Texas et al v. United States of America et al
Filing
91
RESPONSE filed by District of Columbia, State of California, State of Connecticut, State of Delaware, State of Hawaii, State of Illinois, State of Kentucky, State of Massachusetts, State of Minnesota, State of New Jersey, State of New York, State of North Carolina, State of Oregon, State of Rhode Island, State of Vermont, State of Virginia, State of Washington re: 39 MOTION for Injunction (Attachments: # 1 Appendix of Supporting Evidence - Part 1, # 2 Appendix of Supporting Evidence - Part 2, # 3 Proposed Order) (Palma, Neli)
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IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY, and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-O
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAII, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA, and WASHINGTON,
Intervenor-Defendants.
APPENDIX IN SUPPORT OF INTERVENOR-DEFENDANTS’ BRIEF IN
OPPOSITION TO PLAINTIFFS’ APPLICATION FOR A PRELIMINARY
INJUNCTION
The Defendant States submit the following appendix in support of their
Opposition to Plaintiffs’ Application for a Preliminary Injunction.
Appendix in Opposition to Preliminary Injunction (18-cv-167)
Page 1
APPENDIX OF SUPPORTING EVIDENCE
Exhibit No.
Document
Pages
1
Declaration of Henry J. Aaron (Brookings Institution)
001 - 061
2
Declaration of Benjamin Barnes (CT)
062 - 075
3
Declaration of Peter Berns (The ARC)
076 – 080
4
Declaration of Sharon C. Boyle (MA)
081 – 083
5
084 – 104
6
Declaration of Sabrina Corlette (Center on Health
Insurance Reforms)
Declaration of James DeBenedetti (CA)
7
Declaration of Alfred J. Gobeille (VT)
108 – 113
8
Declaration of Carole Johnson (NJ)
114 – 117
9
Declaration of Jennifer Kent (CA)
118 – 121
10
Declaration of Mila Kofman (DC)
122 – 128
11
Declaration of Jennifer Lee (VA)
129 – 133
12
Declaration of Kimberly Lufkin (VA Resident)
134 – 136
13
Declaration of Chris Maley (IL)
137 – 140
14
Declaration of Thea Mounts (WA)
141 – 148
15
Declaration of Neli Palma (Supporting Materials)
149 – 367
16
Declaration of Judy Mohr Peterson (HI)
368 – 372
17
Declaration of Claudia Schlosberg (DC)
373 – 380
18
Declaration of Ryan Smith (IL Resident)
381 – 383
19
Declaration of Kara Odom Walker (DE)
383 – 387
20
Declaration of Sherry White (NY Resident)
388 – 390
21
Declaration of Walker Wilson (NC)
391 – 394
22
Declaration of Howard A. Zucker (NY)
395 – 408
23
Declaration of Patrick M. Allen (OR)
409 - 415
24
Declaration of Zachery W. Sherman (RI)
416 - 420
25
Declaration of John Jay Shannon (IL)
421 - 425
26
Declaration of Kristi M. Bohn (MN)
426 - 429
Appendix in Opposition to Preliminary Injunction (18-cv-167)
105 – 107
Page 2
Dated: June 7, 2018
Respectfully submitted,
Xavier Becerra
Attorney General of California
Julie Weng-Gutierrez
Senior Assistant Attorney General
Kathleen Boergers
Supervising Deputy Attorney General
/s/ Neli N. Palma
/s/ Nimrod P. Elias
Neli N. Palma
Nimrod P. Elias
Deputy Attorneys General
California State Bar No. 203374
California State Bar No. 251634
P.O. Box 944255
Sacramento, CA 94244-2550
Telephone: (916) 210-7522
Fax: (916) 322-8288
E-mail: Neli.Palma@doj.ca.gov
Attorneys for Intervenors-Defendants
GEORGE JEPSEN
Attorney General of Connecticut
JOSEPH RUBIN
Associate Attorney General
Attorneys for Intervenor-Defendant the
State of Connecticut
MATTHEW P. DENN
Attorney General of Delaware
ILONA KIRSHON
Deputy State Solicitor
DAVID J. LYONS
Deputy Attorney General
Attorneys for Intervenor-Defendant the
State of Delaware
RUSSELL A. SUZUKI
Attorney General of Hawaii
HEIDI M. RIAN
Deputy Attorney General
ROBERT T. NAKATSUJI
Deputy Solicitor General
Attorneys for Intervenor-Defendant the
State of Hawaii
Appendix in Opposition to Preliminary Injunction (18-cv-167)
Page 3
LISA MADIGAN
Attorney General of Illinois
David F. Buysse
Deputy Chief, Public Interest Division
Anna P. Crane
Public Interest Counsel
Matthew V. Chimienti
Assistant Attorney General, Special Litigation
Bureau
Attorneys for Intervenor-Defendant the
State of Illinois
ANDY BESHEAR
Attorney General of Kentucky
LA TASHA BUCKNER
Executive Director, Office of Civil and
Environmental Law
S. TRAVIS MAYO
TAYLOR PAYNE
Assistant Attorneys General
Attorneys for Intervenor-Defendant
the Commonwealth of Kentucky
MAURA HEALEY
Attorney General of Massachusetts
STEPHEN P. VOGEL
Assistant Attorney General
Attorneys for Intervenor-Defendant the
Commonwealth of Massachusetts
OFFICE OF THE ATTORNEY GENERAL
State of Minnesota
SCOTT IKEDA
Assistant Attorney General
Attorneys for Intervenor-Defendant the State of
Minnesota by and through its Department of
Commerce
GURBIR S. GREWAL
Attorney General of New Jersey
JEREMY M. FEIGENBAUM
Assistant Attorney General
ANGELA JUNEAU BEZER
Deputy Attorney General
Attorneys for Intervenor-Defendant the
State of New Jersey
Appendix in Opposition to Preliminary Injunction (18-cv-167)
Page 4
BARBARA D. UNDERWOOD
Acting Attorney General of New York
STEVEN C. WU
Deputy Solicitor General
LISA LANDAU
Bureau Chief, Health Care Bureau
ELIZABETH CHESLER
Assistant Attorney General, Health Care Bureau
Attorneys for Intervenor-Defendant the
State of New York
JOSHUA H. STEIN
Attorney General of North Carolina
SRIPRIYA NARASIMHAN
Deputy General Counsel
Attorneys for Intervenor-Defendant the
State of North Carolina
ELLEN F. ROSENBLUM
Attorney General of Oregon
HENRY KANTOR
Special Counsel to the Attorney General
SCOTT KAPLAN
Assistant Attorney General
Attorneys for Intervenor-Defendant the
State of Oregon
PETER KILMARTIN
Attorney General of Rhode Island
MICHAEL W. FIELD
Assistant Attorney General
MARIA R. LENZ
Special Assistant Attorney General
Attorneys for Intervenor-Defendant the
State of Rhode Island
THOMAS J. DONOVAN, JR.
Attorney General of Vermont
BENJAMIN D. BATTLES
Solicitor General
Attorneys for Intervenor-Defendant the
State of Vermont
MARK R. HERRING
Attorney General of Virginia
TOBY J. HEYTENS
Solicitor General
MATTHEW R. MCGUIRE
Deputy Solicitor General
Attorneys for Intervenor-Defendant the
Commonwealth of Virginia
Appendix in Opposition to Preliminary Injunction (18-cv-167)
Page 5
ROBERT W. FERGUSON
Attorney General of Washington
JEFFREY G. RUPERT
Chief, Complex Litigation Division
JEFFREY T. SPRUNG
Assistant Attorney General
Attorneys for Intervenor-Defendant the
State of Washington
KARL A. RACINE
Attorney General for the District of Columbia
ROBYN R. BENDER
Deputy Attorney General
VALERIE M. NANNERY
Assistant Attorney General
Attorneys for Intervenor-Defendant the
District of Columbia
Appendix in Opposition to Preliminary Injunction (18-cv-167)
Page 6
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-O
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAII, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF HENRY J. AARON, PhD., IN SUPPORT OF INTERVENORSDEFENDANTS’ OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
I, Henry J. Aaron, declare as follows:
1.
I am currently the Bruce and Virginia MacLaury Senior Fellow in the Economic Studies
Program at the Brookings Institution. From 1990 through 1996, I was the Director of the
00001
Economic Studies Program. I am a member of the District of Columbia Health Benefits
Exchange Executive Board and a member and former chair of the Social Security Advisory
Board. I am a graduate of UCLA and hold a Ph.D. in economics from Harvard University. I
taught at the University of Maryland from 1967 through 1989, except for 1977 and 1978 when I
served as Assistant Secretary for Planning and Evaluation at the Department of Health,
Education, and Welfare. I chaired the 1979 Advisory Council on Social Security. During the
academic year 1996-97, I was a Guggenheim Fellow at the Center for Advanced Studies in the
Behavioral Sciences at Stanford University. I have been a member of the visiting committees for
the Department of Economics and the Medical and Dental Schools at Harvard University. I am
the author of many books and articles on health insurance and health care policy, including two
studies of the impact on health care of limited resources in Great Britain (with William
Schwartz), a study of health policy in the United States, and recommendations for modifications
in Medicare (a book with Jeanne Lambrew and an article with Robert Reischauer).
2.
In creating this declaration, I consulted with fellow national health experts Sara
Rosenbaum, the Harold and Jane Hirsh Professor of Health Law and Policy and founding chair,
Department of Health Policy, Milken Institute School of Public Health, George Washington
University and Jeffrey Levi, Professor of Health Policy and Management at the Milken Institute
School of Public Health, George Washington University. While I consulted with these
individuals for their expert advice, I can attest to the information in this declaration based on my
independent experience and background.
3.
I understand that this lawsuit involves a challenge to the Affordable Care Act and seeks
to enjoin it. As noted above, I am the author of numerous books and articles on health insurance
and health care policy. In my expert opinion, enjoining the Affordable Care Act would
completely disrupt the U.S. health care market for patients, providers, insurance carriers, and
federal and state governments.
The Affordable Care Act Has Contributed to Improvements in Health Coverage, Access,
Financial Security, and Affordability
00002
4.
The Affordable Care Act (ACA) is a comprehensive law that has improved the quality
and affordability of health care and health insurance. It has done so by: strengthening consumer
protections in private insurance; making the individual insurance market accessible and
affordable; expanding and improving the Medicaid program; modifying Medicare’s payment
systems while filling in benefit gaps; increasing funding and prioritization of prevention and
public health; supporting infrastructure such as community health centers, the National Health
Service Corps, and the Indian Health Service, among other policies. There is widespread
agreement that the ACA is the most significant health legislation enacted since the Social
Security Act amendments that created Medicare and Medicaid in 1965.
5.
The ACA helped lower the number of people without health insurance by an estimated
20.0 million people from October 2013 to early 2016, a drop of 43 percent in the uninsured rate.
This increase in coverage included 3 million African-Americans, 4 million people of Hispanic
origin, and 8.9 million white non-elderly adults. An estimated 6.1 million young adults and 1.2
million children gained coverage between 2010 and early 2016.1,2 The reduction in the uninsured
rate occurred across the income spectrum: the 2013 to 2015 rate reduction was 36 percent, 33
percent, and 31 percent for non-elderly people with income below 138 percent of poverty,
between 138 and 400 percent of poverty, and above 400 percent of poverty respectively.3 The
drop in the uninsured rate was larger in states that expanded Medicaid than in states that did not
do so.4
Uberoi N, Finegold K and Gee E, Health Insurance Coverage and the Affordable Care Act, 2010 – 2016, Office of the Assistant
Secretary for Planning and Evaluation Issue Brief, 2016, https://aspe.hhs.gov/system/files/pdf/187551/ACA2010-2016.pdf
2 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4 Reforming
the Health Care System, U.S. Government Publishing Office, 2017,
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf
3 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4 Reforming
the Health Care System, U.S. Government Publishing Office, 2017,
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf
4 Broaddus, M, Census Data: States Not Expanding Medicaid Lag Further on Health Coverage, Center on Budget and Policy
Priorities, 2017, https://www.cbpp.org/blog/census-data-states-not-expanding-medicaid-lag-further-on-health-coverage
1
00003
6.
Many studies have found that access to health care has improved since the ACA was
enacted, especially among low-income people.5 For example, from the fall of 2013 to the spring
of 2017, the share of non-elderly adults without a regular source of care fell from 30 percent to
24.7 percent; the share that did not receive a routine checkup in the last 12 months fell from
nearly 40 percent to 34 percent.6 The Council of Economic Advisers (CEA) estimated a onethird drop in the share of people who reported that they were unable to obtain needed medical
care because of cost, with the 2015 level falling below its pre-recession level. The CEA also
found a correlation between increased coverage and an increased share of people having a
personal doctor and receiving a checkup in the past 12 months.7 A review of the literature in
2017 found evidence that significant improvements in access to and use of care were associated
with gaining coverage. These gains included increased use of outpatient care; greater rates of
having a usual source of care or personal physician; increased use of preventive services;
increased prescription drug use and adherence; and improved access to surgical care.8 Racial and
ethnic disparities in access to care fell following the expansion of coverage.9
7.
The expansion of coverage and other provisions of the ACA will contribute to longer,
healthier lives. Research on previous coverage expansions has found that having health insurance
coverage improves children’s learning ability, adults’ productivity, and seniors’ qualify of life.10
A recent review found that coverage improves rates of diagnosing chronic conditions, treatment
5 Kominski GF, Nonzee NJ and Sorensen A, The Affordable Care Act’s Impacts on Access to Insurance and Health Care for
Low-Income Populations, Annual Review of Public Health, 2017, 38:489-505,
https://www.annualreviews.org/doi/10.1146/annurev-publhealth-031816-044555
6 Long SK, Bart L, Karmpan M, Shartzer A and Zuckerman S, Sustained Gains in Coverage, Access, and Affordability Under the
ACA: A 2017 Update. Health Affairs, 36(9), 2017, https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2017.0798
7 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4 Reforming
the Health Care System, U.S. Government Publishing Office, 2017,
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf
8 Sommers BD, Gawande AA and Baicker K, Health Insurance Coverage and Health – What the Recent Evidence Tells Us, The
New England Journal of Medicine, 2017, 377:586-593, http://www.nejm.org/doi/full/10.1056/NEJMsb1706645
9 Chen J, Vargas-Bustamante A, Mortensen K and Ortega AN. Racial and Ethnic Disparities in Health Care Access and
Utilization under the Affordable Care Act. Med. Care, 2016, 54:140–146, https://www.ncbi.nlm.nih.gov/pubmed/26595227;
Sommers BD, Gunja MZ, Finegold K and Musco T. Changes in Self-Reported Insurance Coverage, Access to Care, and Health
Under the Affordable Care Act. JAMA, 2015, 314:366–374, https://jamanetwork.com/journals/jama/fullarticle/2411283
10 Institute of Medicine, Board on Health Care Services, Coverage Matters: Insurance and Health Care, National Academies
Press, 2001, http://www.nationalacademies.org/hmd/Reports/2001/Coverage-Matters-Insurance-and-Health-Care.aspx
00004
of such conditions, outcomes for people with depression, and self-reported health.11 The CEA
estimated that, if the ACA experience matches that in Massachusetts, 24,000 deaths are being
avoided annually.12 The Institute of Medicine also found that coverage improves community
health by limiting the spread of communicable diseases and reducing the diversion of public
health resources for medical care for the uninsured.13
8.
The law’s contribution to health extends beyond its coverage provisions. In part thanks to
the ACA’s payment incentives and its Partnership for Patients initiative, an estimated 125,000
fewer patients died in the hospital as a result of hospital-acquired conditions in 2015 compared to
2010, saving approximately $28 billion in health care costs over this period.14 And its Tips from
Former Smokers initiative resulted in an estimated 500,000 people quitting smoking permanently
in the first five years of the campaign.15
9.
The ACA strengthened financial security as well as physical and mental health. A study
found that self-reported concerns about the cost of health care dropped at a greater rate for lowincome people in two states that expanded Medicaid relative to one that did not.16 Between
September 2013 and March 2015, the number of people having problems paying medical bills
dropped by an estimated 9.4 million, a reduction from 22.0 to 17.3 percent of non-elderly
adults.17 One study found that the amount of debt sent to collection was reduced by over $1,000
Sommers BD, Gawande AA and Baicker K, Health Insurance Coverage and Health – What the Recent Evidence Tells Us, The
New England Journal of Medicine, 2017, 377:586-593, http://www.nejm.org/doi/full/10.1056/NEJMsb1706645
12 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4
Reforming the Health Care System, U.S. Government Publishing Office, 2017.
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf
13 Institute of Medicine, Board on Health Care Services, A Shared Destiny: Community Effects of Uninsurance, The National
Acadamies Press, 2003, https://www.nap.edu/catalog/10602/a-shared-destiny-community-effects-of-uninsurance.
14 Agency for Healthcare Research and Quality, National Scorecard on Rates of Hospital-Acquired Conditions 2010 to 2015:
Interim Data from National Efforts to Make Health Care Safer, December 2016, https://www.ahrq.gov/professionals/qualitypatient-safety/pfp/2015-interim.html
15 Centers for Disease Control and Prevention, Tips Impact and Results, no date,
https://www.cdc.gov/tobacco/campaign/tips/about/impact/campaign-impact-results.html?s_cid=OSH_tips_D9391
16 Sommers BD, Blendon RJ, Orav EJ and Epstein AM, Changes in Utilization and Health Among Low-Income Adults after
Medicaid Expansion or Expanded Private Insurance, JAMA Internal Medicine, 2016, 176:1501–1509,
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2542420
17 Kapman M and Long SK, 9.4 Million Fewer Families Are Having Problems Paying Medical Bills, Urban Institute Health
Policy Center, Health Reform Monitoring Survey, 2015, http://hrms.urban.org/briefs/9-4-Million-Fewer-Families-Are-HavingProblems-Paying-Medical-Bills.html
11
00005
per person residing in ZIP Codes with the highest share of low-income, uninsured individuals in
states that expanded Medicaid compared to those that did not expand the program.18 The law also
has reduced income inequality: projected incomes in the bottom tenth of the distribution will
increase by 7.2 percent while those in the top tenth will be reduced by 0.3 percent.19
10.
Most experts agree that the ACA contributed to slower health care cost growth since its
enactment, although there is disagreement about the size of the effect. The prices of health care
goods and services grew more slowly in the period from 2010 to 2016 than in any comparable
period since these data began to be collected in 1959. Adding to this, health care service use
growth per enrollee slowed since 2010. National health expenditures and projections for 2010 to
2019, as of 2016, were over $2.6 trillion lower than the national health expenditure projections
for the same period made in 2010. Additionally, employer-based health plan premiums and outof-pocket costs grew more slowly from 2010 to 2016 than they did from 2000 to 2010. As a
result, total spending associated with a family policy was $4,400 less in 2016 than it would have
been had costs risen as fast as they did during the previous decade. The coverage expansion
under the law also lowered hospitals’ cost of providing uncompensated care by $10.4 billion in
2015; in states that expanded Medicaid, the share of hospital operating costs devoted to
uncompensated care dropped by around half during this period.20
11.
The ACA’s contribution to lower health care cost growth has broader economic effects. It
helped stabilize the share of gross domestic product spent on health. When the ACA was under
consideration, the Congressional Budget Office (CBO) estimated that the ACA would reduce the
federal budget deficit by an estimated $115 billion from 2010 to 2019 by cutting federal health
Hu L, Kaestner R, Mazumder B, Miller S and Wong A, The Effect Of The Patient Protection And Affordable Care Act
Medicaid Expansions On Financial Well-Being, National Bureau of Economic Research, 2016, No. 22170,
http://www.nber.org/papers/w22170.pdf
19 Aaron H and Burtless A, Potential Effects of the Affordable Care Act on Income Inequality, Brookings Report, 2014,
https://www.brookings.edu/research/potential-effects-of-the-affordable-care-act-on-income-inequality/
20 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4
Reforming the Health Care System, U.S. Government Publishing Office, 2017.
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf.
18
00006
spending and raising revenue.21 States have realized budget savings as well because of increased
federal Medicaid support and reduced uncompensated care costs. Because the ACA has lowered
the cost to employers of health insurance for their employees, workers have received higher
wages and other fringe benefits. The ACA also has reduced “job lock,” by freeing workers to
change jobs without fear of losing health insurance coverage. An estimated 1.5 million people
became self-employed because of the ACA’s individual market reforms and financial
assistance.22 Contrary to some critics’ claims, there is no evidence that the law’s benefits have
come at the expense of employment, hours of work, or compensation.23 ACA coverage also
improves the U.S. system of automatic stabilizers by protecting families’ health coverage during
economic downturns. Improvement is greatest in states that expanded Medicaid.
The ACA Expanded Consumer Protections in All Types of Private Insurance
12.
The ACA improved the quality, accessibility, and affordability of health insurance
coverage both for people who were already insured and for the previously uninsured. Insurers
may no longer set higher premiums for people with pre-existing conditions, charge women more
than men, and carve out benefits for people who need them. They can no longer set annual or
lifetime limits on total benefits or rescind coverage except in cases of fraud. Insurers must cover
dependents up to age 26 under their parents’ plans, include annual out-of-pocket limits, and
provide rebates to the insured if total benefits do not exceed statutory shares of premiums
received. All non-grandfathered private plans must cover such evidence-based preventive
services as immunizations and cancer screenings, and they must do so with no cost sharing.
Individual and small group plans now must include essential health benefits: ten categories of
21 Elmendorf DW, Letter to Honorable Nancy Pelosi, Speaker, U.S. House of Representatives, Congressional Budget Office,
March 20, 2010, https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf
22 Blumberg LJ, Corlette S and Lucia K, The Affordable Care Act: Improving Incentives for Entrepreneurship and Self
Employment, Timely Analysis of Immediate Health Policy Issues, Urban Institute, May 2013,
https://www.urban.org/sites/default/files/publication/23661/412830-The-Affordable-Care-Act-Improving-Incentives-forEntrepreneurship-and-Self-Employment.PDF
23 Abraham J and Royalty AB, How Has the Affordable Care Act Affected Work and Wages, Leonard Davis Institute of Health
Economics, University of Pennsylvania, Issue Brief, January 2017, https://ldi.upenn.edu/brief/how-has-affordable-care-actaffected-work-and-wages
00007
health services with a scope that is the same as a typical employer plan. The ACA also filled in
the gaps in the Mental Health Parity and Addiction Equity Act, which requires group health
plans and insurers that offer mental health and substance use disorder benefits to provide
coverage that is comparable to coverage for general medical and surgical care.
