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Health Insurance Markets, and The Affordable Care Act


Academic year: 2021

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Health Insurance Markets, and

The Affordable Care Act


ACA is Behavior Changing

• Individual mandate

• Advanceable premium tax credits for families between

$23,050 and $92,200

• Cost-sharing reductions for families up to $57,625 • Maybe Medicaid expansion for families between

$7,607 and $31,809

• Guaranteed issue with no pre-existing exclusions • Possible employer penalties if FTE > 50

• Temporary small business tax credits, subject to




16,000 young and invincible 69,000 Medicaid eligible


CBO: 5 Primary Populations in FFE

• Vast majority will be previously uninsured

• Those who lose employer-sponsored

insurance (ESI)

• Those who lose Medicaid coverage because

their incomes are above 138% of FPL ($15,000 individual, $32,000 for family of 4)

• Non-exchange, non-group population

• Those with ESI but whose premiums > 9.5% of


Montana’s Federally Facilitated


• 87,000 uninsured may qualify for APTC

– 55,000 uninsured may also qualify for CSR

• 50,000 with private coverage and whose incomes

are < $44,680 (individual) and $92,200 (family of 4)

• 44,000 w/ employer-sponsored health insurance

but whose premiums > 9.5% household income

• Total Possible Population eligible for assistance:


Will ACA Reduce Uninsured Rate to 0?

• Start with 195,000 uninsured

– Medicaid expansion (take-up) -56,000

– Young adults -17,000

– APTC/CSR -87,000

• May reduce uninsured by 160,000

• Leaves 35,000 uninsured, who are they?

– Medicaid eligible but do not enroll

– Uninsured ineligible for APTC/CSR (>400% FPL)

– 16,000 invincibles


Why does 181,000 in FFE ≠ 160,000

• FFE population includes some insured

– Individually insured and eligible for APTC/CSR – ESI with premiums > 9.5% of income


Will Individual Mandate Force 195,000

Uninsured into the FFE?

• “there is an exemption from the individual

mandate if the cost of premiums for employer-sponsored coverage, if the

individual is eligible for it, or for the lowest cost Bronze plan available on the Exchange, after accounting for any employer

contributions or advance payments of the premium tax credit, exceeds 8 percent of household income”


For example…

• Male, age 40, $34,000 income (300% FPL) • Average cost area for health care

• Cost of Bronze Plan $4,500 (CBO)

• Individual will pay $3,279 of estimated


• Advanced premium tax credit = $1,221

• Individual’s share of premium, after APTC,


Opt-Out on non-affordability



And still others may simply “pay”

instead of “play”

• Individual with income $17,000 (150% FPL)

• If qualifies for APTC, will pay about $690 toward

$4,500 insurance premium

• Government picks up rest, $3,810 • In 2016, fine is $695 or 2.5% income

– Individual may pay $695

• The Decision?

– Pay $690 and have insurance (play)


Individual mandate, pay or play?

$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000





Premium, after Tax Credit


Sources of Change in Health Insurance

Previously Eligible Medicaid 1% Crowd-Out Medicaid 4% Newly Eligible Medicaid

11% Young Adults 5%

FFE Population with Subsidies 53% FFE Population without Subsidies 26%


How will uninsured impact Montana’s

health care delivery system?

Primary Care Surgical Specialty Offices Medical Specialty Offices Hospital Outpatient Departments Hospital Emergency Departments Net Incremental Change Privately

Insured 131,768 39,416 32,656 -1,976 -19,760 182,104

Medicaid 106,064 8,904 8,288 36,792 22,736 182,784


Incremental Change


Using different data source, ACS…

Primary Care Surgical Specialty Medical Specialty Hospital Outpatient Hospital ED Total Office Visits Private Coverage 131,768 39,416 32,656 (1,976) (19,760) 182,104 Medicaid Coverage 128,792 10,812 10,064 44,676 27,608 221,952 Total Change 260,560 50,228 42,720 42,700 7,848 404,056


Can Montana’s Primary Care System Handle the Demand?

Primary Care

Supply Primary Care Demand Visits/Year: Shortage (-) Surplus (+)

Montana 2,079,000 1,997,093 +81,907

Cascade 163,800 155,107 +8,693

Flathead 176,400 181,423 -5,023

Gallatin 226,800 172,895 +53,905

Lewis & Clark 147,000 125,022 +21,978

Missoula 201,600 220,684 -19,084

Ravalli 58,800 86,947 -28,147

Silver Bow 71,400 71,081 +319


Will employers drop health insurance?

• Two ways to ascertain employer responses and

both have limitations

– Surveys

– Modeling

• Surveys have no consequences, no detailed

analysis, and generally limited information and/or knowledge of the ACA

• Modeling sophisticated, but best when applied to

small, modest changes


Survey based…mixed bag

• Lockton Employer Survey:

– No change, small firm offer rates may actually increase 14%

– Employees would face premium hikes 79% - 125% if lose ESI

• McKinsey & Company: 30% will terminate coverage • Avalere Health: Stable

• Mercer Employer Survey: 9% will drop if have 500 or

more employees

• International Foundation of Employee Benefit Plans:


Modeling based, more consistent

• Centers for Medicare and Medicaid Services • The Urban Institute

• The Lewin Group • Rand Health

• Congressional Budget Office • Joint Committee on Taxation


What factors will Montana businesses


• Possible Medicaid expansion to 138% FPL • APTC and CSR available if under 400% FPL

• How many firms have all low wage or high wage

workers? (can’t send just some to Exchange)

• Individual mandate—increase in demand for insurance • Small employer tax credits until 2016

• For 37% of Montana’s workforce, employer could face

penalties, but penalty is less than cost of insurance

• Would employers drop coverage without increasing


So where does that leave us?

• Consensus is that small employers are most

likely to abandon ESI, if they offer it

• Advantages or disadvantages of abandoning

ESI will depend on distribution of employee incomes, but firms do not know employees’ total household incomes

• BBER estimates 24,000 – 41,000 could lose

employer-provided insurance, but with considerable margins of error


For high wage firms…

$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000 $16,000

150 200 300 400 478

Percent of Federal Poverty Level

ESI Subsidy


Market Power in Health Insurance

(Kaiser Foundation, 2010)

Individual Market Number with

market share >5% Market share of largest carrier Herfindahl-Hirschman Index

Montana 3 51% 3,459

United States (avg) 4 54% 3,761

Alabama 2 86% 7,426

Wisconsin 6 21% 1,434

Small Group

Montana 5 71% 5,271

United States (avg) 4 51% 3,595

Alabama 1 96% 9,175


Update to 2011 with Leif Associates


Number with > 5% Market Share Market Share of Largest Insurer

U.S. Median HHI U.S. Median


Individual 2 57% 54% 3,703* 3,761

Small Group 4 46% 51% 3,023* 3,595

Large Group 3 78% na 6,220 na

*two new insurers may be added in 2014, Montana Cooperative and Multi-State Carrier, in addition, the impact of Pacific Source is excluded



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