premium

Goal?

  • transform the individual/small group health insurance markets to operate more like the large group market (more insurance options, cheaper premiums)
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8
Q

State Health Insurance Exchanges/Marketplaces

  • How does it prohibit the use of pre-existing conditions by insurers for premiums?
  • what can the adjust community rating on?
  • potential problem with ACR +GI?
  • solution for adverse selection?
A

State Health Insurance Exchanges/Marketplaces

How does it prohibit the use of pre-existing conditions by insurers for premiums?

  • Adjusted community rating
  • guaranteed issue

What can they adjust community rating on?

  • smoking
  • geographic area
  • age

The potential problem with ACR +GI?

  • adverse selection
    • older and sicker people getting coverage
    • younger/ healthier people passing

Solution for adverse selection?

  • individual mandate
    • requires people to purchase coverage or pay a penalty on their taxes
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9
Q

employer play or pay

A

employer play or pay

play by offering coverage or pay a penalty if a firm doesn’t offer coverage

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10
Q

What caused the CBO to increase their projected # of uninsured due to ACA?

A

2012 supreme court case that made Medicaid expansion optional= less people insured

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11
Q

2010 ACA’s Secondary Provisions in Effect Earlier than 2014 (read 5 times)

A

2010 ACA’s Secondary Provisions in Effect Earlier than 2014 (read 5 times)

  • National high-risk pool
  • Dependent children’s coverage up to age 26
  • No use of pre-existing conditions for children’s premiums
  • No copayments for USPSTF’s A/B-rated services (preventative services)
  • Restrictions on using lifetime and annual limits
  • Tax credits for small businesses with low-wage workers
  • Drug discounts for Part D’s “doughnut hole”
  • CLASS: voluntary living assistance coverage (abandoned)
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12
Q

2010 ACA’s Secondary Provisions in Effect Earlier than 2014

  • describe national high risk pool
  • why was it temporary?
A

2010 ACA’s Secondary Provisions in Effect Earlier than 2014

describe the national high-risk pool

  • Government administered source of health insurance coverage for people who are deemed uninsurable due to Pre existing conditions (chronic health conditions)
  • Money to bolster HRP already in states
  • Money to create HRP in new states

why was it temporary?

  • ACR+GI in 2014
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13
Q

2010 ACA’s Secondary Provisions in Effect Earlier than 2014

CLASS Act

Goal

Why abandoned

A

2010 ACA’s Secondary Provisions in Effect Earlier than 2014

CLASS Act

Goal?

  • keep the disabled out of nursing homes
  • Have insurance plan pay for certain home health services

Why abandoned?

  • Concerns about adverse selection leading to excessively high premiums
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14
Q

SHOP EXCHANGES

Who does it help and how?

how pick insurance?

Growth in exchanges?

A

SHOP EXCHANGES

Who does it help and how?

  • tax credit against corporate income tax for small businesses

how pick insurance?

  • firm picks a metal tier
  • workers to choose among the plans in that metal tier

Growth in exchanges?

  • States can add bigger firms as the exchanges grow
  • but, poor roll out of indv exchange
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15
Q

Why did CBO project low ACA spending year 2010-2013?

Why do spending estimates increase after 2014?

A

Why did CBO project low ACA spending year 2010-2013?

  • delays in people enrolling in Medicaid/ buying subsidize coverage on exchanges (unawareness/ procrastination)

Why do spending estimates increase after 2014?

  • individual mandate penalty growing in size over time
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16
Q

ACA’s Main Financing Provisions goals?

Total cost of ACA _ Financing of ACA = _ deficit

A

ACA’s Main Financing Provisions goals?

Goals

  • raise taxes
  • to reduce spending

Total cost of ACA < Financing of ACA = decrease deficit

17
Q

ACA’s Main Financing Provisions (5)

Medicare _

Reductions in _

Reductions in _

New fees on _

new tax

A

ACA’s Main Financing Provisions

  • Medicare HI payroll tax increase (HIGH INCOME PEOPLE)
  • Reductions in FFS Medicare payments’ annual updates (mostly hospitals)
  • Reductions in Medicare Advantage payments*
  • New fees on drugs, devices, and insurers
  • “Cadillac Tax” on high-cost private insurance plans 2018*
18
Q

Which 2 ACA financing provisions will pass costs onto consumers?

A

Which 2 ACA financing provisions will pass costs onto consumers?

  • New fees on drugs, devices, and insurers (HIGHER PRICES)
  • “Cadillac Tax” on high-cost private insurance plans
19
Q

Cadillac tax

  • Describe Cadillac tax
  • goal of excise tax?
  • Impact on consumers?
  • tax passed on as a higher premium
  • What is the tax combating? Why inefficient?
  • Result of generous plans?
A

Describe Cadillac tax

  • excise tax on insurers for high-cost private insurance plans above a threshold

goal of excise tax?

  • reduce HC spending by discourage people from getting generous health plans

Impact on consumers?

  • tax passed on as a higher premium

What is the tax combating? Why inefficient?

  • the inefficient employment-based tax exclusion (magnitude of tax subsidy indv receive tied to plan generosity)
  • causes people to obtain health insurance plans that are too generous

Result of generous plans?

  • Moral hazard- overutilization/ low value care
20
Q

Why will the Cadillac tax make more money in the future?

A

Why will the Cadillac tax make more money in the future?