13.
The ACA’s guarantee of access to health insurance offers peace of mind to the up to 133
million Americans who have a pre-existing health condition, including parents of 17 million
children with such conditions.24 Before the ACA, those with pre-existing conditions had to worry
about finding affordable coverage if they lost a job that provided health insurance or they
stopped being eligible for programs such as Medicaid or the Children’s Health Insurance
Program (CHIP). Even if they could find insurance, they faced the risk that needed services
might be “carved-out” for them or excluded for all enrollees: before 2014, 62 percent of
individual market enrollees lacked maternity coverage, 34 percent lacked coverage for substance
use disorders, 18 percent lacked coverage for mental health care, and 9 percent lacked
prescription drug coverage.25 Before enactment of the ACA, parents of children with autism
typically lacked private health insurance coverage for habilitative services. The ACA bars
benefit carve-outs and requires all individual and small group market plans to cover essential
health benefits. The ACA’s focus on comprehensive benefits has been particularly important in
combatting the opioid epidemic: it requires coverage of screening and treatment for substance
use disorders, has expanded parity to all plans, and supports integrating prevention and treatment
with mental health, primary care, and other related services.26
Office of the Assistant Secretary for Planning and Evaluation, Health Insurance Coverage for Americans with Pre-Existing
Conditions: The Impact of the Affordable Care Act, Issue Brief, January 2017, https://aspe.hhs.gov/system/files/pdf/255396/PreExistingConditions.pdf
25 Office of the Assistant Secretary for Planning and Evaluation, Essential Health Benefits: Individual Market Coverage, Issue
Brief, December 2011, https://aspe.hhs.gov/basic-report/essential-health-benefits-individual-market-coverage
26 Abraham AJ, Andrews CM, Grogan CM, D’Aunno T, Humphreys KN, Pollack HA and Friedmann PD, The Affordable Care
Act Transformation of Substance Use Disorder Treatment, American Journal of Public Health, 2017, 107(1):31-32,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5308192/
24
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14.
The ACA has improved women’s coverage as well. From 2010 to early 2016, 9.5 million
women gained coverage.27 Starting in 2014, the ACA banned the common practice of varying
insurance rates by sex – a practice that had added an estimated $1 billion a year to women’s
health insurance premiums.28 Health plans may no longer carve-out maternity care from plans
and must allow women to see their obstetrician or gynecologist without a referral. All nongrandfathered plans must cover women’s preventive services, which includes contraceptive
services, screening for interpersonal and domestic violence, and breast-feeding services and
supplies. The ACA’s reduction in cost-sharing for contraceptive services increased women’s use
of these services, including long-term contraception methods.29 The ACA’s bar on sex
discrimination makes it an important civil rights, as well as health reform, law.
15.
The ACA has improved coverage for young adults. The ACA requires health insurers to
extend dependent coverage to children up to age 26. An estimated 2.3 million young adults (ages
19 to 25) gained health insurance between 2010 and the end of 2013. Starting in 2014, millions
more gained coverage through the Health Insurance Marketplaces and other reforms.30
According to one review, “a wealth of evidence finds that the ACA dependent coverage
expansions increased access to care, use of a wide variety of services, and reduced out-of-pocket
spending.”31 For example, mental health visits increased by 9.0 percent and inpatient visits by
3.5 percent for young adults gaining coverage on their parents’ plans.32
27 Uberoi N, Finegold K and Gee E, Health Insurance Coverage and the Affordable Care Act, 2010 – 2016, Office of the Assistant
Secretary for Planning and Evaluation Issue Brief, 2016. https://aspe.hhs.gov/system/files/pdf/187551/ACA2010-2016.pdf
28 Garrett D, Greenberger M, Waxman J, Benyo A, Dickerson K, Gallagher-Robbins K, Moore R and Trumble S, Turning To
Fairness: Insurance Discrimination Against Women Today and the Affordable Care Act, National Women’s Law Center, Report,
March 2012, https://www.nwlc.org/sites/default/files/pdfs/nwlc_2012_turningtofairness_report.pdf
29 Carlin CS, Fertig AR and Dowd BE, Affordable Care Act’s Mandate Eliminating Contraceptive Cost Sharing Influenced
Choices of Women With Employer Coverage, Health Affairs 35(9), 2016,
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2015.1457
30 Uberoi N, Finegold K and Gee E, Health Insurance Coverage and the Affordable Care Act, 2010 – 2016, Office of the Assistant
Secretary for Planning and Evaluation Issue Brief, 2016. https://aspe.hhs.gov/system/files/pdf/187551/ACA2010-2016.pdf
31 Abraham J and Royalty AB, How Has the Affordable Care Act Affected Work and Wages, Leonard Davis Institute of Health
Economics, University of Pennsylvania, Issue Brief, January 2017, https://ldi.upenn.edu/brief/how-has-affordable-care-actaffected-work-and-wages
32 Akosa Antwi Y, Moriya AS and Simon KI, Access to Health Insurance and the Use of Inpatient Medical Care: Evidence from
the Affordable Care Act Young Adult Mandate, J Health Econ 39:171-187, 2015,
https://www.ncbi.nlm.nih.gov/pubmed/25544401
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16.
The ACA newly required all private health plans to end the use of annual and lifetime
limits and to include an annual out-of-pocket limit on cost sharing. An estimated 22 million
people enrolled in employer coverage are now protected against catastrophic costs.33 While data
collected on personal bankruptcy does not include causes, filings dropped by about 50 percent
between 2010 and 2016; experts attribute some of this change to the new financial protections
offered by the ACA starting in 2010.34
The ACA’s Health Insurance Marketplaces Have Given Millions Access to Quality Private
Insurance, Often with Financial Assistance
17.
The ACA created Health Insurance Marketplaces (Marketplaces), a new way for people
not eligible for Medicare or Medicaid to get affordable, accessible private insurance independent
of their jobs. These Marketplaces offer websites at which people can compare plans that have
four different levels of cost sharing (bronze, silver, gold, and platinum).35 Financial assistance
comes through income-related, premium-based tax credits for qualified individuals with income
between 100 and 400 percent of the federal poverty level and cost-sharing assistance or
“reductions” for qualified individuals with income between 100 and 250 percent of the federal
poverty level enrolled in silver plans. The Marketplaces also provide people with support in
navigating the system through in-person help and call centers. In 2018, 12 states operate their
State-based Marketplaces (SBMs) (operating their own websites rather than using the federallyrun HealthCare.gov), 28 states rely entirely on the federal government to run their Marketplaces
(use HealthCare.gov), and 11 states have hybrid Marketplaces (assuming some but not all
33 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4
Reforming the Health Care System, U.S. Government Publishing Office, 2017.
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf
34 St. John A, How the Affordable Care Act Drove Down Personal Bankruptcy, Consumer Reports, May 2017,
https://www.consumerreports.org/personal-bankruptcy/how-the-aca-drove-down-personal-bankruptcy/
35 People under age 30 also have access to a plan that only covers catastrophic costs.
00010
functions).36 The Marketplaces also offer small businesses a way to find qualified health plans
(called SHOP).
18.
Several aspects of the ACA contributed to the 57 percent increase between 2013 and
2016 in the number of people covered in the individual market (on and off Marketplaces).37 An
estimated 40 to 50 percent of the coverage gain explained by the ACA resulted from the Health
Insurance Marketplaces’ policies.38 One key reason for this expansion is financial assistance,
primarily in the form of premium tax credits. In 2017, 84 percent of the 10.3 million people
enrolled in Marketplaces received premium tax credits, whose average annualized amount was
$4,458 per enrollee.39 The premium tax credit is set to limit the percent of income an enrollee
pays for the second-lowest silver plan in an area. This method of setting assistance means that
aid varies regionally with health insurance costs. Second, individual market insurance reforms
contributed to increased individual market enrollment. The number of people with pre-existing
conditions covered in the individual market rose by 64 percent between 2010 and 2014.40
Coverage also increased because of the individual mandate, the requirement that people who can
afford coverage have it. How much of this increase in coverage can be traced to financial
incentives, changes in insurance requirements, or the coverage mandate remains a matter of
academic dispute.
19.
The ACA set up the Marketplaces to encourage competition among insurers, both the
keep premiums low and improve customer service. To that end, it standardized benefits to
facilitate shopping on price, required that the Marketplaces create tools to allow consumer to
Kaiser Family Foundation, State Health Insurance Marketplace Types, 2018, https://www.kff.org/health-reform/stateindicator/state-health-insurance-marketplacetypes/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
37 Kaiser Family Foundation, Health Insurance Coverage of Nonelderly 0-64, 2013 and 2016, https://www.kff.org/other/stateindicator/nonelderly-064/?dataView=1¤tTimeframe=3&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
38 Frean M, Gruber J and Sommers BD, Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the
Affordable Care Act, National Bureau of Economic Research, 53:72-86, 2016, http://www.nber.org/papers/w22213
39 Centers for Medicare & Medicaid Services, 2017 Effectuated Enrollment Snapshot, June 2017,
https://downloads.cms.gov/files/effectuated-enrollment-snapshot-report-06-12-17.pdf
40 Office of the Assistant Secretary for Planning and Evaluation, Health Insurance Coverage for Americans with Pre-Existing
Conditions: The Impact of the Affordable Care Act, Issue Brief, January 2017, https://aspe.hhs.gov/system/files/pdf/255396/PreExistingConditions.pdf
36
00011
compare plans, and established a permanent risk-adjustment program to prevent insurers from
profiting by disproportionately enrolling people with lower-than-average health care costs. The
unsubsidized cost of coverage in the Marketplaces, before the start of the Trump Administration,
was 10 percent lower than the average employer-sponsored insurance premium.41 In the early
years after the Marketplaces opened, some insurers set prices so low that they lost money in
order to gain market share; others did not fully understand the risks of their new customers. In
2017, they raised premiums to correct those mistakes. After the 2017 price corrections, analysis
indicated that premiums would have grown in single digits for 2018 but for the policy changes
under the Trump Administration.42 Premiums have been lower in SBMs than in HealthCare.gov
states, because SBMs manage their plans more actively than the administration.43 In 2017, 71
percent of enrollees could buy a health plan with a cost (net of tax-credit assistance) of less than
$75 per month.44 In 2016, most (70 percent) of Marketplace enrollees reported no difficulty
paying out-of-pocket costs in the previous year, slightly lower than enrollees in employer plans
(75 percent).45 States benefited fiscally in two ways: Marketplace financial assistance is fully
federally financed and expanded insurance reduces state outlays to offset the cost to providers of
uncompensated care.
20.
Access and satisfaction as well as affordability of individual market coverage have
improved. According to one survey, in 2010, 60 percent of people seeking individual market
coverage found it very difficult or impossible to find affordable care; by 2016, that proportion
Blumberg LJ, Holahan J and Wengle E, Are Nongroup Marketplace Premiums Really High? Not in Comparison with
Employer Insurance, Urban Institute, Brief, September 2016, https://www.urban.org/research/publication/are-nongroupmarketplace-premiums-really-high-not-comparison-employer-insurance
42 Fiedler M, Taking Stock of Insurer Financial Performance in the Individual Health Insurance Market Through 2017, USCBrookings Schaeffer Initiative for Health Policy, Report, October 2017, https://www.brookings.edu/wpcontent/uploads/2017/10/individualmarketprofitability.pdf
43 Hall MA and McCue MJ, Health Insurance Markets Perform Better in States That Run Their Own Marketplaces, To the Point,
The Commonwealth Fund, March 2018, http://www.commonwealthfund.org/publications/blog/2018/mar/health-insurancemarkets-states
44 Office of the Assistant Secretary for Planning and Evaluation, Health Plan Choice and Premiums in the 2018 Federal Health
Insurance Exchange, Research Brief, October 2017, https://aspe.hhs.gov/system/files/pdf/258456/Landscape_Master2018_1.pdf
45 Presentation: 2016 Survey of US Health Care Consumers: A Look at Exchange Consumers, Deloitte Development LLC, 2016,
https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-consumer-survey-hix.pdf
41
00012
fell to 34 percent.46 A study of people newly enrolled in one plan in California and Colorado
found that the proportion of enrollees with a personal health care provider rose from 59 to 73
percent, and the proportion receiving a flu shot in the previous year rose from 41 to 52 percent.47
Satisfaction was roughly the same among enrollees in Marketplace plans and employer plans in
2016.48 Satisfaction among adults with Marketplace or Medicaid coverage rose between 2014
(78 percent) and 2017 (89 percent).49
The ACA’s Medicaid Provisions Expanded Eligibility, Improved Accessibility and Quality
of Care, and Increased Savings
21.
The ACA included a number of changes to Medicaid. It expanded Medicaid coverage to
adults with income under 138 percent of the federal policy level (which the Supreme Court ruled
was unenforceable as a mandate in 2012, but which 32 states have now adopted). It expanded
minimum coverage standards for children ages 6 to 18, simplified program eligibility rules as
well as the enrollment and renewal process, increased spending on long-term services and
supports, added incentives to encourage quality measurement, and promoted care coordination
for dual Medicare-Medicaid eligible beneficiaries. It made family planning coverage a state
option, extended coverage for young adults aging out of foster care, increased Medicaid drug
rebates, and increased efforts to combat fraud. Through the Center for Medicare and Medicaid
Innovation (CMMI), the ACA also supported testing and evaluation of payment reforms to
improve quality and decrease costs. The ACA also extended funding for CHIP and made policy
changes that Congress recently largely incorporated in a ten-year reauthorization of the program.
Collins SR, Gunja MZ, Doty MM and Beutel S, How the Affordable Care Act Has Improved Americans; Ability to Buy Health
Insurance on Their Own, The Commonwealth Fund, Issue Brief, 2016, http://www.commonwealthfund.org/publications/issuebriefs/2017/feb/how-the-aca-has-improved-ability-to-buy-insurance
47 Schmittdiel JA, Barrow JC, Wiley D, Ma L, Sam D, Chau CV and Shetterly SM, Improvements in Access and Care Through
the Affordable Care Act, American Journal of Managed Care, 23(3):e95-97, 2017,
http://www.ajmc.com/journals/issue/2017/2017-vol23-n3/improvements-in-access-and-care-through-the-affordable-care-act
48 Presentation: 2016 Survey of US Health Care Consumers: A look at Exchange Consumers, Deloitte Development LLC, 2016,
https://www2.deloitte.com/content/dam/Deloitte/us/Documents/life-sciences-health-care/us-dchs-consumer-survey-hix.pdf
49 The Commonwealth Fund, A Majority of Marketplace and Medicaid Enrollees Are Getting Health Care They Could Not Have
Afforded Prior to Having Coverage, Affordable Care Act Tracking Survey, no date, http://acatracking.commonwealthfund.org/
46
00013
22.
The number of non-elderly people with Medicaid coverage increased by 13 percent
between 2013 and 2016,50 largely because 32 states (including the District of Columbia)
expanded eligibility to low-income adults under the new category created by the ACA.51
Eligibility rule streamlining and other simplifications, increased outreach efforts, a “spillover”
effect from the opening of the Marketplaces, and the individual mandate appear to have had a
coverage effect as well. A recent literature review listed numerous studies documenting
reductions in all states of the proportion of people without insurance. Reductions have been
larger in states that expanded Medicaid than in those that did not. It also found that the Medicaid
expansion improved coverage among young adults, people with HIV, veterans, rural residents,
and racial and ethnic minorities.52 The law’s Medicaid expansion’s impact on coverage may have
exceeded that of other ACA policies.53
23.
At least 40 studies have found improved access to and use of health care associated with
the Medicaid expansion. For example, one study found that, from November 2013 to December
2015, low-income adults in two expansion states reported a greater increase (12.1 percentage
points) in having a personal physician and a greater reduction (18.2 percentage points) in costrelated barriers to access to care compared to low-income adults in a non-expansion state.54
Medicaid coverage also has increased access to treatment for substance use disorder, including
opioid addiction.55 Some critics of the ACA have alleged that Medicaid expansion caused
Kaiser Family Foundation, Health Insurance Coverage of Nonelderly 0-64, 2013 and 2016, https://www.kff.org/other/stateindicator/nonelderly-064/?dataView=1¤tTimeframe=3&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
51 Maine has also scheduled an expansion to begin on July 1, 2018.
52 Antonisse L, Garfield R, Rudowitz R and Artiga S, The Effects of Medicaid Expansion Under the ACA: Updated Findings
From a Literature Review, Henry J Kaiser Family Foundation, Issue Brief, September 2017, https://www.kff.org/medicaid/issuebrief/the-effects-of-medicaid-expansion-under-the-aca-updated-findings-from-a-literature-review-september-2017/
53 Frean M, Gruber J and Sommers BD, Premium Subsidies, the Mandate, and Medicaid Expansion: Coverage Effects of the
Affordable Care Act, National Bureau of Economic Research, 53:72-86, 2016, http://www.nber.org/papers/w22213
54 Sommers BD, Blendon RJ, Orav EJ and Epstein AM, Changes in Utilization and Health Among Low-Income Adults After
Medicaid Expansion or Expanded Private Insurance, JAMA Intern Med., 176(1):1501-1509, 2016,
https://jamanetwork.com/journals/jamainternalmedicine/fullarticle/2542420
55 Clemens-Cope L, Epstein M and Kenney G, Rapid Growth in Medicaid Spending on Medications to Treat Opioid Use
Disorder and Overdose, The Urban Institute, Report, 2017, http://www.urban.org/sites/default/files/publication/91521/2001386rapid-growth-in-medicaid-spending-on-medications-to-treat-opioid-use-disorder-and-overdose_3.pdf
50
(continued…)
00014
addiction. What researchers have found is that states that expanded eligibility tended to have
higher rates of addiction before enactment of the ACA but that drug related mortality fell
compared to states that did not expand Medicaid after enactment.56 Evidence is also building that
Medicaid coverage for low-income adults has helped provide continuity of care for people going
in and out of prisons and may reduce recidivism.57
24.
Much of the evidence on improvements to health stemming from the ACA comes from
its Medicaid expansion. One analysis found a 6.1 percent relative reduction in adjusted all-cause
mortality in states that had expanded Medicaid before the ACA.58 In addition, studies have
documented improved outcomes for such services as cardiac surgery associated with the ACA’s
Medicaid policies.59
25.
The ACA’s Medicaid expansion has also led to documented savings to people, states, and
the health system. For example, self-reported medical debt in Ohio fell by nearly 50 percent after
it broadened Medicaid eligibility.60 An analysis of prescription drug transaction data found that
uninsured people gaining Medicaid coverage due to the expansion experienced a 79 percent
reduction in out-of-pocket spending per prescription.61 State budgets may have also benefited
from receiving federal matching payments for state-funded programs and reductions in payments
for uncompensated care; Louisiana, for example, estimated such savings at $199 million in
(…continued)
Wen H, Hockenberry J, Borders T and Druss B, Impact of Medicaid Expansion on Medicaid-Covered Utilization of
Buprenorphine for Opioid Use Disorder Treatment, Medical Care, 55(4):336-341, 2017, http://journals.lww.com/lwwmedicalcare/Fulltext/2017/04000/Impact_of_Medicaid_Expansion_on_Medicaid_covered.5.aspx
56 Goodman-Bacon A and Sandoe E, Did Medicaid Expansion Cause The Opioid Epidemic? There’s Little Evidence That It Did.,
Health Affairs Blog, August 2017, https://www.healthaffairs.org/do/10.1377/hblog20170823.061640/full/.
57 Regenstein M and Rosenbaum S, What The Affordable Care Act Means For People With Jail Stays, Health Affairs, 33(3),
2014, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2013.1119.
58 Sommers BD, Baicker K and Epstein AM, Mortality and Access to Care among Adults after State Medicaid Expansions, The
New England Journal of Medicine, 367:(1025-1034), 2012, http://www.nejm.org/doi/full/10.1056/nejmsa1202099.
59 Charles E, Johnston LE, Herbert MA, Mehaffey JH, Yount KW, Likosky DS, Theurer PF, Fonner CE, Rich JB, Speir AL,
Ailawadi G, Prager RL and Kron IL, Impact of Medicaid Expansion on Cardiac Surgery Volume and Outcomes, The Annals of
Thoracic Surgery, 104:1251-1258, June 2017, http://www.annalsthoracicsurgery.org/article/S0003-4975(17)30552-0/pdf.
60 The Ohio Department of Medicaid, Ohio Medicaid Group VIII Assessment: A Report to the Ohio General Assembly, January
2017, http://medicaid.ohio.gov/Portals/0/Resources/Reports/Annual/Group-VIII-Assessment.pdf.
61 Mulcahy AW, Eibner C and Finegold K, Gaining Coverage through Medicaid Or Private Insurance Increased Prescription Use
And Lowered Out-Of-Pocket Spending, Health Affairs, 35(9), 2016,
https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2016.0091.
00015
2017.62 A recent national study found no significant increase in state Medicaid spending, nor a
decrease in education, transportation, or other state spending, as a result of the expansion.63
States also have not shown regret about their decisions to expand Medicaid, as indicated by
reauthorizations of and public statements supporting the Medicaid expansion, even in
Republican-led states.64 The health system, in particular the hospital sector, has also gained
financially from the Medicaid expansion. As previously mentioned, not only has uncompensated
care decreased to a greater degree in states that expanded Medicaid as compared to those that did
not; the hospitals that gained the most tended to be small, rural, for-profit, and non-federal
governmental hospitals.65
26.
The ACA’s Medicaid provisions indirectly and directly improved coverage for people
with disabilities. Its expansion directly helped those who did not qualify under pre-ACA rules,
including those awaiting a disability determination. It also authorized a new eligibility pathway
for full Medicaid benefits for people who were previously only eligible for partial Medicaid
benefits under home- and community-based care waivers. The law created new programs such as
the Community First Choice Options as well as demonstration programs to integrate care for
people eligible for both Medicaid and Medicare. Medicaid covers about 6 million low-income
seniors and 10 million non-elderly people with disabilities, with these two groups accounting for
nearly two-thirds of overall Medicaid spending. As of 2016, 17 states had adopted the ACA’s
option for home- and community-based services and 8 were participating in Community First
Choice.66
62 Louisiana Department of Health, Medicaid Expansion 2016/17, June
2017, http://dhh.louisiana.gov/assets/HealthyLa/Resources/MdcdExpnAnnlRprt_2017_WEB.pdf.
63 Sommers B and Gruber J, Federal Funding Insulated State Budgets From Increased Spending Related To Medicaid Expansion,
Health Affairs, 65(5):938-944, 2017, https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.2016.1666.
64 Hall M, Do States Regret Expanding Medicaid? USC-Brookings Schaeffer On Health Policy, March, 2018,
https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2018/03/26/do-states-regret-expanding-medicaid/
65 Blavin F, How Has the ACA Changed Finances for Different Types of Hospitals? Updated Insights from 2015 Cost Report
Data, The Urban Institute, April 2017, https://www.rwjf.org/content/dam/farm/reports/issue_briefs/2017/rwjf436310.
66 Musumeci M and Young K, State Variation in Medicaid Per Enrollee Spending for Seniors and People with Disabilities, Henry
J Kaiser Family Foundation, Issue Brief, May 2017, https://www.kff.org/medicaid/issue-brief/state-variation-in-medicaid-perenrollee-spending-for-seniors-and-people-with-disabilities/.
00016
The ACA’s Medicare Provisions Improved Benefits, Reduced Overpayments, Supported
Value-Based Purchasing, and Tackled Fraud and Abuse
27.
The ACA modified Medicare to improve its benefits; promote quality, value-based
purchasing, and alternative payment models; and lower overpayments and fraud in its traditional
program and Medicare Advantage. It created CMMI to develop and test new payment models
which, if determined to reduce spending without harming quality of care (or to improve quality
without increasing spending), could be adopted by Medicare nationwide. It also included specific
payment models as alternatives to paying for volume, such as Accountable Care Organizations
(ACOs) and bundled payments that pay per person or episode, respectively. New quality “star
rating” programs were expanded to inform choices. The law also raised the Medicare payroll tax
for high-income people to support Medicare’s Hospital Insurance Trust Fund.
28.
The ACA included a major focus on preventive services (described below as well). It
created an annual wellness visit in Medicare and eliminated cost sharing for certain evidencebased preventive services. In 2016, more than 10.3 million Medicare beneficiaries had an annual
wellness visit and 40.1 million used at least one preventive service with no copay (provisions
included in the ACA). It also included a provision that would gradually close the coverage gap or
“donut hole” in Medicare’s Part D drug benefit. Before the ACA, Medicare beneficiaries had no
drug coverage after the standard benefit that ends with $2,830 in total spending and its
catastrophic benefit that begins with $4,550 in out-of-pocket spending (2010 values). Because of
changes contained in the ACA, nearly 12 million Medicare beneficiaries received cumulative
prescription drug savings from 2010 to 2016 that averaged $2,272 per person ($1,149 per
beneficiary in 2016 alone).67 Research suggests the policy both reduced out-of-pocket costs and
contributed to greater use of generic drugs.68 Drug savings for Medicare – and other payers –
67 Centers for Medicare & Medicaid Services, Nearly 12 Million People with Medicare Have Saved over $26 Billion on
Prescription Drugs since 2010, Press Release, January 2017, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Pressreleases/2017-Press-releases-items/2017-01-13.html.
68 Bonakdar Tehrani A and Cunningham PJ, Closing the Medicare Doughnut Hole: Changes in Prescription Drug Utilization and
Out-of-Pocket Spending Among Medicare Beneficiaries With Part D Coverage After the Affordable Care Act, Medical Care,
(continued…)
00017
will also flow from ACA’s new pathway for approval of lower-cost “biosimilar” drugs. A
RAND analysis estimated that this provision could reduce U.S. health spending by $54 billion
from 2017 to 2026.69
29.
Most of the ACA’s savings come from reducing Medicare overpayments. The ACA, for
the first time, built permanent productivity adjustments into Medicare payment formulas. The
ACA also phased in new benchmark payment rates and reduced upcoding for risk in Medicare
Advantage (MA). Despite concerns about an estimated 12 percentage point reduction in MA
rates, MA program enrollment has grown by over 70 percent and premiums have dropped since
2010.70 The ACA also included new tools and resources to combat health care fraud; in 2015, the
government recovered $2.4 billion, returning $6.10 for each dollar invested, and conducted its
largest ever nationwide health care fraud takedown, charging 243 people with false billing.71
30.
The ACA prioritized delivery system reform to promote more efficient, high-quality care,
led by Medicare. As of 2016, nearly 30 percent of payments in Medicare and major private plans
were made through new payment models, virtually none of which existed in 2010.72 In 2017, 21
percent of Medicare beneficiaries received care from an ACO or medical home, with another 33
percent in Medicare Advantage.73 Because these innovations are new, few evaluations have been
done. Some demonstrations seem to have been successful. For example, the pioneer ACOs saved
Medicare $24 million in 2016, reduced spending by 1 to 2 percent relative to a comparison group
(…continued)
55(1):43-49, 2017, https://journals.lww.com/lwwmedicalcare/Abstract/2017/01000/Closing_the_Medicare_Doughnut_Hole__Changes_in.7.aspx.
69 Mulcahy AW, Hlavka JP and Case SR, Biosimilar Cost Savings in in the United States, RAND Corporation, Perspectives,
2017, https://www.rand.org/pubs/perspectives/PE264.html.
70 Jacobson G, Damico A, Neuman T and Gold M, Medicare Advantage 2017 Spotlight: Enrollment Market Update, Henry J
Kaiser Family Foundation, Issue Brief, June 2017, https://www.kff.org/medicare/issue-brief/medicare-advantage-2017-spotlightenrollment-market-update/.
71 Department of Justice, Fact Sheet; The Health Care Fraud and Abuse Control Program Protects Consumers and Taxpayers by
Combating Health Care Fraud, Press Release, February 2016, https://www.justice.gov/opa/pr/fact-sheet-health-care-fraud-andabuse-control-program-protects-conusmers-and-taxpayers.
72 Health Care Payment Learning & Action Network, Measuring Progress: Adoption of Alternative Payment Models in
Commercial, Medicaid, Medicare Advantage, and Fee-for-Service Medicare Programs, Report, October 2017, https://hcplan.org/groups/apm-fpt-work-products/apm-report/.
73 Henry J Kaiser Family Foundation, Medicare Delivery System Reform: The Evidence Link, no date,
https://www.kff.org/medicare-delivery-system-reform-the-evidence-link/.
00018
in 2013, and had overall quality composite scores that increased over time.74 And, research has
found that the bundled payments for lower extremity joint replacement reduced readmissions
while cutting average Medicare per-episode spending by 21 percent if there were no
complications and 14 percent if there were complications.75
31.
Medicare is on stronger financial footing because of the ACA. In 2010, CBO estimated
that the ACA would reduce Medicare spending by over $400 billion from 2010 to 2019.76 A
study by the U.S. Department of Health and Human Services found Medicare spent $473.1
billion less from 2009 to 2014 than it would have had the 2000 to 2008 average growth rate
continued.77 Reduced Medicare spending, combined with increased revenue, contributed to
extending the life of Medicare’s Hospital Insurance Trust Fund by 12 years (to 2029) as
compared to its projected insolvency when the ACA was enacted (2017).78 The benefits of
slower Medicare cost growth accrue to beneficiaries and states as well. In 2016, Medicare
premiums and cost sharing for traditional Medicare were $700 lower per beneficiary compared
to what such spending would have been under 2009 projections.79 States similarly have saved
since they pay Medicare premiums and cost sharing for certain low-income beneficiaries.
The ACA Strengthened the Public Health System and Made Other Capacity Improvements
74 Henry J Kaiser Family Foundation, Medicare Delivery System Reform: The Evidence Link, Side-by-Side Comparison:
Medicare Accountable Care Organization (ACO) Model, no date, https://www.kff.org/interactive/side-by-side-comparisonmedicare-accountable-care-organization-aco-models/.
75 Navathe AS, Troxl AB, Liao JM, Nan N, Zhu J, Zhon W, and Emanuel EJ, Cost of Joint Replacement Using Bundled Payment
Models, JAMA Intern Med., 177(2):214-222, 2017, https://jamanetwork.com/journals/jamainternalmedicine/articleabstract/2594805.
76 Elmendorf DW, Letter to Honorable Nancy Pelosi, Speaker, U.S. House of Representatives, Congressional Budget Office,
March 20, 2010, https://www.cbo.gov/sites/default/files/111th-congress-2009-2010/costestimate/amendreconprop.pdf
77 Chappel A, Sheingold S and Nguyen N, Health Care Spending Growth And Federal Policy, Office of the Assistant Secretary
for Planning and Evaluation, Issue Brief, March 2016, https://aspe.hhs.gov/system/files/pdf/190471/SpendingGrowth.pdf.
78 Medicare Trustees Report. Note that 2029 was also the projection in the 2010 report in which the Trustees attributed much of
the improvement to the ACA. For Trustees report, see: https://www.cms.gov/Research-Statistics-Data-and-Systems/StatisticsTrends-and-Reports/ReportsTrustFunds/index.html.
79 Executive Office of the President Council of Economic Advisors, 2017 Economic Report of the President, Chapter 4
Reforming the Health Care System, U.S. Government Publishing Office, 2017.
https://obamawhitehouse.archives.gov/sites/default/files/docs/chapter_4-reforming_health_care_system_2017.pdf
00019
32.
Key coverage and funding provisions of the ACA have protected millions of Americans
from infectious and chronic diseases through clinical preventive services, funding for state and
local public health services, and investments in healthier communities. It supports improving
health system infrastructure through policies such as a new Community Health Center Fund to
expand services, a program to build school-based health clinics, a permanent authorization of the
Indian Health Care Improvement Act, and a set of workforce policies to promote primary care
and increase the number of people trained through the National Health Service Corps. It also
encourages integration of behavioral and primary care services through training programs as well
its insurance and payment policies.
33.
The required coverage of clinical preventive services has resulted in increased use of key
preventive services such as blood pressure and cholesterol screenings and flu vaccinations.80
Insurance coverage of vaccinations and ACA investments in the Section 317 Immunization
Program, totaling almost $768 million for fiscal years 2010 to 2017, have increased protection
against vaccine-preventable diseases among Americans. For example, women were 3.3 times as
likely to have had the HPV vaccine after implementation of the ACA.81 Increased coverage of
smoking cessation services under Medicaid, newly mandated under the ACA, has also been
demonstrated both to reduce state health care costs and to improve health outcomes. One
analysis in Massachusetts found savings of $3.12 in medical costs for every $1 spent on smoking
cessation services.82
Han X, Yabroff KR, Guy GP, Zheng Z and Jemal A, Has Recommended Preventive Service Use Increased after Elimination of
Cost-Sharing as Part of the Affordable Care Act in the United States? Preventive Medicine, 78:85–91, 2015,
http://doi.org/10.1016/j.ypmed.2015.07.012.
81 Corriero R, Gay JL, Robb SW and Stowe EW, Human Papillomavirus Vaccination Uptake Before and After the Affordable
Care Act: Variation According to Insurance Status, Race, and Education (NHANES 2006-2014), Journal of Pediatric and
Adolescent Gynecology, 31(1):23-27, 2017, https://doi.org/10.1016/j.jpag.2017.07.002.
82 Richard P, West K and Ku L, The Return on Investment of a Medicaid Tobacco Cessation Program in Massachusetts, PLoS
ONE, 7(1): e29665, 2012. https://doi.org/10.1371/journal.pone.0029665.https://doi.org/10.1371/journal.pone.0029665
80
00020
34.
The Prevention and Public Health Fund (PPHF), a new funding stream created by the
ACA, has sent over $3.9 billion to states since 2010 ($650 million for fiscal year 2017).83 This
fund has supported key programs, three of which are described below in paragraphs 35-37.
35.
The PPHF funded Tips from Former Smokers, an advertising campaign to encourage quit
attempts. The Centers for Disease Control and Prevention estimated that it led 500,000 people to
quit smoking for good in the first five years of the campaign, with an estimated cost of $2,000
for every life saved from a smoking death.84 In addition, states have received PPHF grants for
their smoking cessation programs, totaling over $133 million since 2010.
36.
The PPHF investment, including nearly $17 million in fiscal year 2017, permitted
expansion of the Diabetes Prevention Program (DPP), a community-based lifestyle change
program. This program has been shown to prevent progression to diabetes among many of those
with prediabetes, resulting in savings and improved health outcomes. In testing by CMMI, DPP
saved Medicare an estimated $2,650 for each person enrolled in DPP over a 15-month period.85
The Medicare Diabetes Prevention Program (MDPP) is now available to all eligible
beneficiaries.
37.
PPHF has been critical in expanding and sustaining the capacity of state and local health
departments to meet the needs of their communities, in particular through annual funding of the
Preventive Health and Health Services Block Grant ($160 million a year) and Epidemiology and
Laboratory Grants ($40 million a year). The two grants combined have put over $1.1 billion into
communities in fiscal years 2010 through 2017.
38.
The ACA invested $1.5 billion in the Maternal, Infant, and Early Childhood Home
Visiting Grants to support state-level expansion of the Nurse-Family Partnership. This program
83 Trust for America’s Health, Updated Prevention and Public Health Fund (PPHF) State Funding Data (FY10-FY17), March
2018, http://healthyamericans.org/health-issues/news/updated-prevention-and-public-health-fund-pphf-state-funding-data-fy10fy17/
84 Centers for Disease Control and Prevention, Tips Impact and Results, no date,
https://www.cdc.gov/tobacco/campaign/tips/about/impact/campaign-impact-results.html?s_cid=OSH_tips_D9391.
85 Centers for Medicare & Medicaid Services, Medicare Diabetes Prevention Program (MDPP) Expanded Model, no date,
https://innovation.cms.gov/initiatives/medicare-diabetes-prevention-program/.
00021
has had a dramatic impact on medical care, child welfare, special education, and criminal justice
system involvement by the families served by the program, with a savings to government
programs of 1.9 times the cost.86
39.
There is growing evidence that pediatric asthma, diabetes, heart disease and other chronic
conditions are linked with social and economic factors or conditions where people live, grow,
and work.87 Through both the PPHF and CMMI, the ACA has supported investments in the
multi-sector partnerships that can address the health-related social needs of people served by our
health system. CMMI is supporting a $157 million initiative, Accountable Health Communities
(AHC), in 23 states across the country as well as accountable communities for health models
through the State Innovation Models grants in 10 states.88 Through various community
prevention programs supported by the PPHF’s over $1 billion investment from 2010 to 2017,
every state has received support to build stronger partnerships across sectors that will improve
the health of communities.
40.
ACA investments have also expanded the health care workforce in every state. More
primary care providers are now working in teams to address complex care needs of populations.
The increases are due in large part to the expansion of primary care training programs for
physicians, physician assistants, and nurse practitioners funded through the PPHF, which added
approximately 4,500 providers.89 There was also the expansion of residency training programs
under the ACA, such as the Teaching Health Centers program, that added approximately 1,555
primary care physicians working in shortage areas. Through a $1.5 billion investment in the
National Health Service Corps, the number of people served by Corps clinicians rose from 9
86 Miller, TR, Projected Outcomes of Nurse-Family Partnership Home Visitation during 1996-2013, USA., Prevention Science,
16(6):765-777, 2015, https://www.ncbi.nlm.nih.gov/pubmed/26076883.
87 Magnan, S, Social Determinants of Health 101 for Health Care: Five Plus Five. NAM Perspectives. National Academy of
Medicine, 2017, https://nam.edu/social-determinants-of-health-101-for-health-care-five-plus-five.
88 Centers for Medicare & Medicaid Services, CMS’ Accountable Health Communities Model Selects 32 Participants to Serve as
Local ‘Hubs’ Linking Clinical and Community Services, Press Release, April 2017,
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-04-06.html.
89 Health Resources and Services Administration, FY 2016 Annual Performance Report, 2016,
https://www.hrsa.gov/sites/default/files/about/budget/peformancereport2016.pdf.
00022
million in 2010 to 15.9 million in 2016. The ACA investment increased its number of health care
providers from 7,358 to 15,159, including physicians, nurses, dentists, and behavior health
providers serving in over 14,000 shortage area sites. Corps clinicians had an 80 percent retention
rate after one year of completed service requirements.
41.
The ACA invested in health care facilities as well as workers. Its Community Health
Center Fund has been used, among other activities, for facility improvement, expanded access
points, and expanded service capacity.90 This Fund, plus the expansion of Medicaid, contributed
to growth in the number of patients served from 19.5 million in 2010 to 25.9 million in 2016.91 It
supported construction and renovation of school-based health clinics, providing about 520
awards.92 The ACA also authorized new programs within the Indian Health Service, including
behavior health programs, and expanded subsidies in Medicaid and the Marketplaces for
American Indians and Native Americans.93
Enjoining the ACA Would Cause Widespread Harm in All States for the Vast Majority of
Americans
42.
As this review of the impact of the ACA illustrates, enjoining the ACA would cause
grievous immediate and long-term harm to Americans’ health and financial security, to the
health system, and to federal and state budgets. The law’s provisions are so interwoven in the
health system that the harms from an injunction would go far beyond negating the benefits
directly traceable to the ACA. Some ACA policies could not simply fall back to what they were
almost a decade ago. For example, Medicare probably could not make payments to Medicare
Advantage plans pursuant to an injunction since the ACA replaced the previous payment system;
90 Congressional Research Service Reports, The Community Health Center Fund: In Brief, 2017,
https://www.everycrsreport.com/reports/R43911.html.
91 Rosenbaum S, Tolbert J, Sharac J, Shin P, Gunsalus R and Zur J, Community Health Centers: Growing Importance in a
Changing Health System, Henry J Kaiser Family Foundation, Issue Brief, March 2018, http://files.kff.org/attachment/Issue-BriefCommunity-Health-Centers-Growing-Importance-in-a-Changing-Health-Care-System
92 Pilkey D, Skopec L, Gee E, Finegold K, Amaya K and Robinson W, The Affordable Care Act and Adolescents, Office of the
Assistant Secretary for Planning and Evaluation, Research Brief, August 2013,
https://aspe.hhs.gov/system/files/pdf/180281/rb_adolescent.pdf.
93 Ross RW, Garfield LD, Brown DS and Raghavan R, The Affordable Care Act and Implications for Health Care Services for
American Indian and Alaska Native Individuals, J Health Care Poor Underserved, 26(4):1081-1088, 2015,
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4824684/.
00023
19 million beneficiaries could lose their plans and publicly traded insurers’ stocks could
plummet. Some programs that pre-dated the ACA would cease to function under an injunction.
For example, the ACA’s PPHF is now the only source of support for the long-standing
Preventive and Public Health Services Block Grant. This grant supports critical services,
including lab capacity to test for outbreaks of flu or virus-borne diseases such as Zika, responses
to emerging public health threats such as the opioid epidemic, and chronic health threats such as
damage to children through exposure to lead.94 Beyond the heightened threat to public health,
states’ credit ratings could fall due to their increased financial exposure from such funding cuts
along with the loss of federal Medicaid funding.95
43.
CBO acknowledged these and other challenges when it estimated the implications of the
full repeal of the ACA in 2015. It projected that repealing the ACA would increase the federal
budget deficit by $353 billion over ten years, not taking into account macroeconomic feedback.
Medicare spending would increase by $802 billion over this period, raising seniors’ premiums
and hastening Medicare Trust Fund insolvency. CBO projected that 24 million people would
become uninsured.96
44.
CBO prepared similar estimates in 2016 and early 2017 when legislation to repeal parts
of the ACA (without a replacement) was under consideration. The Urban Institute found that
partial repeal would increase in the number of uninsured by 29.8 million, of whom 82 percent
would be in working families and 38 percent would be young adults. This dramatic increase in
the number of uninsured would increase the cost of uncompensated care by an estimated $1.1
trillion over a decade, which would put significant budget stress on state and local governments
Clary A, Rosenthal J, Riley T, The Prevention and Public Health Fund – Lessons from States; Questions for Policymakers,
National Academy for State Health Policy, State Health Policy Blog, March 2017, https://nashp.org/the-prevention-and-publichealth-fund-lessons-from-states-questions-for-policymakers/
95 Schneider A, Fitch Report: Proposed Medicaid Cuts Could Impact States’ Credit Ratings, Georgetown University Health
Policy Institute, Center for Children and Families, Say Ahhh! Blog, June 2017, https://ccf.georgetown.edu/2017/06/28/fitchreport-medicaid-cuts-will-impact-states-schools-and-more/
96 Congressional Budget Office, Budgetary and Economic Effects of Repealing the Affordable Care Act, June 2015,
https://www.cbo.gov/sites/default/files/114th-congress-2015-2016/reports/50252-effectsofacarepeal.pdf
94
00024
as well as the health system.97 An analysis funded by the American Hospital Association
estimated that income of hospitals would be reduced by $165.8 billion from 2018 to 2026.98
45.
No analysis has systematically examined the immediate implications of an injunction of
the entire law. It is not clear how Medicare would continue to make payments if the basis for
those payment rates is nullified, whether states would get federal funding in the next quarter for
service and eligibility categories authorized by the ACA, and if insurers no longer receiving
premium tax credits could immediately revert to medical underwriting. Workers in programs
funded by the ACA, such as CMMI programs, may become immediately unemployed. Drug
discounts provided to seniors with Medicare coverage could immediate cease. People with
disabilities whose care is funded by Community First Choice could immediately lose access to
care without state intervention. These few examples illustrate that enjoining the entire ACA
would create both chaos and inflict harm.
State-Specific Impacts
46.