  • plan thresholds indexed to general inflation
  • inflation rate of insurance plans > general inflation
  • over time, more plans will be taxed
21
Q

ACA: Reducing in Spending- Private (2)

REDUCE PRIVATE SPENDING

A

ACA: Reducing in Spending- Private

  • Cadillac tax
    • combat moral hazard from generous health plan due to the employment-based tax exclusion
  • State health exchange flat subsidy
    • NOT tied to generosity of plan
    • Flat subsidy based on 2nd cheapest silver plan
22
Q

ACA: Reducing admin overhead- Private (3)

increased competition and transparency

A

ACA: Reducing admin overhead- Private (3)

  • State Health Insurance Exchanges fostering competition and transparency​
  • New state CO-OP plans and (as initially written) multi-state OPM plans
  • Minimum Medical Loss Ratio (MLR) requirements for insurers​
    • benefits paid/ premiums collect
    • minimum MLR requirement to insure lower administrative costs if the competition alone doesn’t work
23
Q

ACA reductions in PUBLIC SPENDING (3)

A

ACA reductions in PUBLIC SPENDING (3)

  1. FFS Medicare payments: Decrease annual updates to provider payments
    • Productivity adjustments to market basket (HOSPITALS better use of inputs)
  2. reduction in prices paid for drugs for seniors in the donut hole of Medicare Part D
  3. Reduction in prices for drugs form the _Medicaid*_ program (increased rebate)
    • Price based on average market price (AMP)
24
Q

Efforts to decrease inefficient Medicare utilization (5)

UTILIZATION!!!!

A

Efforts to decrease inefficient Medicare utilization (5)

  1. Medicare reduced payments to hospitals with high readmission rates
    • Price adjustment: IPPS/DRG payments
  2. bundled payments over a longer episode of care
  3. Created ACOs (“Shared Savings Program”)
    • Savings/ penalty based on utilization
  4. Created CMMI
    • create new payment models
  5. Created Independent Payment Advisory Board (IPAB)
    • b4 MedPac (Senate vote)
    • Alter Medicare payments (no senate)
    • Payment models: disincentivize the utilization of low value services
25
Q

The ACA’s Provisions for Healthcare Prevention (5 times)

Private

Medicare

Medicaid

Primary care physicians

Increased funding for _ _ _ _ to (2)

A

The ACA’s Provisions for Healthcare Prevention (5 times)

Private: No copayments for A/B preventative services

Medicare: annual physicals and reimbursement for personal prevention plan

Medicaid: smoking cessation for prego women

Primary care physicians: temporary increase in reimbursements/grants for training

increased funding for FQHCs: serve Medicaid/ immigrants. now teach centers

26
Q

The ACA’s Provisions for Public Health Prevention

  • Prevention and public health fund
  • Employment-based wellness programs
  • Large chain restaurants: calorie info on menus
  • 10% excise tax on tanning services
A

The ACA’s Provisions for Public Health Prevention

  • Prevention and public health fund
  • Employment-based wellness programs
  • Large chain restaurants: calorie info on menus
  • 10% excise tax on tanning services
27
Q

Argument to strike down entire ACA?

A

Argument to strike down entire ACA?

  • individual mandate = unconstitutional,
  • Individual mandate essential to ACA
  • so, whole ACA had to go
28
Q

4 main Supreme court questions

A

4 main Supreme court questions

  1. Could the Supreme Court rule on a tax that hasn’t yet been imposed?
  2. Was the individual mandate constitutional?
  3. Was the Medicaid expansion coercive to the states?
  4. individual mandate be “severable” from the ACA ?
    1. ACA didn’t have that severability clause
29
Q

Supreme Court’s 2012 Decision on the Individual Mandate

What upheld it?

What 2 clauses was it not valid under?

A

Supreme Court’s 2012 Decision on the Individual Mandate

What upheld it?

  • Ruled to uphold the mandate under the Taxing Clause.*

It’s a tax -> Congress can pass taxes

What 2 clauses was it not valid under?

  • Necessary and Proper clause
  • Commerce clause
30
Q

Describe ACA Medicaid expansion

Expansion

Funds to states

why initially mandatory

A

Describe ACA Medicaid expansion

Expansion

  • all non-elderly 133% FPL

Funds to states:

  • FMAP Matching funds
  • Decrease over time to 90%

why initially mandatory

  • States not complying with the ACA’s Medicaid expansion will lose all of their federal Medicaid funds
31
Q

What clause made Medicaid expansion optional?

Issue?

Why some states want optional?

A

What clause made Medicaid expansion optional?

  • Spending Clause
    • Cant penalize states when they have a choice whether or not to accept the federal conditions in exchange for federal funds

Issue?

  • a state not expanding Medicaid would have many adults under the poverty line ineligible for coverage. While all adults just over the poverty line would still be eligible for generous tax credit subsidies

Why some states want optional?

  • more flexibility in devising their Medicaid plans through a negotiation with CMS (Cost sharing/ benefits)
32
Q

Data for the Reduction in Uninsured Resulting from the ACA

  • proportion of uninsured adults has _ as a result of the ACA
  • Expansion states vs non-expansion uninsured %?
  • uninsured % has _ in the states that didn’t expand their Medicaid programs, primarily due to _ _
  • Who set up exhanges/ expanded Medicaid immediatley?

*

A

Data for the Reduction in Uninsured Resulting from the ACA

  • proportion of uninsured adults has fallen as a result of the ACA
  • Expansion states and non-expansion states saw the same decrease in the uninsured
  • uninsured % has still fallen in the non-expansion states, primarily due to the new exchange marketplaces

*

US HC Final (3 decks)

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