Enjoining the ACA would harm the health system, public health, and budgets of states
across the country. If people cannot access health coverage, more people will become uninsured,
uncompensated care costs for states will increase, and states will be pressured to fill the void left
from the ACA. The estimates described below come from four sources: (1) state fact sheets from
the Department of Health and Human Services;99 (2) Urban Institute estimates of the impact of a
repeal of the ACA’s funding-related provisions;100 (3) the Trust for America’s Health;101 and (4)
97 Blumberg LK, Buettgens M and Holahan J, Implications of Partial Repeal of the ACA through Reconciliation, Urban Institute,
Report, December 2016, https://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-of-partial-repealof-the-aca-through-reconciliation_1.pdf
98 Dobson DaVanzo & Associates, LLC, Estimating the Impact of Repealing the Affordable Care Act on Hospitals, 2016,
American Hospital Association, Report, 2016, https://www.aha.org/system/files/2018-02/impact-repeal-aca-report_0.pdf
99 Office of the Assistant Secretary of Planning and Evaluation, Compilation of State Data on the Affordable Care Act, December
2016, https://aspe.hhs.gov/compilation-state-data-affordable-care-act. Note that some estimates are not available for all states due
to small sample size.
100 Blumberg LK, Buettgens M and Holahan J, Implications of Partial Repeal of the ACA through Reconciliation, Urban
Institute, Report, December 2016, https://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-ofpartial-repeal-of-the-aca-through-reconciliation_1.pdf.
(continued…)
00025
the Centers for Medicare and Medicaid Services.102 While some of these numbers come from
older or national versus state-specific studies, they are consistent in magnitude and direction with
the likely impact of an injunction.
California
47.
Between 2010 and 2015, an estimated 3,826,000 people in California gained coverage.
This includes a large fraction of the people covered in the California Health Insurance
Marketplace (called Covered California), an estimated 294,000 young adults who gained
coverage by staying on their parents’ health insurance, and those gaining coverage from the
law’s Medicaid (called Medi-Cal) expansion and employer shared responsibility policy. This
coverage would be at risk if the ACA were enjoined.
48.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
16,133,192 people in California have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 12,092,000 people in California with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
injunction to the ACA. An estimated 15,867,909 people in California, including 6,324,503
women ages 15–64, would lose federally guaranteed of preventive services — like flu shots,
(…continued)
Buettgens M, Blumberg LJ, Holahan J, The Impact on Health Care Providers of Partial ACA Repeal Through Reconciliation,
Urban Institute, Report, January 2017, https://www.urban.org/sites/default/files/publication/86916/2001046-the-impact-onhealth-care-providers-of-partial-aca-repeal-through-reconciliation_1.pdf.
101 Trust for America’s Health, Updated Prevention and Public Health Fund (PPHF) State Funding Data (FY10-FY17), March
2018, http://healthyamericans.org/health-issues/news/updated-prevention-and-public-health-fund-pphf-state-funding-data-fy10fy17/
102 Centers for Medicare & Medicaid Services, 2017 Effectuated Enrollment Snapshot, June 2017,
https://downloads.cms.gov/files/effectuated-enrollment-snapshot-report-06-12-17.pdf; Centers for Medicare & Medicaid
Services, Nearly 12 Million People with Medicare Have Saved over $26 Billion on Prescription Drugs since 2010, Press Release,
January 2017, https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2017-Press-releases-items/2017-0113.html.
00026
cancer screenings, and contraception – which are now provided at no extra cost to consumers.
These are just a few of the ACA’s consumer protections that could be lost if this court allows the
ACA to be enjoined.
49.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 1,389,886 people in California covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 85 percent of
Marketplace enrollees in California received a premium tax credit that averaged $4,150 per
person. That financial assistance would no longer be available under an injunction.
50.
Impact on Medicaid: Without the ACA, an estimated 1,188,000 fewer people in
California would have Medicaid coverage. The law’s Medicaid expansion improved access to
care, financial security, and health. For example, it resulted in an estimated 136,000 more getting
all needed care, 169,000 fewer struggling to pay medical bills, 109,000 fewer experiencing
symptoms of depression, and 1,430 avoided deaths each year in California. Enjoining the law
would put these benefits at risk, along with improvements to long-term services and supports,
eligibility simplifications, and policies to lower drug costs and improve the quality of care in
Medicaid. This could, for example, mean that people with disabilities in California’s Community
First Choice program could lose access to services.
51.
Impact on Medicare: The 5,829,777 people with Medicare in California would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 403,631
people in California with $1,169 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 3,879,678
people with Medicare in California used in 2016. It would suspend payment policies which
would increase premiums, cost sharing, and well as taxpayer costs in California. It would also
disrupt programs to reduce preventable patient harms and avoidable readmissions. Hospital
readmissions for Medicare beneficiaries dropped between 2010 and 2015, which translates into
00027
5,580 fewer unnecessary returns to the hospital in California in 2015. The 29 Accountable Care
Organizations (ACOs) in California that offer Medicare beneficiaries the opportunity to receive
higher quality, more coordinated care would no longer operate under an injunction.
52.
Impact on Public Health: Support for public health in California would also be reduced
under an injunction. California received $317,998,658 from the law’s Prevention and Public
Health Fund between fiscal years 2012 and 2016. This includes $61,653,559 for immunizations
and $15,110,953 for tobacco cessation efforts.
53.
Impact on Finances: The financial impact on California would be significant. From
2019 to 2028, it would lose $61.1 billion in federal Marketplace spending and $99.1 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$160.2 billion. This would have a major impact on health care providers. From 2019 to 2028,
California hospitals could lose $64.1 billion and physicians could lose $24.7 billion.
Uncompensated care costs in California would increase by $140.1 billion over this period.
Connecticut
54.
Between 2010 and 2015, an estimated 110,000 people in Connecticut gained coverage.
This includes a large fraction of the people covered in the Connecticut Health Insurance
Marketplace (called AccessHealthCT), an estimated 25,000 young adults who gained coverage
by staying on their parents’ health insurance, and those gaining coverage from the law’s
Medicaid expansion and employer shared responsibility policy. This coverage would be at risk if
the ACA were enjoined.
55.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
1,554,628 people in Connecticut have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 1,386,000 people in Connecticut with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
00028
injunction to the ACA. An estimated 1,819,938 people in Connecticut, including 746,444 women
ages 15–64, would lose federally guaranteed of preventive services — like flu shots, cancer
screenings, and contraception – which are now provided at no extra cost to consumers. These are
just a few of the ACA’s consumer protections that could be lost if this court allows the ACA to
be enjoined.
56.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 98,260 people in Connecticut covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 77 percent of
Marketplace enrollees in Connecticut received a premium tax credit that averaged $5,312 per
person. That financial assistance would no longer be available under an injunction.
57.
Impact on Medicaid: Without the ACA, an estimated 72,000 fewer people in
Connecticut would have Medicaid coverage. The law’s Medicaid expansion improved access to
care, financial security, and health. For example, it resulted in an estimated 8,000 more getting
all needed care, 10,200 fewer struggling to pay medical bills, 7,000 fewer experiencing
symptoms of depression, and 90 avoided deaths each year in Connecticut. Enjoining the law
would put these benefits at risk, along with improvements to long-term services and supports,
eligibility simplifications, and policies to lower drug costs and improve the quality of care in
Medicaid. This could, for example, mean that people with disabilities in Connecticut’s
Community First Choice program could lose access to services.
58.
Impact on Medicare: The 644,136 people with Medicare in Connecticut would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 65,248
people in Connecticut with $1,268 in average annual savings per beneficiary in 2016, would end.
It would roll back the coverage of proven preventive services with no cost sharing which
473,312 people with Medicare in Connecticut used in 2016. It would suspend payment policies
which would increase premiums, cost sharing, and well as taxpayer costs in Connecticut. It
00029
would also disrupt programs to reduce preventable patient harms and avoidable readmissions.
Hospital readmissions for Medicare beneficiaries dropped between 2010 and 2015, which
translates into 1,306 fewer unnecessary returns to the hospital in Connecticut in 2015. The 12
Accountable Care Organizations (ACOs) in Connecticut that offer Medicare beneficiaries the
opportunity to receive higher quality, more coordinated care would no longer operate under an
injunction.
59.
Impact on Public Health: Support for public health in Connecticut would also be
reduced under an injunction. Connecticut received $86,545,015 from the law’s Prevention and
Public Health Fund between fiscal years 2012 and 2016. This includes $10,382,997 for
immunizations and $971,964 for tobacco cessation efforts.
60.
Impact on Finances: The financial impact on Connecticut would be significant. From
2019 to 2028, it would lose $4.3 billion in federal Marketplace spending and $10.5 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$14.8 billion. This would have a major impact on health care providers. From 2019 to 2028,
Connecticut hospitals could lose $6.0 billion and physicians could lose $2.4 billion.
Uncompensated care costs in Connecticut would increase by $14.9 billion over this period.
Delaware
61.
Between 2010 and 2015, an estimated 35,000 people in Delaware gained coverage. This
includes a large fraction of the people covered in the Delaware Health Insurance Marketplace, an
estimated 7,000 young adults who gained coverage by staying on their parents’ health insurance,
and those gaining coverage from the law’s Medicaid expansion and employer shared
responsibility policy. This coverage would be at risk if the ACA were enjoined.
62.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
383,607 people in Delaware have a pre-existing condition and would be at risk for being charged
unaffordable premiums or denied coverage altogether without the ACA. Before the ACA,
00030
320,000 people in Delaware with employer or individual market coverage had a lifetime limit on
their insurance policy: annual and lifetime limits would return under an injunction to the ACA.
An estimated 417,265 people in Delaware, including 171,575 women ages 15–64, would lose
federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
63.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 24,171 people in Delaware covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 83 percent of
Marketplace enrollees in Delaware received a premium tax credit that averaged $5,010 per
person. That financial assistance would no longer be available under an injunction.
64.
Impact on Medicaid: Without the ACA, an estimated 6,000 fewer people in Delaware
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 1,000 more getting all
needed care, 900 fewer struggling to pay medical bills, 1,000 fewer experiencing symptoms of
depression, and 10 avoided deaths each year in Delaware. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
65.
Impact on Medicare: The 186,835 people with Medicare in Delaware would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 23,485
people in Delaware with $1,292 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 149,051
people with Medicare in Delaware used in 2016. It would suspend payment policies which
would increase premiums, cost sharing, and well as taxpayer costs in Delaware. It would also
disrupt programs to reduce preventable patient harms and avoidable readmissions. Hospital
00031
readmissions for Medicare beneficiaries dropped between 2010 and 2015, which translates into
575 fewer unnecessary returns to the hospital in Delaware in 2015. The 7 Accountable Care
Organizations (ACOs) in Delaware that offer Medicare beneficiaries the opportunity to receive
higher quality, more coordinated care would no longer operate under an injunction.
66.
Impact on Public Health: Support for public health in Delaware would also be reduced
under an injunction. Delaware received $34,384,937 from the law’s Prevention and Public
Health Fund between fiscal years 2012 and 2016. This includes $5,146,859 for immunizations
and $314,964 for tobacco cessation efforts.
67.
Impact on Finances: The financial impact on Delaware would be significant. From 2019
to 2028, it would lose $900 million in federal Marketplace spending and $2.7 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $3.6
billion. This would have a major impact on health care providers. From 2019 to 2028, Delaware
hospitals could lose $1.5 billion and physicians could lose $500 million. Uncompensated care
costs in Delaware would increase by $2.8 billion over this period.
District of Columbia
68.
Between 2010 and 2015, an estimated 25,000 people in the District of Columbia gained
coverage. This includes a large fraction of the people covered in the District of Columbia Health
Insurance Marketplace (called DC Health Link), an estimated 6,000 young adults who gained
coverage by staying on their parents’ health insurance, and those gaining coverage from the
law’s Medicaid expansion and employer shared responsibility policy. This coverage would be at
risk if the ACA were enjoined.
69.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
268,134 people in the District of Columbia have a pre-existing condition and would be at risk for
being charged unaffordable premiums or denied coverage altogether without the ACA. Before
the ACA, 208,000 people in the District of Columbia with employer or individual market
00032
coverage had a lifetime limit on their insurance policy: annual and lifetime limits would return
under an injunction to the ACA. An estimated 281,235 people in the District of Columbia,
including 127,531 women ages 15–64, would lose federally guaranteed of preventive services —
like flu shots, cancer screenings, and contraception – which are now provided at no extra cost to
consumers. These are just a few of the ACA’s consumer protections that could be lost if this
court allows the ACA to be enjoined.
70.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 18,038 people in the District of Columbia
covered in the Health Insurance Marketplace would lose coverage without the ACA. In 2017, 4
percent of Marketplace enrollees in the District of Columbia received a premium tax credit that
averaged $2,967 per person. That financial assistance would no longer be available under an
injunction.
71.
Impact on Medicaid: Without the ACA, an estimated 16,000 fewer people in the
District of Columbia would have Medicaid coverage. The law’s Medicaid expansion improved
access to care, financial security, and health. For example, it resulted in an estimated 2,000 more
getting all needed care, 2,300 fewer struggling to pay medical bills, 1,000 fewer experiencing
symptoms of depression, and 20 avoided deaths each year in the District of Columbia. Enjoining
the law would put these benefits at risk, along with improvements to long-term services and
supports, eligibility simplifications, and policies to lower drug costs and improve the quality of
care in Medicaid.
72.
Impact on Medicare: The 90,492 people with Medicare in the District of Columbia
would also lose benefits and pay more under an injunction. Prescription drug discounts, which
provided 3,360 people in the District of Columbia with $1,181 in average annual savings per
beneficiary in 2016, would end. It would roll back the coverage of proven preventive services
with no cost sharing which 54,535 people with Medicare in the District of Columbia used in
00033
2016. It would suspend payment policies which would increase premiums, cost sharing, and well
as taxpayer costs in the District of Columbia. It would also disrupt programs to reduce
preventable patient harms and avoidable readmissions. Hospital readmissions for Medicare
beneficiaries dropped between 2010 and 2015, which translates into 346 fewer unnecessary
returns to the hospital in the District of Columbia in 2015. The 8 Accountable Care
Organizations (ACOs) in the District of Columbia that offer Medicare beneficiaries the
opportunity to receive higher quality, more coordinated care would no longer operate under an
injunction.
73.
Impact on Public Health: Support for public health in the District of Columbia would
also be reduced under an injunction. The District of Columbia received $79,091,220 from the
law’s Prevention and Public Health Fund between fiscal years 2012 and 2016. This includes
$9,212,443 for immunizations and $2,144,515 for tobacco cessation efforts.
74.
Impact on Finances: The financial impact on the District of Columbia would be
significant. From 2019 to 2028, it would lose about $100 million in federal Marketplace
spending and $1.7 billion in federal Medicaid spending. The combined loss of federal spending
over this period would be about $1.7 billion. This would have a major impact on health care
providers. From 2019 to 2028, District of Columbia hospitals could lose $700 million and
physicians could lose $200 million. Uncompensated care costs in the District of Columbia would
increase by $1.7 billion over this period.
Hawaii
75.
Between 2010 and 2015, an estimated 54,000 people in Hawaii gained coverage. This
includes a large fraction of the people covered in the Hawaii Health Insurance Marketplace, an
estimated 9,000 young adults who gained coverage by staying on their parents’ health insurance,
and those gaining coverage from the law’s Medicaid expansion and employer shared
responsibility policy. This coverage would be at risk if the ACA were enjoined.
00034
76.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
560,494 people in Hawaii have a pre-existing condition and would be at risk for being charged
unaffordable premiums or denied coverage altogether without the ACA. Before the ACA,
462,000 people in Hawaii with employer or individual market coverage had a lifetime limit on
their insurance policy: annual and lifetime limits would return under an injunction to the ACA.
An estimated 631,152 people in Hawaii, including 256,448 women ages 15–64, would lose
federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
77.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 16,711 people in Hawaii covered in the Health
Insurance Marketplace would lose coverage without the ACA. In 2017, 82 percent of
Marketplace enrollees in Hawaii received a premium tax credit that averaged $4,238 per person.
That financial assistance would no longer be available under an injunction.
78.
Impact on Medicaid: Without the ACA, an estimated 33,000 fewer people in Hawaii
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 4,000 more getting all
needed care, 4,700 fewer struggling to pay medical bills, 3,000 fewer experiencing symptoms of
depression, and 40 avoided deaths each year in Hawaii. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
79.
Impact on Medicare: The 252,514 people with Medicare in Hawaii would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 22,212
people in Hawaii with $1,361 in average annual savings per beneficiary in 2016, would end. It
00035
would roll back the coverage of proven preventive services with no cost sharing which 158,239
people with Medicare in Hawaii used in 2016. It would suspend payment policies which would
increase premiums, cost sharing, and well as taxpayer costs in Hawaii. It would also disrupt
programs to reduce preventable patient harms and avoidable readmissions. Hospital readmissions
for Medicare beneficiaries dropped between 2010 and 2015, which translates into 315 fewer
unnecessary returns to the hospital in Hawaii in 2015.
80.
Impact on Public Health: Support for public health in Hawaii would also be reduced
under an injunction. Hawaii received $30,145,284 from the law’s Prevention and Public Health
Fund between fiscal years 2012 and 2016. This includes $3,914,688 for immunizations and
$227,370 for tobacco cessation efforts.
81.
Impact on Finances: The financial impact on Hawaii would be significant. From 2019 to
2028, it would lose $500 million in federal Marketplace spending and $3.7 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $4.3
billion. This would have a major impact on health care providers. From 2019 to 2028, Hawaii
hospitals could lose $2.6 billion and physicians could lose $800 million. Uncompensated care
costs in Hawaii would increase by $2.8 billion over this period.
Illinois
82.
Between 2010 and 2015, an estimated 850,000 people in Illinois gained coverage. This
includes a large fraction of the people covered in the Illinois Health Insurance Marketplace, an
estimated 91,000 young adults who gained coverage by staying on their parents’ health
insurance, and those gaining coverage from the law’s Medicaid expansion and employer shared
responsibility policy. This coverage would be at risk if the ACA were enjoined.
83.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
5,635,622 people in Illinois have a pre-existing condition and would be at risk for being charged
unaffordable premiums or denied coverage altogether without the ACA. Before the ACA,
00036
4,670,000 people in Illinois with employer or individual market coverage had a lifetime limit on
their insurance policy: annual and lifetime limits would return under an injunction to the ACA.
An estimated 5,883,105 people in Illinois, including 2,380,326 women ages 15–64, would lose
federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
84.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 314,038 people in Illinois covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 81 percent of
Marketplace enrollees in Illinois received a premium tax credit that averaged $4,372 per person.
That financial assistance would no longer be available under an injunction.
85.
Impact on Medicaid: Without the ACA, an estimated 340,000 fewer people in Illinois
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 39,000 more getting all
needed care, 48,400 fewer struggling to pay medical bills, 31,000 fewer experiencing symptoms
of depression, and 410 avoided deaths each year in Illinois. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
86.
Impact on Medicare: The 2,118,300 people with Medicare in Illinois would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 187,357
people in Illinois with $1,133 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 1,546,769
people with Medicare in Illinois used in 2016. It would suspend payment policies which would
increase premiums, cost sharing, and well as taxpayer costs in Illinois. It would also disrupt
programs to reduce preventable patient harms and avoidable readmissions. Hospital readmissions
00037
for Medicare beneficiaries dropped between 2010 and 2015, which translates into 8,108 fewer
unnecessary returns to the hospital in Illinois in 2015. The 29 Accountable Care Organizations
(ACOs) in Illinois that offer Medicare beneficiaries the opportunity to receive higher quality,
more coordinated care would no longer operate under an injunction.
87.
Impact on Public Health: Support for public health in Illinois would also be reduced
under an injunction. Illinois received $115,192,088 from the law’s Prevention and Public Health
Fund between fiscal years 2012 and 2016. This includes $28,383,246 for immunizations and
$5,106,535 for tobacco cessation efforts.
88.
Impact on Finances: The financial impact on Illinois would be significant. From 2019 to
2028, it would lose $12.5 billion in federal Marketplace spending and $37.4 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $49.9
billion. This would have a major impact on health care providers. From 2019 to 2028, Illinois
hospitals could lose $24.6 billion and physicians could lose $8.0 billion. Uncompensated care
costs in Illinois would increase by $54.5 billion over this period.
Kentucky
89.
Between 2010 and 2015, an estimated 404,000 people in Kentucky gained coverage. This
includes a large fraction of the people covered in the Kentucky Health Insurance Marketplace, an
estimated 31,000 young adults who gained coverage by staying on their parents’ health
insurance, and those gaining coverage from the law’s Medicaid expansion and employer shared
responsibility policy. This coverage would be at risk if the ACA were enjoined.
90.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
1,894,874 people in Kentucky have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 1,414,000 people in Kentucky with employer or individual market coverage had a lifetime
limit on their insurance policy: annual and lifetime limits would return under an injunction to the
00038
ACA. An estimated 1,884,719 people in Kentucky, including 762,897 women ages 15–64, would
lose federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
91.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 71,585 people in Kentucky covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 78 percent of
Marketplace enrollees in Kentucky received a premium tax credit that averaged $3,519 per
person. That financial assistance would no longer be available under an injunction.
92.
Impact on Medicaid: Without the ACA, an estimated 151,000 fewer people in Kentucky
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 17,000 more getting all
needed care, 21,500 fewer struggling to pay medical bills, 14,000 fewer experiencing symptoms
of depression, and 180 avoided deaths each year in Kentucky. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
93.
Impact on Medicare: The 881,938 people with Medicare in Kentucky would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 83,989
people in Kentucky with $1,194 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 634,656
people with Medicare in Kentucky used in 2016. It would suspend payment policies which
would increase premiums, cost sharing, and well as taxpayer costs in Kentucky. It would also
disrupt programs to reduce preventable patient harms and avoidable readmissions. Hospital
readmissions for Medicare beneficiaries dropped between 2010 and 2015, which translates into
2,384 fewer unnecessary returns to the hospital in Kentucky in 2015. The 22 Accountable Care
00039
Organizations (ACOs) in Kentucky that offer Medicare beneficiaries the opportunity to receive
higher quality, more coordinated care would no longer operate under an injunction.
94.
Impact on Public Health: Support for public health in Kentucky would also be reduced
under an injunction. Kentucky received $36,712,458 from the law’s Prevention and Public
Health Fund between fiscal years 2012 and 2016. This includes $11,025,151 for immunizations
and $2,112,229 for tobacco cessation efforts.
95.
Impact on Finances: The financial impact on Kentucky would be significant. From 2019
to 2028, it would lose $2.9 billion in federal Marketplace spending and $46.8 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $49.7
billion. This would have a major impact on health care providers. From 2019 to 2028, Kentucky
hospitals could lose $23.1 billion and physicians could lose $6.9 billion. Uncompensated care
costs in Kentucky would increase by $15.6 billion over this period.
Massachusetts
96.
Between 2010 and 2015, an estimated 107,000 people in Massachusetts gained coverage.
This includes a large fraction of the people covered in the Massachusetts Health Insurance
Marketplace (called the Massachusetts Health Connector), an estimated 52,000 young adults
who gained coverage by staying on their parents’ health insurance, and those gaining coverage
from the law’s Medicaid expansion and employer shared responsibility policy. This coverage
would be at risk if the ACA were enjoined.
97.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
2,931,068 people in Massachusetts have a pre-existing condition and would be at risk for being
charged unaffordable premiums without the ACA. Before the ACA, 2,520,000 people in
Massachusetts with employer or individual market coverage had a lifetime limit on their
insurance policy: annual and lifetime limits would return under an injunction to the ACA. An
estimated 3,399,092 people in Massachusetts, including 1,412,394 women ages 15–64, would
00040
lose federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
98.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 242,221 people in Massachusetts covered in
the Health Insurance Marketplace would lose coverage without the ACA. In 2017, 74 percent of
Marketplace enrollees in Massachusetts received a premium tax credit that averaged $2,135 per
person. That financial assistance would no longer be available under an injunction.
99.
Impact on Medicaid: Without the ACA, an estimated 2,000 fewer people in
Massachusetts would have Medicaid coverage. The law’s Medicaid expansion improved access
to care, financial security, and health. Enjoining the law would put these benefits at risk, along
with improvements to long-term services and supports, eligibility simplifications, and policies to
lower drug costs and improve the quality of care in Medicaid.
100.
Impact on Medicare: The 1,252,277 people with Medicare in Massachusetts would also
lose benefits and pay more under an injunction. Prescription drug discounts, which provided
90,664 people in Massachusetts with $1,194 in average annual savings per beneficiary in 2016,
would end. It would roll back the coverage of proven preventive services with no cost sharing
which 938,405 people with Medicare in Massachusetts used in 2016. It would suspend payment
policies which would increase premiums, cost sharing, and well as taxpayer costs in
Massachusetts. It would also disrupt programs to reduce preventable patient harms and avoidable
readmissions. Hospital readmissions for Medicare beneficiaries dropped between 2010 and 2015,
which translates into 2,213 fewer unnecessary returns to the hospital in Massachusetts in 2015.
The 14 Accountable Care Organizations (ACOs) in Massachusetts that offer Medicare
beneficiaries the opportunity to receive higher quality, more coordinated care would no longer
operate under an injunction.
00041
101.
Impact on Public Health: Support for public health in Massachusetts would also be
reduced under an injunction. Massachusetts received $108,021,166 from the law’s Prevention
and Public Health Fund between fiscal years 2012 and 2016. This includes $12,404,884 for
immunizations and $2,147,272 for tobacco cessation efforts.
102.
Impact on Finances: The financial impact on Massachusetts would be significant. From
2019 to 2028, it would lose $5.4 billion in federal Marketplace spending and $17.2 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$22.5 billion. This would have a major impact on health care providers. From 2019 to 2028,
Massachusetts hospitals could lose $6.1 billion and physicians could lose $2.6 billion.
Uncompensated care costs in Massachusetts would increase by $17.1 billion over this period.
Minnesota
103.
Between 2010 and 2015, an estimated 250,000 people in Minnesota gained coverage.
This number includes a large fraction of the people covered in the Minnesota Health Insurance
Marketplace (called MNsure), an estimated 38,000 young adults who gained coverage by staying
on their parents’ health insurance, and those gaining coverage from the law’s Medicaid
expansion and employer shared responsibility policy. This coverage would be at risk if the ACA
were enjoined.
104.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law.
Without the ACA up to 2,318,738 people in Minnesota have a pre-existing condition and would
be at risk for being charged unaffordable premiums or denied coverage altogether. Before the
ACA, 2,043,000 people in Minnesota with employer or individual market coverage had lifetime
limits on their insurance policies: if the ACA were enjoined, annual and lifetime limits would
surely return. An estimated 2,761,583 people in Minnesota, including 1,075,362 women ages
15–64, would lose the federal guarantee of preventive services — such as flu shots, cancer
screenings, and contraception – which are now provided at no extra cost to consumers. These are
00042
just a few of the ACA’s consumer protections that could be lost if this court allows the ACA to
be enjoined.
105.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families who have benefitted from these provisions would pay more out of
pocket for health coverage or go without it altogether. Many of the 90,146 people in Minnesota
covered in the Health Insurance Marketplace would lose coverage without the ACA. In 2017, 70
percent of Marketplace enrollees in Minnesota received premium tax credits that averaged
$5,220 per person. That financial assistance would no longer be available under an injunction.
106.
Impact on Medicaid: Without the ACA, an estimated 36,000 fewer people in Minnesota
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 4,000 more getting all
needed care, 5,100 fewer struggling to pay medical bills, 3,000 fewer experiencing symptoms of
depression, and 40 avoided deaths each year in Minnesota. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
107.
Impact on Medicare: The 944,222 people with Medicare in Minnesota would also lose
benefits and pay more under an injunction than they now do. Prescription drug discounts, that
saved 66,930 Minnesotans an average of $1,077 per beneficiary in 2016 would end. It would roll
back the coverage of proven preventive services with no cost sharing which 604,022 people with
Medicare in Minnesota used in 2016. It would suspend payment policies that have lowered
premiums, cost sharing, and taxpayer costs in Minnesota. It would also disrupt programs to
reduce preventable patient harms and avoidable readmissions. Hospital readmissions for
Medicare beneficiaries dropped between 2010 and 2015, which translates into 1,435 fewer
unnecessary returns to the hospital in Minnesota in 2015. The 8 Accountable Care Organizations
(ACOs) in Minnesota that offer Medicare beneficiaries the opportunity to receive higher quality,
more coordinated care would no longer operate under an injunction.
00043
108.
Impact on Public Health: Support for public health in Minnesota would also be reduced
under an injunction. Minnesota received $83,959,272 from the law’s Prevention and Public
Health Fund between fiscal years 2012 and 2016. This sum includes $18,224,535 for
immunizations and $3,177,506 for tobacco cessation efforts.
109.
Impact on Finances: The financial impact on Minnesota would be significant. From
2019 to 2028, Minnesota would lose $1.9 billion in federal Marketplace spending and $14.6
billion in federal Medicaid spending. The combined loss of federal spending over this period
would be $16.4 billion. Such a reduction in spending would have a major impact on health care
providers. From 2019 to 2028, Minnesota hospitals could lose $7.3 billion and physicians could
lose $2.7 billion. Uncompensated care costs in Minnesota would increase by $24.5 billion over
this period.
New Jersey
110.
Between 2010 and 2015, an estimated 398,000 people in New Jersey gained coverage.
This includes a large fraction of the people covered in the New Jersey Health Insurance
Marketplace, an estimated 59,000 young adults who gained coverage by staying on their parents’
health insurance, and those gaining coverage from the law’s Medicaid expansion and employer
shared responsibility policy. This coverage would be at risk if the ACA were enjoined.
111.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
3,847,727 people in New Jersey have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 3,274,000 people in New Jersey with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
injunction to the ACA. An estimated 4,210,183 people in New Jersey, including 1,701,115
women ages 15–64, would lose federally guaranteed of preventive services — like flu shots,
cancer screenings, and contraception – which are now provided at no extra cost to consumers.
00044
These are just a few of the ACA’s consumer protections that could be lost if this court allows the
ACA to be enjoined.
112.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 243,743 people in New Jersey covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 79 percent of
Marketplace enrollees in New Jersey received a premium tax credit that averaged $4,205 per
person. That financial assistance would no longer be available under an injunction.
113.
Impact on Medicaid: Without the ACA, an estimated 194,000 fewer people in New
Jersey would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 22,000 more getting all
needed care, 27,600 fewer struggling to pay medical bills, 18,000 fewer experiencing symptoms
of depression, and 230 avoided deaths each year in New Jersey. Enjoining the law would put
these benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
114.
Impact on Medicare: The 1,528,961 people with Medicare in New Jersey would also
lose benefits and pay more under an injunction. Prescription drug discounts, which provided
202,098 people in New Jersey with $1,344 in average annual savings per beneficiary in 2016,
would end. It would roll back the coverage of proven preventive services with no cost sharing
which 1,131,754 people with Medicare in New Jersey used in 2016. It would suspend payment
policies which would increase premiums, cost sharing, and well as taxpayer costs in New Jersey.
It would also disrupt programs to reduce preventable patient harms and avoidable readmissions.
Hospital readmissions for Medicare beneficiaries dropped between 2010 and 2015, which
translates into 6,774 fewer unnecessary returns to the hospital in New Jersey in 2015. The 29
Accountable Care Organizations (ACOs) in New Jersey that offer Medicare beneficiaries the
00045
opportunity to receive higher quality, more coordinated care would no longer operate under an
injunction.
115.
Impact on Public Health: Support for public health in New Jersey would also be
reduced under an injunction. New Jersey received $54,491,391 from the law’s Prevention and
Public Health Fund between fiscal years 2012 and 2016. This includes $14,039,534 for
immunizations and $2,578,857 for tobacco cessation efforts.
116.
Impact on Finances: The financial impact on New Jersey would be significant. From
2019 to 2028, it would lose $6.7 billion in federal Marketplace spending and $53 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$59.7 billion. This would have a major impact on health care providers. From 2019 to 2028, New
Jersey hospitals could lose $30.2 billion and physicians could lose $10.4 billion. Uncompensated
care costs in New Jersey would increase by $29.0 billion over this period.
New York
117.
Between 2010 and 2015, an estimated 939,000 people in New York gained coverage.
This includes a large fraction of the people covered in the New York Health Insurance
Marketplace (called New York State of Health), an estimated 147,000 young adults who gained
coverage by staying on their parents’ health insurance, and those gaining coverage from the
law’s Medicaid expansion and employer shared responsibility policy. This coverage would be at
risk if the ACA were enjoined.
118.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
8,616,234 people in New York have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 6,432,000 people in New York with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
injunction to the ACA. An estimated 8,619,856 people in New York, including 3,582,133
00046
women ages 15–64, would lose federally guaranteed of preventive services — like flu shots,
cancer screenings, and contraception – which are now provided at no extra cost to consumers.
These are just a few of the ACA’s consumer protections that could be lost if this court allows the
ACA to be enjoined.
119.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 207,083 people in New York covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 55 percent of
Marketplace enrollees in New York received a premium tax credit that averaged $2,763 per
person. That financial assistance would no longer be available under an injunction.
120.
Impact on Medicaid: Without the ACA, an estimated 143,000 fewer people in New
York would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 16,000 more getting all
needed care, 20,300 fewer struggling to pay medical bills, 13,000 fewer experiencing symptoms
of depression, and 170 avoided deaths each year in New York. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
This could, for example, mean that people with disabilities in New York’s Community First
Choice program could lose access to services.
121.
Impact on Medicare: The 3,424,666 people with Medicare in New York would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 348,566
people in New York with $1,320 in average annual savings per beneficiary in 2016, would end.
It would roll back the coverage of proven preventive services with no cost sharing which
2,440,280 people with Medicare in New York used in 2016. It would suspend payment policies
which would increase premiums, cost sharing, and well as taxpayer costs in New York. It would
also disrupt programs to reduce preventable patient harms and avoidable readmissions. Hospital
00047
readmissions for Medicare beneficiaries dropped between 2010 and 2015, which translates into
8,407 fewer unnecessary returns to the hospital in New York in 2015. The 38 Accountable Care
Organizations (ACOs) in New York that offer Medicare beneficiaries the opportunity to receive
higher quality, more coordinated care would no longer operate under an injunction.
122.
Impact on Public Health: Support for public health in New York would also be reduced
under an injunction. New York received $211,920,470 from the law’s Prevention and Public
Health Fund between fiscal years 2012 and 2016. This includes $49,114,866 for immunizations
and $6,245,494 for tobacco cessation efforts.
123.
Impact on Finances: The financial impact on New York would be significant. From
2019 to 2028, it would lose $9.9 billion in federal Marketplace spending and $47.3 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$57.2 billion. This would have a major impact on health care providers. From 2019 to 2028, New
York hospitals could lose $23.2 billion and physicians could lose $9.0 billion. Uncompensated
care costs in New York would increase by $47.4 billion over this period.
North Carolina
124.
Between 2010 and 2015, an estimated 552,000 people in North Carolina gained coverage.
This includes a large fraction of the people covered in the North Carolina Health Insurance
Marketplace, an estimated 70,000 young adults who gained coverage by staying on their parents’
health insurance, and those gaining coverage from the law’s Medicaid expansion and employer
shared responsibility policy. This coverage would be at risk if the ACA were enjoined.
125.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
4,099,922 people in North Carolina have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 3,091,000 people in North Carolina with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
00048
injunction to the ACA. An estimated 3,966,308 people in North Carolina, including 1,631,312
women ages 15–64, would lose federally guaranteed of preventive services — like flu shots,
cancer screenings, and contraception – which are now provided at no extra cost to consumers.
These are just a few of the ACA’s consumer protections that could be lost if this court allows the
ACA to be enjoined.
126.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 450,822 people in North Carolina covered in
the Health Insurance Marketplace would lose coverage without the ACA. In 2017, 93 percent of
Marketplace enrollees in North Carolina received a premium tax credit that averaged $7,100 per
person. That financial assistance would no longer be available under an injunction.
127.
Impact on Medicaid: If North Carolina expanded Medicaid under the ACA, an
estimated 313,000 people would gain Medicaid coverage. This coverage would improve access
to care, financial security, and health. For example, it would result in an estimated 36,000 more
getting all needed care, 44,500 fewer struggling to pay medical bills, 29,000 fewer experiencing
symptoms of depression, and 380 avoided deaths each year in North Carolina. Enjoining the law
would put these potential benefits at risk, along with improvements to long-term services and
supports, eligibility simplifications, and policies to lower drug costs and improve the quality of
care in Medicaid.
128.
Impact on Medicare: The 1,823,454 people with Medicare in North Carolina would also
lose benefits and pay more under an injunction. Prescription drug discounts, which provided
165,931 people in North Carolina with $1,117 in average annual savings per beneficiary in 2016,
would end. It would roll back the coverage of proven preventive services with no cost sharing
which 1,377,219 people with Medicare in North Carolina used in 2016. It would suspend
payment policies which would increase premiums, cost sharing, and well as taxpayer costs in
North Carolina. It would also disrupt programs to reduce preventable patient harms and
00049
avoidable readmissions. Hospital readmissions for Medicare beneficiaries dropped between 2010
and 2015, which translates into 2,472 fewer unnecessary returns to the hospital in North Carolina
in 2015. The 20 Accountable Care Organizations (ACOs) in North Carolina that offer Medicare
beneficiaries the opportunity to receive higher quality, more coordinated care would no longer
operate under an injunction.
129.
Impact on Public Health: Support for public health in North Carolina would also be
reduced under an injunction. North Carolina received $109,531,769 from the law’s Prevention
and Public Health Fund between fiscal years 2012 and 2016. This includes $12,919,323 for
immunizations and $3,778,227 for tobacco cessation efforts.
130.
Impact on Finances: The financial impact on North Carolina would be significant. From
2019 to 2028, it would lose $38.2 billion in federal Marketplace spending and $20.7 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$59.0 billion. This would have a major impact on health care providers. From 2019 to 2028,
North Carolina hospitals could lose $22.7 billion and physicians could lose $8.7 billion.
Uncompensated care costs in North Carolina would increase by $35.0 billion over this period.
Oregon
131.
Between 2010 and 2015, an estimated 403,000 people in Oregon gained coverage. This
includes a large fraction of the people covered in the Oregon Health Insurance Marketplace
called OregonHealthCare.gov, an estimated 28,000 young adults who gained coverage by staying
on their parents’ health insurance, and those gaining coverage from the law’s Medicaid
expansion and employer shared responsibility policy. This coverage would be at risk if the ACA
were enjoined.
132.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
1,692,205 people in Oregon have a pre-existing condition and would be at risk for being charged
unaffordable premiums or denied coverage altogether without the ACA. Before the ACA,
00050
1,356,000 people in Oregon with employer or individual market coverage had a lifetime limit on
their insurance policy: annual and lifetime limits would return under an injunction to the ACA.
An estimated 1,737,240 people in Oregon, including 721,318 women ages 15–64, would lose
federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
133.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 137,305 people in Oregon covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 75 percent of
Marketplace enrollees in Oregon received a premium tax credit that averaged $4,144 per person.
That financial assistance would no longer be available under an injunction.
134.
Impact on Medicaid: Without the ACA, an estimated 159,000 fewer people in Oregon
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 18,000 more getting all
needed care, 22,600 fewer struggling to pay medical bills, 15,000 fewer experiencing symptoms
of depression, and 190 avoided deaths each year in Oregon. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
This could, for example, mean that people with disabilities in Oregon’s Community First Choice
program could lose access to services.
135.
Impact on Medicare: The 784,032 people with Medicare in Oregon would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 50,777
people in Oregon with $1,035 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 496,232
people with Medicare in Oregon used in 2016. It would suspend payment policies which would
00051
increase premiums, cost sharing, and well as taxpayer costs in Oregon. It would also disrupt
programs to reduce preventable patient harms and avoidable readmissions. Hospital readmissions
for Medicare beneficiaries dropped between 2010 and 2015, which translates into 75 fewer
unnecessary returns to the hospital in Oregon in 2015. The 4 Accountable Care Organizations
(ACOs) in Oregon that offer Medicare beneficiaries the opportunity to receive higher quality,
more coordinated care would no longer operate under an injunction.
136.
Impact on Public Health: Support for public health in Oregon would also be reduced
under an injunction. Oregon received $52,128,626 from the law’s Prevention and Public Health
Fund between fiscal years 2012 and 2016. This includes $15,494,592 for immunizations and
$1,864,629 for tobacco cessation efforts.
137.
Impact on Finances: The financial impact on Oregon would be significant. From 2019
to 2028, it would lose $3.3 billion in federal Marketplace spending and $35.1 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $38.4
billion. This would have a major impact on health care providers. From 2019 to 2028, Oregon
hospitals could lose $17.5 billion and physicians could lose $5.7 billion. Uncompensated care
costs in Oregon would increase by $15.2 billion over this period.
Rhode Island
138.
Between 2010 and 2015, an estimated 68,000 people in Rhode Island gained coverage.
This includes a large fraction of the people covered in the Rhode Island Health Insurance
Marketplace (called HealthSource RI), an estimated 8,000 young adults who gained coverage by
staying on their parents’ health insurance, and those gaining coverage from the law’s Medicaid
expansion and employer shared responsibility policy. This coverage would be at risk if the ACA
were enjoined.
139.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
462,538 people in Rhode Island have a pre-existing condition and would be at risk for being
00052
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 374,000 people in Rhode Island with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
injunction to the ACA. An estimated 484,193 people in Rhode Island, including 201,595 women
ages 15–64, would lose federally guaranteed of preventive services — like flu shots, cancer
screenings, and contraception – which are now provided at no extra cost to consumers. These are
just a few of the ACA’s consumer protections that could be lost if this court allows the ACA to
be enjoined.
140.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 29,065 people in Rhode Island covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 78 percent of
Marketplace enrollees in Rhode Island received a premium tax credit that averaged $2,974 per
person. That financial assistance would no longer be available under an injunction.
141.
Impact on Medicaid: Without the ACA, an estimated 22,000 fewer people in Rhode
Island would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. For example, it resulted in an estimated 3,000 more getting all
needed care, 3,200 fewer struggling to pay medical bills, 2,000 fewer experiencing symptoms of
depression, and 30 avoided deaths each year in Rhode Island. Enjoining the law would put these
benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
142.
Impact on Medicare: The 208,324 people with Medicare in Rhode Island would also
lose benefits and pay more under an injunction. Prescription drug discounts, which provided
14,990 people in Rhode Island with $1,004 in average annual savings per beneficiary in 2016,
would end. It would roll back the coverage of proven preventive services with no cost sharing
which 148,724 people with Medicare in Rhode Island used in 2016. It would suspend payment
00053
policies which would increase premiums, cost sharing, and well as taxpayer costs in Rhode
Island. It would also disrupt programs to reduce preventable patient harms and avoidable
readmissions. Hospital readmissions for Medicare beneficiaries dropped between 2010 and 2015,
which translates into 487 fewer unnecessary returns to the hospital in Rhode Island in 2015. The
5 Accountable Care Organizations (ACOs) in Rhode Island that offer Medicare beneficiaries the
opportunity to receive higher quality, more coordinated care would no longer operate under an
injunction.
143.
Impact on Public Health: Support for public health in Rhode Island would also be
reduced under an injunction. Rhode Island received $34,890,537 from the law’s Prevention and
Public Health Fund between fiscal years 2012 and 2016. This includes $5,997,036 for
immunizations and $326,347 for tobacco cessation efforts.
144.
Impact on Finances: The financial impact on Rhode Island would be significant. From
2019 to 2028, it would lose $700 million in federal Marketplace spending and $6.7 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$7.4 billion. This would have a major impact on health care providers. From 2019 to 2028,
Rhode Island hospitals could lose $3.8 billion and physicians could lose $1.4 billion.
Uncompensated care costs in Rhode Island would increase by $2.8 billion over this period.
Vermont
145.
Between 2010 and 2015, an estimated 26,000 people in Vermont gained coverage. This
includes a large fraction of the people covered in the Vermont Health Insurance Marketplace
(called Vermont Health Connect), an estimated 5,000 young adults who gained coverage by
staying on their parents’ health insurance, and those gaining coverage from the law’s Medicaid
expansion and employer shared responsibility policy. This coverage would be at risk if the ACA
were enjoined.
146.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
00054
280,727 people in Vermont have a pre-existing condition and would be at risk for being charged
unaffordable premiums or denied coverage altogether without the ACA. Before the ACA,
215,000 people in Vermont with employer or individual market coverage had a lifetime limit on
their insurance policy: annual and lifetime limits would return under an injunction to the ACA.
An estimated 285,858 people in Vermont, including 122,892 women ages 15–64, would lose
federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
147.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 29,088 people in Vermont covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 76 percent of
Marketplace enrollees in Vermont received a premium tax credit that averaged $3,898 per
person. That financial assistance would no longer be available under an injunction.
148.
Impact on Medicaid: Without the ACA, an estimated 3,000 fewer people in Vermont
would have Medicaid coverage. The law’s Medicaid expansion improved access to care,
financial security, and health. Enjoining the law would put these benefits at risk, along with
improvements to long-term services and supports, eligibility simplifications, and policies to
lower drug costs and improve the quality of care in Medicaid.
149.
Impact on Medicare: The 136,021 people with Medicare in Vermont would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 10,466
people in Vermont with $1,206 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 94,170
people with Medicare in Vermont used in 2016. It would suspend payment policies which would
increase premiums, cost sharing, and well as taxpayer costs in Vermont. It would also disrupt
programs to reduce preventable patient harms and avoidable readmissions. Hospital readmissions
00055
for Medicare beneficiaries dropped between 2010 and 2015. The 3 Accountable Care
Organizations (ACOs) in Vermont that offer Medicare beneficiaries the opportunity to receive
higher quality, more coordinated care would no longer operate under an injunction.
150.
Impact on Public Health: Support for public health in Vermont would also be reduced
under an injunction. Vermont received $16,564,102 from the law’s Prevention and Public Health
Fund between fiscal years 2012 and 2016. This includes $2,706,809 for immunizations and
$299,828 for tobacco cessation efforts.
151.
Impact on Finances: The financial impact on Vermont would be significant. From 2019
to 2028, it would lose $1.0 billion in federal Marketplace spending and $1.9 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $2.9
billion. This would have a major impact on health care providers. From 2019 to 2028, Vermont
hospitals could lose $500 million and physicians could lose $300 million. Uncompensated care
costs in Vermont would increase by $2.4 billion over this period.
Virginia
152.
Between 2010 and 2015, an estimated 327,000 people in Virginia gained coverage. This
includes a large fraction of the people covered in the Virginia Health Insurance Marketplace, an
estimated 59,000 young adults who gained coverage by staying on their parents’ health
insurance, and those who gained coverage due to the employer shared responsibility policy. This
coverage would be at risk if the ACA were enjoined.
153.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
3,491,076 people in Virginia have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 2,974,000 people in Virginia with employer or individual market coverage had a lifetime
limit on their insurance policy: annual and lifetime limits would return under an injunction to the
ACA. An estimated 3,902,716 people in Virginia, including 1,587,663 women ages 15–64,
00056
would lose federally guaranteed of preventive services — like flu shots, cancer screenings, and
contraception – which are now provided at no extra cost to consumers. These are just a few of
the ACA’s consumer protections that could be lost if this court allows the ACA to be enjoined.
154.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 364,614 people in Virginia covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 83 percent of
Marketplace enrollees in Virginia received a premium tax credit that averaged $3,807 per person.
That financial assistance would no longer be available under an injunction.
155.
Impact on Medicaid: Virginia is debating expanding Medicaid under the ACA, which
could lead to an estimated 179,000 people in Virginia gaining coverage. This would improve
access to care, financial security, and health. For example, it could result in an estimated 20,000
more getting all needed care, 25,500 fewer struggling to pay medical bills, 16,000 fewer
experiencing symptoms of depression, and 220 avoided deaths each year in Virginia. Enjoining
the law would put these potential benefits at risk, along with improvements to long-term services
and supports, eligibility simplifications, and policies to lower drug costs and improve the quality
of care in Medicaid.
156.
Impact on Medicare: The 1,392,261 people with Medicare in Virginia would also lose
benefits and pay more under an injunction. Prescription drug discounts, which provided 109,517
people in Virginia with $1,104 in average annual savings per beneficiary in 2016, would end. It
would roll back the coverage of proven preventive services with no cost sharing which 1,026,111
people with Medicare in Virginia used in 2016. It would suspend payment policies which would
increase premiums, cost sharing, and well as taxpayer costs in Virginia. It would also disrupt
programs to reduce preventable patient harms and avoidable readmissions. Hospital readmissions
for Medicare beneficiaries dropped between 2010 and 2015, which translates into 2,302 fewer
unnecessary returns to the hospital in Virginia in 2015. The 25 Accountable Care Organizations
00057
(ACOs) in Virginia that offer Medicare beneficiaries the opportunity to receive higher quality,
more coordinated care would no longer operate under an injunction.
157.
Impact on Public Health: Support for public health in Virginia would also be reduced
under an injunction. Virginia received $79,675,902 from the law’s Prevention and Public Health
Fund between fiscal years 2012 and 2016. This includes $15,357,774 for immunizations and
$3,545,823 for tobacco cessation efforts.
158.
Impact on Finances: The financial impact on Virginia would be significant. From 2019
to 2028, it would lose $15.4 billion in federal Marketplace spending and $2.6 billion in federal
Medicaid spending. The combined loss of federal spending over this period would be $18.0
billion. This would have a major impact on health care providers. From 2019 to 2028, Virginia
hospitals could lose $7.8 billion and physicians could lose $3.7 billion. Uncompensated care
costs in Virginia would increase by $28.7 billion over this period.
Washington
159.
Between 2010 and 2015, an estimated 537,000 people in Washington gained coverage.
This includes a large fraction of the people covered in the Washington Health Insurance
Marketplace (called Washington Healthplanfinder), an estimated 50,000 young adults who
gained coverage by staying on their parents’ health insurance, and those gaining coverage from
the law’s Medicaid expansion and employer shared responsibility policy. This coverage would
be at risk if the ACA were enjoined.
160.
Impact on Consumer Protections: Numerous consumer protections in private insurance
would also be lost if the ACA were enjoined or if there were an injunction ending the law. Up to
2,969,739 people in Washington have a pre-existing condition and would be at risk for being
charged unaffordable premiums or denied coverage altogether without the ACA. Before the
ACA, 2,427,000 people in Washington with employer or individual market coverage had a
lifetime limit on their insurance policy: annual and lifetime limits would return under an
injunction to the ACA. An estimated 3,079,369 people in Washington, including 1,258,201
00058
women ages 15–64, would lose federally guaranteed of preventive services — like flu shots,
cancer screenings, and contraception – which are now provided at no extra cost to consumers.
These are just a few of the ACA’s consumer protections that could be lost if this court allows the
ACA to be enjoined.
161.
Impact on Marketplace Coverage: The ACA provides financial support for private
coverage through premium tax credits and cost-sharing reductions. If the ACA were enjoined,
individuals and families that have benefitted from these provisions would pay more for health
coverage or go without it altogether. Many of the 184,070 people in Washington covered in the
Health Insurance Marketplace would lose coverage without the ACA. In 2017, 63 percent of
Marketplace enrollees in Washington received a premium tax credit that averaged $3,040 per
person. That financial assistance would no longer be available under an injunction.
162.
Impact on Medicaid: Without the ACA, an estimated 55,000 fewer people in
Washington would have Medicaid coverage. The law’s Medicaid expansion improved access to
care, financial security, and health. For example, it resulted in an estimated 6,000 more getting
all needed care, 7,800 fewer struggling to pay medical bills, 5,000 fewer experiencing symptoms
of depression, and 70 avoided deaths each year in Washington. Enjoining the law would put
these benefits at risk, along with improvements to long-term services and supports, eligibility
simplifications, and policies to lower drug costs and improve the quality of care in Medicaid.
This could, for example, mean that people with disabilities in Washington’s Community First
Choice program could lose access to services.
163.
Impact on Medicare: The 1,238,649 people with Medicare in Washington would also
lose benefits and pay more under an injunction. Prescription drug discounts, which provided
71,499 people in Washington with $1,065 in average annual savings per beneficiary in 2016,
would end. It would roll back the coverage of proven preventive services with no cost sharing
which 805,142 people with Medicare in Washington used in 2016. It would suspend payment
policies which would increase premiums, cost sharing, and well as taxpayer costs in Washington.
It would also disrupt programs to reduce preventable patient harms and avoidable readmissions.
00059
Hospital readmissions for Medicare beneficiaries dropped between 2010 and 2015, which
translates into 1,388 fewer unnecessary returns to the hospital in Washington in 2015. The 6
Accountable Care Organizations (ACOs) in Washington that offer Medicare beneficiaries the
opportunity to receive higher quality, more coordinated care would no longer operate under an
injunction.
164.
Impact on Public Health: Support for public health in Washington would also be
reduced under an injunction. Washington received $84,038,862 from the law’s Prevention and
Public Health Fund between fiscal years 2012 and 2016. This includes $21,648,368 for
immunizations and $4,207,707 for tobacco cessation efforts.
165.
Impact on Finances: The financial impact on Washington would be significant. From
2019 to 2028, it would lose $4.7 billion in federal Marketplace spending and $38.1 billion in
federal Medicaid spending. The combined loss of federal spending over this period would be
$42.8 billion. This would have a major impact on health care providers. From 2019 to 2028,
Washington hospitals could lose $23.3 billion and physicians could lose $7.7 billion.
Uncompensated care costs in Washington would increase by $33.9 billion over this period.
Conclusion
166.
Based on my knowledge and experience, I believe that invalidating the Affordable Care
Act would cause significant harm to the nation, across all States, to the economy and to the
health insurance market. It would immediately end federal support for Medicaid coverage for
nearly 12 million individuals in 32 states and the District of Columbia; it would deprive residents
of the remaining states of the option to expand Medicaid coverage, an option that is under active
debate in Virginia, Maine, and others, of broadening coverage in the future; it would reduce
access to coverage for low and middle income Americans; it would increase drug costs. Further,
the disruption caused by such an occurrence would cause immediate financial harm to medical
providers and insurance companies, and significantly disrupt their ability to conduct business
00060
across all healthcare markets, including individual, Medicaid and Medicare, and small group
markets.
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on May 29, 2018, in Washington, D.C.
Bruce and Virginia MacLaury Senior Fellow
The Brookings Institution
*The views expressed here are my own and do not necessarily represent those of the trustees, officers or other staff
ofthe Brookings Institution. Affiliation listed for identification only.
00061
1
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
2
3
8
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA, PAUL
LeP AGE, Governor of Maine, Governor Phil
Bryant of the State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA, SOUTH
CAROLINA, SOUTH DAKOTA, TENNESSEE,
UTAH, WEST VIRGINIA, NEILL HURLEY and
JOHN NANTZ,
9
Plaintiffs,
4
5
6
7
10
11
12
13
14
Civil Action No. 4:18-cv-00167-0
V.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
15
Defendants.
16
17
18
19
20
21
22 ·
23
24
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAIi,
ILLINOIS, KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its Department of
Commerce, NEW JERSEY, NEW YORK,
NORTH CAROLINA, OREGON, RHODE
ISLAND, VERMONT, VIRGINIA and
WASHINGTON,
Intervenors-Defendants.
DECLARATION OF BENJAMIN BARNES IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
25
26
27
28
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: l 8-cv-00167-0)
00062
1
I, Benjamin Barnes declare:
2
3
1. I am the Secretary of the Connecticut Office of Policy and Management. In that role, I
4
report directly to the Governor and oversee budget and policy development and implementation
5
for the State of Connecticut, including health policy issues. The facts stated herein are of my own
6
personal knowledge and knowledge I have gained from information provided by the Departments
7
of Public Health and Social Services, the Office of Health Strategy and Access Health CT.
8
2. The Connecticut Office of Policy and Management (OPM) functions as the Governor's
9
10
11
staff agency and plays a central role in state government, providing the information and analysis
used to formulate public policy for the state and assisting state agencies and municipalities in
implementing policy decisions on the Governor's behalf. OPM prepares the Governor's budget
12
proposal and implements and monitors the execution of the budget as adopted by the General
13
14
15
Assembly. Through intra-agency and inter-agency efforts, OPM strengthens and improves the
delivery of services to the citizens of Connecticut, and increases the efficiency and effectiveness
of state government through integrated processes and system improvements.
16
17
This declaration is submitted in support of the Intervenors-Defendants' Opposition to Application
18
for Preliminary Injunction. Based on my knowledge and experience, dismantling the Affordable
19
Care Act would cause severe harm to the State of Connecticut, to its residents and to its economy.
20
In addition to loss of benefits and services and federal investments to support Connecticut's
21
healthcare system, dismantling or suspending implementation of the Affordable Care Act would
22
cause harm and increased costs from the dismantling of the state's administrative structure and
23
apparatus, created in compliance with, and to work in conjunction with, the Affordable Care Act "
24
Connecticut projects costs of at least $3.2 million to change eligibility and issue notices,
25
including the cost of system changes. While the cost of mailings to notify impacted individuals is
26
projected to cost approximately $600,000, the cost to design, develop and implement the
27
necessary system changes is projected to cost a minimum.of $2.6 million. These figures do not
28
2
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-00167-0)
00063
1
2
include state staff costs nor the potential cost of evaluating impacted individuals to determine
eligibility for alternative coverage prior to termination.
3
4
5
3. The Affordable Care Act directs billions of dollars directly to Connecticut.
•
Connecticut sought and received extensive new federal resources under the
6
Affordable Care Act (ACA). Specifically, Connecticut has received $5.9 billion via
7
Medicaid expansion ($1.2 billion as an early adopter beginning April 2010 and $4. 7
8
billion from January 2014 through December 2017); $73.1 million through the
9
Community First Choice Option; $51.5 million in enhanced reimbursement related
10
to the Money Follows the Person Demonstration (from October 2011, when the
11
demonstration was extended ( and expanded) under the ACA, through December
12
2017); $29.0 million through the Prevention and Public Health Fund and $19.8
13
million through other public health grants-in-aid that were awarded to Connecticut
14
state agencies; $77 .5 million through the Balancing Incentive Program; $11.3
15
million in enhanced reimbursement related to the behavioral health, health homes;
16
and $21.8 million in enhanced reimbursement for the Children's Health Insurance
17
Program (CHIP).
18
•
The ACA also enabled Connecticut's Medicaid agency, the Department of Social
19
Services, to partner with the state-based health insurance exchange, Access Health
20
CT, to launch a shared/ integrated eligibility system that encompasses HUSKY
21
Health (Medicaid / CHIP) and private qualified health plans offered through the
22
Exchange. This has created a common entry point for all individuals seeking health
23
insurance, has automated many aspects of eligibility verification and has improved
24
the integrity and timeliness of the eligibility process. Efficient and comprehensive
25
documentation of eligibility is an essential feature of ensuring appropriate access to
26
the range of available insurance coverage options.
27
28
•
In addition to the $48.8 million provided through the Prevention and Public Health
Fund (PPHF) and other public health grants-in-aid awarded to state agencies, other
3
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-OO 167-0)
00064
1
Connecticut organizations were direct beneficiaries of ACA-funded initiatives to
2
help address the health care needs of vulnerable populations, such as federally
3
qualified health centers, school based health centers, hospitals, and universities.
4
Furthermore, since 100% of funding for the Preventive Health and Health Services
5
Block Grant (PHHSBG) comes from the Prevention and Public Health Fund, if the
6
ACA is repealed and funding for the block grant is eliminated, the following
7
programs would be greatly impacted: asthma management education, cancer
8
prevention, cardiovascular disease prevention, childhood lead poisoning
9
surveillance, diabetes education and self-management classes, smoking cessation,
10
injury prevention, suicide prevention, and rape crisis programs. PHHSBG funds
11
also support the state's emergency medical services, public health surveillance and
12
evaluation efforts, and national and local public health accreditation initiatives.
13
Since 2014, Connecticut has received a total of $9.0 million in PHHSBG funding.
14
15
16
4. The Affordable Care Act increased access to affordable coverage.
•
Overall, the number of individuals with insurance has significantly increased. Based
17
on data from the U.S. Census Bureau, the percentage of people in Connecticut
18
without health insurance decreased from 9.4% in 2013 to 4.9% in 2016. The
19
percentage of uninsured adults between 18 and 64 years of age decreased from
20
14.8% in 2011 to 8.2% in 2016. Connecticut has historically had a high percentage
21
of children with health coverage and saw similar improvements in the rate of insured
22
children, although exact numbers are not readily available.
23
•
The ACA expanded coverage through two key mechanisms: Medicaid expansion
24
for those individuals with the lowest incomes, and federal health subsidies which
25
allowed individuals with moderate incomes to purchase coverage in new health
26
insurance exchanges.
27
28
•
Medicaid is an important source of healthcare coverage and has resulted in
significant coverage gains, as well as reductions in the uninsured rate, both among
4
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-00167-0)
00065
1
the low-income population and within other vulnerable populations. As a result of
2
Medicaid expansion, approximately 240,000 people have coverage which enabled
3
them to access a Medicaid benefit - HUSKY D, our Medicaid expansion group,
4
which increased from 44,753 in April 2010, when Connecticut became an early
5
adopter, to 99,103 in December 2013. With the increase in income eligibility to
6
138% of the federal poverty level, emollment has grown to approximately 240,000.
7
o
Research shows that coverage: gives people more financial security from the
8
catastrophic costs of a serious health condition; tends to improve mental
9
health; and enables earlier diagnosis and more effective self-management of
10
conditions such as diabetes.
11
•
Pursuant to the ACA, the Exchange serves the residents of the State of Connecticut
12
by offering emollees in qualified health plans financial assistance through advance
13
payments of the premium tax credit (APTCs) to help pay health insurance
14
premiums, and cost-sharing reductions (CSRs) that reduce the amount of out-of15
pocket costs that eligible consumers are required to pay for health care expenses
16
during the year.
17
e
The Exchange is one of the important reforms created by the ACA, allowing
18
individuals and small employers to access health insurance plans in a setting where
19
they can compare various options, and also apply for and receive financial assistance
20
to help pay for their coverage. In Connecticut, an average of 85,000 individuals per
21
year receive federally subsidized coverage because of the ACA.
22
•
The ACA created robust consumer protections to help ensure individuals can access
23
the healthcare system. Through Connecticut's Exchange, over 14,000 individuals
24
under age 26 receive health insurance coverage on their parent's plan- a benefit
25
offered under the ACA. Connecticut does not have statewide estimates for how
26
many individuals under age 26 receive coverage under parent-held policies, but
27
given the rate of coverage under parental plans for the 85,000 Access Health CT
28
5
Deel. of Benjamin Barnes in Support of Intervenors-Defendants' Opposition to Application for Preliminary
Injunction (4:18-cv-00167-0)
00066
1
recipients (slightly over 16%), one could assume tens of thousands more each year
2
receive coverage under parent-held policies.
3
4
5
5. The ACA has had positive economic benefits on states.
•
budget savings, revenue gains, and overall economic growth.
6
7
Studies have shown that states expanding Medicaid under the ACA have realized
•
Based on an analysis prepared by the Milken Institute School of Public Health at the
8
George Washington University, repealing two key elements of the ACA (federal
9
premium tax credits and federal payments to states for expansion of Medicaid
10
eligibility for low-income adults) would result in the loss in 2019 of approximately
11
35,900 jobs across many industries in Connecticut and would result in the loss of the
12
following over a five-year period (from 2019 through 2023):
13
o
$12.5 billion in federal funds;
14
o
$3 9 .1 billion in business output;
15
o
$23 .3 billion in gross state product; and
16
o
$748 million in state and local taxes.
17
6. The ACA expanded programs in Medicaid to provide States with increased
18
opportunities to increase access to home and community-based services.
19
•
The ACA authorized the extension of and additional federal funding for the highly
20
successful Money Follows the Person (MFP) demonstration grant; MFP has
21
supported nearly 5,000 individuals with disabilities and older adults in moving from
22
nursing facilities to their setting of choice, at lower cost and with greater opportunity
23
for community engagement;
24
•
The ACA established the Community First Choice (CFC) State Plan Option,
25
encouraging states to provide home and community-based attendant services and
26
supports to individuals who would otherwise require institutional level of care under
27
the Medicaid State Plan, by providing a State Plan option that enabled states to
28
6
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-00167-0)
00067
1
provide payment for self-directed personal care attendants and other services without
2
needing to apply for a waiver and which provided additional programmatic
3
flexibility beyond that authorized under waivers; under the ACA, CFC also provides
4
a 6 percentage point increase in federal matching payments for these services; CFC
5
has enabled thousands of people at risk of nursing home placement to hire personal
6
7
care attendants, providing flexible, personalized in-home supports;
•
The ACA appropriated funding for the Balancing Incentive Program (BIP), which
8
provided an enhanced match rate of 2% for non-institutional long-term services and
9
supports to states that commit to increasing access to community-based long-term
10
services and supports; in total, Connecticut received over $77 million in BIP
11
funding, which was reinvested in home and community-based long-term services
12
and supports; and
13
•
The ACA expanded the permissible eligibility limits and scope of services under the
14
section 1915(i) Home and Community-Based Services State Plan Option (which was
15
an optional State Plan service initially established by the Deficit Reduction Act of
16
2005).
17
These programs have all helped Connecticut in its efforts to continue to shift the balance
18
of long-term services and supports spending for Medicaid members from institutional settings to
19
home and community-based care.
20
21
22
23
7. The ACA has allowed States to test and implement reforms to healthcare delivery
systems that support State policy priorities of increasing efficiency and quality of care.
•
Since 2013, Connecticut has received $2.8 million for a planning grant and a
24
commitment of $45 million through 2020 for the State Innovation Model (SIM) Test
25
grant from the Center for Medicare and Medicaid Innovation (CMMI) to develop
26
and implement a model for healthcare delivery supported by value-based payment
27
methodologies tied to the totality of care delivered to at least 80% of our population
28
within five years, supporting the triple aim of better health while eliminating health
7
Deel. of Benjamin Barnes in Support ofintervenors-Defendants' Opposition to Application for Preliminary
Injunction (4:18-cv-00167-0)
00068
1
disparities, improving healthcare quality and experience, and reducing growth in
2
healthcare costs. This initiative has brought private and public payers, including
3
Medicaid, together to implement a value-based care delivery and payment approach
4
that has focused upon alignment with the Medicare Accountable Care Organization
5
(ACO) strategy, development of common quality measures, and use of shared
6
savings and other payment mechanisms. In addition, Connecticut Medicaid has
7
implemented a pay-for-performance primary care medical home initiative that serves
8
almost half of all members, and has built on this by layering on additional features of
9
care coordination and a shared savings feature.
10
o
Implementing value-based care delivery reforms and payment strategies has
11
enabled new person-centered strategies that have better coordinated services
12
and supports for high need, high cost individuals and allowed Medicaid to
13
tie outcomes and care experience to payment.
14
Under Connecticut's Medicaid program, the ACA has:
15
•
Permitted coverage of new services that are of great benefit to Medicaid
16
beneficiaries - just one example is coverage of tobacco cessation services
17
(counseling, treatment and medications)
18
o
This is a well-targeted service because many sources estimate that far more
19
Medicaid beneficiaries smoke than is typical of the general population, and
20
smoking-related conditions are ubiquitous and expensive to manage
21
•
Provided new family planning services for eligible individuals
22
o
Family planning services support good reproductive health and help reduce
23
unintended pregnancies, which in tum promotes better long-term health,
24
completion of education and improved outcomes of subsequent pregnancies
25
•
Enabled Connecticut to implement a behavioral health, health home effort under
26
section 1945 of the Social Security Act whereby providers integrate and coordinate
27
all primary, acute, behavioral health, and long-term services and supports to treat the
28
8
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-OO 167-0)
00069
1
whole person. In addition to the increased programmatic options provided to health
2
homes under the ACA, Connecticut also received federal reimbursement of 90% on
3
behavioral health, health home expenditures during the first eight calendar quarters
4
after the health home was established.
5
o
6
to integrate behavioral health, primary care and community-based supports
7
8
for people with Serious and Persistent Mental Illness (SPMI)
•
9
Fully funded primary care provider rate increases in calendar years 2013 and 2014.
These increases, though continued on a somewhat more limited basis in Connecticut,
10
have dramatically increased participation of primary care practitioners in Medicaid
11
from 1,622 in January 2012 to 3,598 in December 2017
12
o
13
16
17
18
19
20
21
22
23
24
25
26
27
Access to primary care is a key aspect of Medicaid reform and an essential
means ofreducing use of the emergency department, as well as effective
14
15
Health homes are enabling local mental health authorities and their affiliates
management of chronic conditions.
•
Broadened the scope of the preventive services benefit category in section
1905(a)(13)(C) of the Social Security Act to include services recommended by a
physician or other licensed practitioner of the healing arts (previously, this benefit
category was limited only to services actually provided by physicians and other
licensed practitioners). The increased scope of this benefit category is crucial to
enable appropriate coverage of services that are most effectively provided by a
variety of practitioners and in a variety of settings (especially in home and
community-based settings), particularly relevant for services that address behavioral
health, substance use disorder, and/or developmental conditions.
o
This increased programmatic flexibility under this broadened Medicaid State
Plan benefit category has enabled Connecticut to add coverage for Autism
Spectrum Disorder services and is a key component of Connecticut's updated
coverage of Early Intervention Services pursuant to Early and Periodic
28
9
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4: 18-cv-00167-0)
00070
1
Screening, Diagnostic and Treatment (EPSDT) services. Both of these
2
services are primarily provided in the home and other community-based
3
settings and permit broader access to early intervention services which are
4
critical for school and social success and, to the degree feasible, ultimately
5
6
independent living and integration within the community as adults.
•
Established various optional State Plan services, demonstrations, and other
7
flexibility that Connecticut is reviewing for potential future adoption. For example,
8
Connecticut may elect to establish one or more additional health homes in the future
9
and/or may establish coverage for one or more additional types of services under the
10
11
12
ACA-broadened preventive services Medicaid State Plan benefit category.
In addition, the ACA strengthened overall public health with many initiatives, including:
•
13
direct patient access employees oflong-term care facilities - 42,658 background
14
15
16
17
18
19
20
21
22
Establishing a nationwide program for national and state background checks on
checks completed since October 1, 2015, helping to ensure a safe workforce.
•
Requiring nursing facilities to: (1) report information regarding members of the
governing body of the facility, promoting transparency of governance to
Connecticut's nursing facility residents, their families and/or other responsible
parties; (2) implement and strictly enforce a compliance and ethics program, thereby
fostering compliance with regulations and a culture of program integrity; (3)
establish standards for Quality Assurance and Performance Improvement programs
and codify best practices, improving quality of care and service delivery; (4)
electronically submit staffing information to help ensure adequate staffing is in place
23
to deliver quality care and services; and (5) provide written notification at least 60
24
days in advance of a closure to allow residents adequate time to successfully relocate
25
26
27
to another facility or a home or community-based setting.
• . Developing consumer-oriented websites, providing useful information to consumers
when accessing care, posting deficiency statements, violation letters, and facility
28
10
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4:18-cv-00167-0)
00071
1
plans of corrections, and standardizing a complaint process for consumers to report
2
quality of care or other issues.
3
e
4
Requiring that nurse aide training programs include dementia management training
and patient abuse prevention training, thus enhancing the skill set of the workforce.
5
6
7
8
8. The ACA resulted in better quality and more accessible, affordable healthcare for
consumers.
•
The ACA not only improves access to healthcare for the uninsured, it ensures better
healthcare coverage for immunizations for those with existing insurance coverage by
9
10
requiring that insurance plans cover all recommended vaccines outside of the
11
patient's insurance deductible.
12
•
The ACA helped meet the increasing needs of Connecticut's most vulnerable
13
populations by increasing National Health Service Corps funding for scholarships
14
and loan repayment, more than doubling the primary, dental, and mental health
15
clinicians working in Connecticut's Health Professional Shortage Areas.
16
•
The PPHF allowed 16 health systems, between 2014 and 2018, to improve their
17
capacity to identify patients with poorly controlled diabetes and hypertension,
18
resulting in improved care for up to 164,118 individuals in Connecticut (and also
19
improved their awareness of prediabetes, identifying 33, 081 patients with
20
prediabetes)
21
•
ACA funding supported an expansion in the capacity of the CT Quitline. Between
22
July 1, 2013 and June 30, 2017, an additional 500 Quitline callers stopped their
23
tobacco use, resulting in an estimated $4 million in averted future medical and non-
24
medical costs related to tobacco use.
25
•
Between 2011 and 2018, over 6,830 youth ages 13-19 have participated in the ACA-
26
funded Personal Responsibility Education Program (PREP) program, which
27
provides education on abstinence and contraception in order to prevent pregnancy
28
and sexually transmitted infections. The delivery of evidence-based, comprehensive
11
Deel. of Benjamin Barnes in Support ofintervenors-Defendants' Opposition to Application for Preliminary
Injunction ( 4: 18-cv-OO 167-0)
00072
1
PREP prevention education to at-risk youth has contributed to a significant decline
2
in the birth rates for teens ages 15-19. The Connecticut teen birth rate dropped from
3
.18.8 per 1,000 births in 2012 to 14.9 per 1,000 births in 2014.
4
•
ACA PHHSBG funding allowed community-based public health providers to
5
address existing service gaps in their communities. These providers reported
6
measurable improvements in health outcomes, access to services, and reductions in
7
health risk behaviors as a result of their programmatic interventions, such as:
8
o
Reduction in children under 6 years of age with confirmed blood lead levels
9
at or above the CDC reference value of (5µg/dL) from 3.1 % in 2012 to 2.7%
10
in 2016
11
o
12
Reduction in the percent of youth (high school) who currently smoke
cigarettes from 14% in 2011 to 5.6% in 2015
13
o
Increases in estimated influenza vaccination coverage levels for adults (18-
14
64 years of age) from 34.4% in 2012 to 43.6% in 2016
15
o
Increases in estimated HPV vaccination coverage for female adolescents 13-
16
17 years of age meeting the CDC guidelines from 43.6% in 2012 to 56.9% in
17
2016
18
o
Increases in estimated HPV vaccination coverage for male adolescents 13-17
19
years of age meeting the CDC guidelines from 8.5% in 2012 to 41.5% in
20
2016
21
o
22
Reduction in number of newly diagnosed cases of HIV from 3 51 in 2011 to
269 in 2016
23
o
Reduction in rate of chlamydia incidence among youth 15-19 years of age
24
from 1,973 per 100,000 in 2011 to 1,289 per 100,000 in 2016
25
o
Increases in estimated vaccine coverage levels for Advisory Committee on
26
Immunization Practices recommended vaccines among children 19-35
27
months of age from 57.9% in 2010 to 75.7% in 2016.
28
12
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4·18-cv-00167-0)
00073
1
•
2
Prevention and Public Health Fund dollars have been utilized to maintain high
childhood immunization coverage levels, track vaccination coverage and contain
3
disease outbreaks. If this funding were eliminated, it could adversely affect
4
Connecticut's vaccination rates, resulting in disease outbreaks of vaccine
5
preventable diseases. Of note, newborn babies would be at increased risk,
6
particularly from hepatitis B, influenza and pertussis. Additionally, the state would
7
experience a loss of funding for critical technology to sustain the state's
8
immunization information system.
9
•
10
In addition, ACA funding has strengthened the state's capacity to address infectious
disease outbreaks through the use of molecular fingerprinting tools, resulting in
11
more timely identification and treatment of impacted individuals. These funds have
12
also supported the state's capacity to address hospital-acquired infections and drug-.
13
14
15
16
17
resistant infections.
All of the foregoing benefits of the Affordable Care Act would be removed if the Plaintiffs'
motion for preliminary injunction were granted. It would then be a policy decision for the next
administration and/or legislature as to whether some of these programs are retained at state
expense.
18
19
20
21
22
23
24
25
26
27
28
13
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4-J 8-cv-00167-0)
00074
1
I declare under penalty of perjury that the foregoing is true and correct to the best of my
2
knowledge and belief.
3
Executed on June 5, 2018, in Hartford, Connecticut.
4
5
6
7
8
9
10
11
12
ELEANOR M. MICHAEL
NOTARY PUBLIC
MY COMMISSION EXPIRES JUNE 30, 2018
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
14
Deel. of Benjamin Barnes in Support oflntervenors-Defendants' Opposition to Application for Preliminary
Injunction (4· 18-cv-00167-0)
00075
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-O
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAII, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF PETER BERNS IN SUPPORT OF INTERVENORSDEFENDANTS’ OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
I, Peter Berns, declare:
1.
Since July 2008, I have served as Chief Executive Officer of The Arc. Prior to taking on
this position, I served as the Executive Director of the Maryland Association of Nonprofit
00076
Organizations for sixteen years as well as Deputy Chief of Consumer Protection in the
Maryland Attorney General’s Office. In my current role, I oversee the wide variety of work
performed by our national office staff-in conjunction with our nationwide chapter
network—in support of the right of people with intellectual and developmental disabilities
and their families to live, work, learn, and socialize in the community, free from
discrimination. Preserving and protecting the Affordable Care Act has been and continues
to be a top priority for The Arc.
2.
The Arc is the largest national community-based organization advocating for and serving
people with intellectual and developmental disabilities (I/DD) and their families, with
more than 650 state and local chapters nationwide. The Arc promotes and protects the
human rights of people with intellectual and developmental disabilities and actively
supports their full inclusion and participation in the community throughout their lifetimes.
3.
The Arc views the Affordable Care Act (ACA) as critical for people with I/DD and their
families in providing benefits, supports, and civil rights protections that help make
community living possible. Through its public policy and legal advocacy work, The Arc
has and continues to work vigorously to ensure the ACA is protected and preserved.
4.
The ACA increased access to affordable coverage for individuals with I/DD and their
families. People, including those with I/DD, who have access to comprehensive and
affordable health insurance are more likely to receive the prescription drugs, therapies, and
medical treatment they need to be healthy and maintain the ability to function in the
community. The ACA has helped this population gain insurance through a variety of
mechanisms:
• The ACA ended exclusions for pre-existing conditions, prohibiting medical
underwriting, and ending retroactive denials of coverage. Children and adults can
access health insurance now that was previously denied because of a pre-existing
condition. A pre-existing condition is one that existed before health coverage began
00077
and can include conditions that many people with I/DD have including seizures,
diabetes, asthma and other conditions.
• The ACA allowed coverage of dependents through age 26. This benefits many
people with I/DD, who may have a longer transition period from youth to
employment-based health coverage.
• The ACA gave states the opportunity to expand Medicaid eligibility to childless
adults with incomes up to 133% of the federal poverty level.
• The ACA created private insurance exchanges for individuals as well as subsidies to
assist low-income individuals in purchasing coverage.
5.
The ACA has also improved the quality of insurance and health care that people with I/DD
receive. People with I/DD often have multiple health conditions and are at risk of
developing secondary disabilities without quality health care. Studies have documented a
higher prevalence of adverse conditions, inadequate attention to health care needs,
inadequate focus on health promotion, and inadequate access to quality health care
services. The ACA improved health care quality in many ways, including the following:
• The ACA eliminated co-pays for critical prevention services
• The ACA included mental health services, rehabilitative and habilitative services and
devices, and other critical disability services in the health plans sold in the
exchanges
• The ACA included coverage of dental and vision care for children in health
insurance plans sold on the exchanges
•
The ACA eliminated lifetime limits on health insurance coverage and phasing out
annual limits. These benefits can be crucial to many families with a member with
I/DD who experiences complex and lifelong medical needs such as compromised
breathing or swallowing or difficulty walking.
• The ACA allows a free annual Medicare well visit with assessments and an
individualized prevention plan.
00078
• The ACA eliminated Medicare Part D (drug coverage) co-pays for persons who are
dual-eligible for Medicaid and Medicare, and who are receiving Medicaid waiver
services.
• The ACA expanded Medicare Part D coverage of anti-seizure, anti-anxiety, and antispasm medications.
6.
The ACA prioritized home care rather than institutionalization as a cost-effective and
community-based method of care for people with I/DD. Expanding home- and communitybased long term services and supports will reduce the need for nursing home and other
institutional settings. In the long run, these investments in health care and home- and
community-based services will improve health and reduce dependence on costly
institutions.
• The ACA created an option to provide health homes for Medicaid enrollees with
chronic conditions. Health homes are intended to be person-centered systems of
care that integrate primary, acute, behavioral health, and long term services.
• The ACA established the Community First Choice Option for states to cover
comprehensive community attendant services under the state’s Medicaid optional
service plan and avoid costlier nursing home and other institutional care.
• The ACA improved the existing Medicaid Section 1915(i) option for home and
community based services by making it easier for individuals to qualify for
services, allow states to target specific populations, and avoid costlier nursing home
and other institutional care.
• The ACA reduced Medicaid’s institutional bias by creating new financial incentives
for states to rebalance their services from costlier institutional settings toward home
and community based services.
• The ACA extended the Money Follows the Person Demonstration program that
provides additional federal payments to help people transition from costlier
institutions to home- and community-based services.
00079
7.
The ACA expands the information that researchers, policy makers and advocates have
about the health care status of people with disabilities and supports future developments in
health care for people with I/DD through a variety of programs that nurture innovation and
improvement:
• The ACA allows states in partnership with the federal government to try new models
of care to provide better health care at lower costs to people with complex health
care needs who are eligible for both Medicare and Medicaid.
• The ACA created the Prevention and Public Health Fund to greatly expand wellness,
disease prevention, and other public health priorities.
• The ACA has improved data collection on health care access for people with
disabilities.
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on May 29, 2018, in Washington, DC.
~~
Chief Executive Officer
The Arc
SA2018100536
00080
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA, PAUL
LeP AGE, Governor of Maine, Governor Phil
Bryant of the State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA, SOUTH
CAROLINA, SOUTH DAKOTA, TENNESSEE,
UTAH, WEST VIRGINIA, NEILL HURLEY and
JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HA WAIi,
ILLINOIS, KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its Department of
Commerce, NEW JERSEY, NEW YORK,
NORTH CAROLINA, OREGON, RHODE
ISLAND, VERMONT, VIRGINIA and
WASHINGTON,
Intervenors-Defendants.
DECLARATION OF SHARON C. BOYLE IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
00081
I, Sharon C. Boyle, do hereby depose and state the following:
1.
I am the General Counsel for the Massachusetts Executive Office of Health
and Human Services (EOHHS). Prior to April 15, 20 18, I was the First Deputy General
Counsel at the EOHHS and Chief MassHealth Counsel. MassHealth is the Medicaid and
Children's Health Insurance Program for the Commonwealth of Massachusetts ..
2.
I began working as an Assistant General Counsel at the Division of Medical
Assistance, the agency then responsible for administration of the MassHealth program in or
about 1995. The Executive Office of Health and Human Services has administered the
MassHealth program since in or around 2003. I moved into my role as Chief MassHealth
Counse l in or about 2011 . As General Counsel, I remain responsible to provide legal counsel to the
MassHealth program. I have personal knowledge of the rules, regulations, and processes
governing MassHealth, including those related to the Affordable Care Act (ACA).
3.
I have either personal knowledge of the matters set forth below or, with
respect to those matters for which I do not have personal knowledge; I have reviewed
information gathered for me in my capacity as Chief MassHealth Counsel or General Counsel.
4.
The ACA established a new Medicaid eligibility group for childless adults
below 133% of the federal poverty limit (as determined using a Medicaid formula known as
Medicaid Adjusted Gross Income or MAGI). This eligibility group is commonly referred to
as the "Medicaid Expansion Population" or the "New Adult Group."
5.
Under the ACA, states that opt to provide Medicaid coverage to the Medicaid
Expansion population receive federal matching funds on their medical assistance expenditures at
the rate of 89.6% in calendar year2018 .
2
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6.
Currently, the Commonwealth's Medicaid program includes approximately
350,000 Massachusetts residents who are enrolled Members under the Medicaid Expansion. In
the most recently completed state fiscal year 2017, MassHealth claimed $1.775 billion in federal
financial participation for these members.
7.
If the Plaintiffs' motion for preliminary injunction is granted, the foregoing benefits
of the ACA would be lost.
PURSUANT T028 U.S.C. § 1746, I DECLARE UNDER PENALTY OF PERJURY THAT
THE FOREGOING IS TRUE AND CORRECT.
/
EXECUTED ON June~' 2018.
General Counsel
Executive Office of Health and Human Services
Commonwealth ofMassachusetts
3
00083
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-O
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAII, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF SABRINA CORLETTE IN SUPPORT OF INTERVENORSDEFENDANTS’ OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
I, Sabrina Corlette, declare:
1.
I am a Research Professor at the Center on Health Insurance Reforms (CHIR) at
Georgetown University’s Health Policy Institute. At CHIR, I direct research on health insurance
00084
reform issues. My areas of focus include state and federal regulation of private health insurance
plans and markets and evolving insurance market rules. I have published numerous papers
relating to the regulation of private health insurance and health insurance marketplaces. I also
serve on the Standards Committee for the National Committee for Quality Assurance. Prior to
joining the Georgetown faculty, I was Director of Health Policy Programs at the National
Partnership for Women & Families, where I provided policy expertise and strategic direction for
the organization’s advocacy on health care reform, with a particular focus on insurance market
reform, benefit design, and the quality and affordability of health care. I also served as an
attorney at Hogan Lovells, during which time I advised clients on health insurance, health
finance, and food and drug regulatory matters.
2.
Since 2010, I have authored over 25 research papers about the Affordable Care Act and
its implementation. I have been invited to testify as an Affordable Care Act expert before seven
congressional committees (U.S. House of Representatives and U.S. Senate) in the last five years.
The California General Assembly invited me in January 2018 to testify about the status of the
individual health insurance market. I regularly provide technical assistance to state departments
of insurance, state policymakers, and other health care organizations regarding Affordable Care
Act regulations and guidance and their impact on consumers and other health care stakeholders. I
am frequently consulted by journalists seeking Affordable Care Act expertise, and have been
quoted numerous times on health insurance and Affordable Care Act issues in national and local
print, radio, web-based, and television media. A full list of my publications and media is
available on our website at https://chir.georgetown.edu.
3.
I understand that this lawsuit involves a challenge to the Affordable Care Act and seeks
to enjoin it. In my expert opinion, enjoining the Affordable Care Act would cause significant
disruption to the U.S. health care market, resulting in harm to patients, providers, insurance
carriers, and federal and state governments.
4.
The Affordable Care Act was enacted in part to correct serious deficiencies in the
individual health insurance market that left millions uninsured and millions more with
00085
inadequate coverage that failed to protect them from serious financial harm if and when they got
sick. In order to assess the effect the Affordable Care Act has had on the individual insurance
market today, it is important to understand the market that Congress was seeking to change when
it enacted the Affordable Care Act in 2010.
5.
Prior to implementation of the Affordable Care Act’s market reforms, approximately 48
million Americans lacked health insurance.1 Those without health insurance have a lower life
expectancy than those with coverage. Before the Affordable Care Act was enacted, an estimated
22,000 people per year died prematurely because they lacked insurance.2 This is likely because
the uninsured are more than six times as likely as the privately insured to delay or forego needed
care due to costs. For example, uninsured cancer patients are more than five times more likely
than their insured counterparts to forego cancer treatment due to cost.3
6.
Being uninsured also results in financial insecurity. In 2010, when the Affordable Care
Act was enacted, sixty percent of the uninsured reported having problems with medical bills or
medical debt.4
7.
Additionally, prior to the Affordable Care Act, the high and rising uninsured rate led to
high and rising uncompensated care costs for providers, in 2009 estimated at $1000 worth of
DeNavas-Walt C, Proctor BD, Smith J. Income, Poverty, and Health Insurance
Coverage in the United States: 2012, U.S. Census Bureau, Sept. 2013. Available
at https://www.census.gov/prod/2013pubs/p60-245.pdf.
2
Dorn S. Uninsured and Dying Because of It, The Urban Institute, Jan. 2008.
Available at https://www.urban.org/sites/default/files/publication/31386/411588Uninsured-and-Dying-Because-of-It.PDF.
3
Lives on the Line: The Deadly Consequences of Delaying Health Reform,
Families USA, Feb. 2010. Available at
http://familiesusa.org/sites/default/files/product_documents/delaying-reform.pdf.
4
Cunningham, P. and Sommers, A. Medical Bill Problems Steady for U.S.
Families 2007-2010, Center for Studying Health System Change, Dec. 2011. Available at
http://www.hschange.org/CONTENT/1268/?words=tracking%20report%2028.
1
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services per uninsured person.5 Providers ultimately passed those costs onto insured consumers
and taxpayers.
8.
Before the Affordable Care Act, approximately 19 million Americans purchased
coverage in the individual insurance market because they lacked access to employer-based
insurance or were not eligible for public programs such as Medicare or Medicaid.6 The
individual insurance market was an inhospitable place, particularly for anyone in less than
perfect health. An estimated 133 million Americans have at least one pre-existing condition that
could threaten their access to health care and health insurance.7
9.
Prior to the Affordable Care Act, in most states, applicants for health insurance could be
denied a policy because of their health status, or charged more in premiums based on their health
and gender, along with a number of other factors. Insurers could also issue policies that didn’t
cover critical medical services like pharmacy benefits, mental health or substance use treatment,
maternity, or any of the care required to treat a person’s pre-existing condition. In addition,
insurers often rescinded an individual’s coverage if they got sick after enrolling in the plan, and
many plans imposed annual or lifetime dollar limits on covered benefits.8
10.
Prior to the Affordable Care Act, coverage was often simply not available to many
individuals applying for coverage. One of the many ways insurers maximized revenue was
through aggressive underwriting practices resulting in a denial of coverage to individuals posing
Hu, L. et al. The Effect of the Patient Protection and Affordable Care Act
Medicaid Expansions on Financial Wellbeing, National Bureau of Economic Research,
Feb. 2018. Available at http://www.nber.org/papers/w22170.
6
DeNavas-Walt C, et al. Income, Poverty, and Health Insurance Coverage in the
United States: 2012.
7
Office of the Assistant Secretary for Planning and Evaluation, Health Insurance
Coverage for Americans with Pre-Existing Conditions: The Impact of the Affordable
Care Act, Issue Brief, Jan. 2017. Available at
https://aspe.hhs.gov/system/files/pdf/255396/Pre-ExistingConditions.pdf.
8
Corlette S, Volk J, Lucia K. Real Stories, Real Reforms. Robert Wood Johnson
Foundation, Sept. 2013. Available at https://georgetown.app.box.com/file/124506387872.
5
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a potential health risk.9 In most states, when an individual wanted to buy health insurance, they
had to fill out and submit a voluminous application that included detailed information about their
health history and status. Insurers would then review the individual’s application and assess the
likelihood he or she would incur future health costs. A Georgetown University study found that
even people with minor health care conditions, such as hay fever, could be turned down for
coverage.10 Health insurers maintained underwriting guidelines that listed as many as 400
separate medical conditions that could trigger a denial of coverage.11
11.
A U.S. Government Accountability (GAO) study in 2011 found that average insurer
denial rates were 19 percent, but they varied dramatically market-to-market and insurer-toinsurer. For example, across six insurers in one state, denial rates ranged from 6 percent to 40
percent.12 In practice, access to coverage for people with pre-existing conditions was probably
less available than this study suggests, because of a common industry practice known as “street
underwriting,” in which an insurance agent or broker would ask a potential applicant questions
about their health status, and discourage them from applying if they posed a health risk. These
underwriting practices were banned by the Affordable Care Act in 2014.
12.
Prior to the Affordable Care Act, it was not uncommon for insurers to rescind coverage
after they had accepted an applicant. If an enrollee had any health care claims within their first
U.S. Government Printing Office, Senate Hearing 113-663. A New, Open
Marketplace: The Effect of Guaranteed Issue and New Rating Rules, U.S. Senate Health,
Education, Labor & Pension Committee, Apr. 11, 2013. Available at
https://www.gpo.gov/fdsys/pkg/CHRG-113shrg95186/html/CHRG-113shrg95186.htm.
10
Pollitz K, Sorian R. How Accessible is Individual Health Insurance for
Consumers in Less-than-perfect Health? Georgetown University and Kaiser Family
Foundation, Jun. 2001. Available at
https://kaiserfamilyfoundation.files.wordpress.com/2013/01/how-accessible-isindividual-health-insurance-for-consumers-in-less-than-perfect-health-executivesummary-june-2001.pdf.
11
U.S. Government Printing Office, Senate Hearing 113-663.
12
U.S. Government Accountability Office. Private Health Insurance: Data on
Application and Coverage Denials, Mar. 2011. Available at
https://www.gao.gov/assets/320/316699.pdf.
9
00088
year of coverage, the insurer would investigate that person’s health history. If they found
evidence that their condition was a pre-existing one and not fully disclosed during the initial
underwriting process, the company would deny the relevant claims and rescind or cancel the
coverage.13 The Affordable Care Act prohibited this practice except in clear cases of fraud by the
policyholder.
13.
Prior to the Affordable Care Act, individual insurance was often unaffordable. Unlike
those with employer sponsored coverage or in public programs like Medicare or Medicaid,
people with individual insurance must pay the full cost of their premium. According to one
national survey prior to the Affordable Care Act, 31 percent of individual market respondents
spent 10 percent or more of their income on premium costs.14
14.
Prior to the Affordable Care Act the cost of premiums caused many individuals to forego
coverage completely. A national survey found that nearly three-quarters (73 percent) of people
seeking coverage in the individual market did not end up buying a plan, most often because the
premium was too high. The coverage was least affordable for those individuals who needed it the
most – people with pre-existing conditions. The same national survey found that 70 percent of
people with health problems reported it “very difficult” or “impossible” to find an affordable
plan, compared to 45 percent of people in better health.15
Girion L. Health Insurer Tied Bonuses to Dropping Sick Policyholders, Los
Angeles Times, Nov. 9, 2007. Available at
http://articles.latimes.com/2007/nov/09/business/fi-insure9.
14
Collins SR, Robertson R, Garber T, Doty MM. Insuring the Future: Current
Trends in Health Coverage and the Effects of Implementing the Affordable Care Act, The
Commonwealth Fund, Apr. 2013. Available at
http://www.commonwealthfund.org/~/media/Files/Publications/Fund%20Report/2013/A
pr/1681_Collins_insuring_future_biennial_survey_2012_FINAL.pdf.
15
Doty MM, Collins SR, Nicholson JL, Rustgi SG. Failure to Protect: Why the
Individual Insurance Market Is Not a Viable Option for Most U.S. Families, The
Commonwealth Fund, Jul. 2009. Available at
http://www.commonwealthfund.org/~/media/Files/Publications/Issue%20Brief/2009/Jul/
Failure%20to%20Protect/1300_Doty_failure_to_protect_individual_ins_market_ib_v2.p
df.
13
00089
15.
Prior to the Affordable Care Act, older and less healthy individuals had to pay more for
coverage because health insurers would segment their enrollees into different groups and charge
them different prices based on their health or other risk factors. In practice, this meant that
people would be charged more because of a pre-existing condition (even if they had been
symptom-free for years), because of their age, gender (insurers assume women use more health
care services than men), family size, geographic location, the work they do, and even their
lifestyle.16 A Georgetown University study of insurers’ rating practices before the Affordable
Care Act found rate variation of more than nine-fold for the same policy based on age and health
status. In many states, people in their early sixties would be charged as much as six times the
premium of someone in their early twenties, based on age alone. Even young people, when rated
based on health status, could be subjected to significant premium costs.17
16.
Under the Affordable Care Act, using health status and gender to set premium rates is
prohibited. In addition, the Affordable Care Act provides low- and moderate-income people
between 100 and 400 percent of the federal poverty line with subsidies to help defray their
premium costs. In 2018, the average monthly premium tax credit is $550, resulting in an average
monthly premium for consumers receiving a premium tax credit of $89.18
17.
Prior to the Affordable Care Act, coverage in the individual market was often inadequate
to meet people’s health care needs. In addition to paying more in premiums, people in the
Buntin MB, Marquis MS, Yegian JM. The Role Of The Individual Health
Insurance Market And Prospects For Change, Health Affairs, Nov./Dec. 2004. Available
at https://www.healthaffairs.org/doi/pdf/10.1377/hlthaff.23.6.79.
17
Pollitz K, Sorian R. How Accessible is Individual Health Insurance for
Consumers in Less-than-perfect Health?
18
Kaiser Family Foundation. Marketplace Average Premiums and Average
Advanced Premium Tax Credit (APTC), Open Enrollment 2018. Available at
https://www.kff.org/health-reform/state-indicator/marketplace-average-premiums-andaverage-advanced-premium-tax-creditaptc/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%
22:%22asc%22%7D.
16
00090
individual market also spent a larger share of their income on cost-sharing than those with
employer-sponsored coverage. Prior to the Affordable Care Act, people in the individual market
were more than twice as likely to be considered “underinsured” than those in an employer plan.19
Someone is considered “underinsured” when they have insurance but because of high
deductibles, high cost-sharing, or non-covered benefits, the insurance offers inadequate financial
protection for the health care services people need.
18.
Prior to the Affordable Care Act, a primary reason people buying individual insurance
coverage had high out-of-pocket costs was that many individual plans – over half according to
one study – did not meet minimum standards for coverage.20 Coverage in the individual market
was inadequate for a number of reasons, including:
19.
Pre-existing condition exclusions: in many states, insurers were permitted to permanently
or for a period of time exclude from covered benefits treatments for any health problem that a
consumer disclosed on their application. This practice was banned under the Affordable Care
Act.
20.
Benefit exclusions: Insurers in the individual market often sold policies that did not cover
basic benefits such as maternity care, prescription drugs, mental health, and substance use
treatment services. For example, 20 percent of adults with individual insurance lacked coverage
for prescription medicines before the Affordable Care Act.21 The Affordable Care Act requires
individual market insurers to cover a minimum set of essential health benefits that includes
maternity services, prescription drugs, and mental health and substance use treatment.
Collins SR, Robertson R, Garber T, Doty MM. Insuring the Future: Current
Trends in Health Coverage and the Effects of Implementing the Affordable Care Act.
20
Gabel JR et al. More Than Half Of Individual Health Plans Offer Coverage
That Falls Short Of What Can Be Sold Through Exchanges As Of 2014, Health Affairs,
Jun. 2012. Available at https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2011.1082.
21
Doty MM, Collins SR, Nicholson JL, Rustgi SG. Failure to Protect: Why the
Individual Insurance Market Is Not a Viable Option for Most U.S. Families
19
00091
21.
High out-of-pocket costs: Prior to the Affordable Care Act, individual insurance policies
often came with high deductibles – $10,000 or more was not uncommon – and high cost-sharing.
In fact, deductibles were often three times what they were in employer-sponsored plans.22 As a
result, many individual insurance plans were extremely low-value. One study found that
individual policies paid for just 55 percent of the expenses for covered services, compared to 83
percent for small employer group plans.23 The Affordable Care Act requires insurers to meet a
minimum adequacy of coverage standard of 60 percent (meaning that on average, the plan must
cover 60 percent of an average enrollee’s covered health care costs). The law also helps protect
consumers from catastrophic medical costs by capping their annual out-of-pocket spending (for
2018, the annual cap is $7350 per individual).
22.
Lifetime or annual dollar limits on coverage: Prior to enactment of the Affordable Care
Act, an estimated 102 million people were in plans with a lifetime limit on benefits and about
20,000 people hit those limits every year. An estimated 18 million people were in plans with
annual dollar limits on their benefits. For people with serious high cost medical conditions, such
as hemophilia, serious cancers, or end-stage renal disease, this can literally be a life or death
issue. The Affordable Care Act ushered in bans on lifetime and annual dollar limits.
23.
Among Congress’ goals for the Affordable Care Act were to extend affordable, adequate
health insurance coverage to more people and to correct many of the dysfunctions of the
individual market, described above. Congress tried to achieve these goals through a threepronged strategy:
24.
(1) Insurance reforms to help people locked out of the system due to pre-existing
conditions;
McDevitt R et al. Group Insurance: A Better Deal For Most People Than
Individual Plans, Health Affairs, Jan. 2010. Available at
https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2009.0060.
23
Gabel J et al. Trends In The Golden State: Small-Group Premiums Rise Sharply
While Actuarial Values For Individual Coverage Plummet, Health Affairs, Jul./Aug.
2007. Available at https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.26.4.w488.
22
00092
25.
(2) An individual mandate to encourage healthy people to enroll in the insurance pool and
keep premiums stable; and
26.
(3) Subsidies to help people afford the insurance coverage (with Medicaid expansion
available for people under 138 percent of the federal poverty line). The Affordable Care Act also
created state-based insurance marketplaces where people can apply for the subsidies and shop for
plans.
27.
To a significant degree, the Affordable Care Act has achieved its goals. It has expanded
access to insurance coverage, improved health outcomes, and improved families’ financial
security.
28.
Under the Affordable Care Act, the percentage of people uninsured declined from 14.5
percent in 2013 to 9.1 percent in 2017. An estimated 20 million people gained insurance
coverage because of the Affordable Care Act.24
29.
The goal of expanding coverage is ultimately to improve people’s health outcomes and
their financial security in the event of an unexpected illness or injury. The Affordable Care Act’s
reforms were fully implemented in 2014, so it is still relatively early to try to assess the law’s
impact on access to care, health outcomes, and financial security. However, data are emerging to
suggest the law is having a significant positive impact.
30.
Since enactment of the Affordable Care Act, the percentage of Americans reporting that
they didn’t see a doctor or fill a prescription because they couldn’t afford it has declined by more
Cohen RA, Zammitti EP, Martinez ME. Health Insurance Coverage: Early
Release of Estimates From the National Health Interview Survey, 2017, Centers for
Disease Control and Prevention, National Center for Health Statistics, May 2018.
Available at https://www.cdc.gov/nchs/data/nhis/earlyrelease/insur201805.pdf.
24
00093
than one-third.25 Further, more people are reporting that they have a primary care doctor or have
had a check-up in the last 12 months.26
31.
Research to date also strongly suggests that expanding access to coverage leads to better
health outcomes. For example, studies of the health reforms in Massachusetts, upon which the
Affordable Care Act was modeled, have found that coverage expansion in that state led to
reported improvements in physical and mental health, as well as reductions in mortality.27 A
Harvard study found that expanded coverage under the Affordable Care Act was linked to major
improvements in the diagnosis and treatment of chronic diseases such as hypertension, diabetes,
and high cholesterol.28
32.
In addition to improving access to care, health insurance also provides financial security,
particularly in the event of a large, unanticipated medical expense. Unfortunately, in this country,
health care is extremely expensive. For example, the average cost of a single MRI is $1,119. An
uncomplicated hospital labor and delivery costs an average of $10,808, while a C-section will
average over $16,000. One course of treatment for colon cancer will cost between $21,000 and
McCarthy, J. U.S. Women More Likely Than Men to Put Off Medical Treatment,
Gallup, Dec. 2017. Available at http://news.gallup.com/poll/223277/women-likely-menput-off-medical-treatment.aspx.
26
Karpman, M. et al. Time for a Checkup: Changes in Health Insurance
Coverage, Health Care Access and Affordability, and Plan Satisfaction among Parents
and Children between 2013 and 2015, Urban Institute, Jan. 2016. Available at
http://hrms.urban.org/briefs/changes_coverage_access_affordability_parents_children.pdf
.
27
Van Der Wees, PJ, et al. Improvements In Health Status After Massachusetts
Health Care Reform, National Center for Biotechnology Information, Dec. 2013.
Available at https://www.ncbi.nlm.nih.gov/pubmed/24320165.
28
Hogan DR et al. Estimating The Potential Impact Of Insurance Expansion On
Undiagnosed And Uncontrolled Chronic Conditions, Health Affairs, Sept. 2015.
Available at https://www.healthaffairs.org/doi/abs/10.1377/hlthaff.2014.1435.
25
00094
$52,000. Yet over half of American families report that they would not be able to afford to pay
just $500 in cash for an unexpected expense.29
33.
Research suggests that the Affordable Care Act is helping to improve the financial
security of the newly insured. Survey data show that the number of families who say they are
having problems paying medical bills has fallen dramatically since 2013, particularly among
low- and moderate-income families.30 Other studies have shown that the Affordable Care Act’s
Medicaid expansion has led to reductions in the amount of debt sent to collection agencies and
improvements in families’ credit scores.31
34.
The Affordable Care Act has also helped reduce uncompensated care costs borne by
providers. For example, hospital-based uncompensated care fell by over 25 percent between
2013 and 2015, and in Medicaid expansion states it has fallen by closer to 50 percent.32
35.
Unfortunately, much of the progress under the Affordable Care Act is at risk due to
recent federal policy decisions designed to roll back key provisions of the law and bypass
consumer protections. Ultimately, some of these decisions are likely to result in many consumers
facing higher premiums and fewer plan choices in the individual insurance market.
36.
A stable health insurance market depends on a large risk pool that is reasonably balanced
between healthy individuals and sicker ones. The Affordable Care Act had a “three-prong”
29
Picchi A, A $500 Surprise Expense Would Put Most Americans into Debt, CBS
MoneyWatch, Jan. 2017. Available at https://www.cbsnews.com/news/most-americanscant-afford-a-500-emergency-expense/.
30
Karpman, M and Long, S. 9.4 Million Fewer Families Are Having Problems
Paying Medical Bills, Urban Institute, May 2015. Available at
http://hrms.urban.org/briefs/9-4-Million-Fewer-Families-Are-Having-Problems-PayingMedical-Bills.pdf.
31
Hu, L. et al. The Effect of the Patient Protection and Affordable Care Act
Medicaid Expansions on Financial Wellbeing, National Bureau of Economic Research,
Feb. 2018. Available at http://www.nber.org/papers/w22170.
32
Schubel, J and Broaddus, M. Medicaid Waivers That Create Barriers to
Coverage Jeopardize Gains, May 2018. Available at
https://www.cbpp.org/research/health/uncompensated-care-costs-fell-in-nearly-everystate-as-acas-major-coverage.
00095
strategy designed to facilitate such a stable insurance market by requiring all participating
insurers to play by the same rules and, through subsidies and the individual mandate, encourage
healthy people to become insured before they get sick.
37.
The Affordable Care Act marketplaces had a rocky early start, but that was not
unexpected given that insurers had little knowledge of the new population of people they were
covering, leading many to make significant adjustments to their business strategy as they gained
more experience and data about their enrollees. In addition, unanticipated Congressional actions,
such as the dramatic reduction in funding for a key premium stabilization program (the “risk
corridor” program) resulted in significant financial losses for many insurers.
38.
Specifically, the Affordable Care Act included three programs intended to ensure that
premiums remain stable, both during the initial years of the law’s implementation and over the
long term. These are the risk corridors, reinsurance, and risk adjustment programs – often called
the “3Rs.” The risk corridor program in particular was a temporary program designed to provide
a buffer for insurers that did not adequately price their plans due to a lack of data about the
health risk of the newly insured population in the Affordable Care Act marketplaces.
39.
The risk corridor program works by requiring the federal government (through the U.S.
Department of Health & Human Services or HHS) to partially reimburse insurers whose
premium revenue was insufficient to pay claims. Insurers whose premium revenue exceeded
their claims were required to pay HHS a fraction of the excess premium.33
40.
In the first two years of the Affordable Care Act marketplaces, many insurers set
relatively low premiums in order to capture more market share. In late 2014, long after insurers’
pricing decisions were made, a Congressional appropriations bill dramatically limited the funds
available to HHS to compensate insurers for significant losses.34
33
34
42 U.S.C. §18062.
Pub. L. No. 113-235.
00096
41.
Because more insurers experienced losses than gains in the first two years of the
marketplaces, HHS was able to pay insurers only 12.6 percent of the risk corridor payments they
were owed.35 This decision had a serious financial impact on insurers, resulting in an estimated
$12.3 billion in losses,36 and likely accelerated the demise of several small, non-profit CO-OP
health plans.37
42.
The loss of risk corridor funds contributed to the significant premium increases many
insurers implemented for plan year 2016. However, it is noteworthy that premiums in the
individual market were still often below or close to those in the employer-sponsored insurance
market in 2016.38 Given that Affordable Care Act individual market benefit plans are designed to
be similar to a typical employer plan, this suggests that during the first two years of the
Affordable Care Act marketplaces (2014 and 2015), many insurers had underpriced their
products in an effort to gain market share. Many of these same insurers subsequently left the
35
Department of Health and Human Services, Risk Corridors Payment Proration
Rate for 2014, Oct. 1,
2015, https://www.cms.gov/CCIIO/Programs-and-Initiatives/PremiumStabilization-Programs/Downloads/RiskCorridorsPaymentProrationRatefor2014.pdf.
36
Small L. Government's unpaid risk corridor tab swells to $12.3B,
FierceHealthcare, Nov. 2017. Available at
https://www.fiercehealthcare.com/aca/government-s-unpaid-risk-corridor-tab-swells-to12-3b.
37
Corlette S, Miskell S, Lerche J, Lucia K. Why are Many CO-OPs Failing? How
New Non-profit Health Plans Have Responded to Market Competition, The
Commonwealth Fund, Dec. 2015. Available at
http://www.commonwealthfund.org/~/media/files/publications/fundreport/2015/dec/1847_corlette_why_are_many_coops_failing.pdf.
38
Holahan J, Blumberg LJ, Clemans-Cope L, McMorrow S, and Wengle E. The
Evidence on Recent Health Care Spending Growth and the Impact of the Affordable Care
Act, The Urban Institute and Robert Wood Johnson Foundation, May 2017. Available at
https://www.urban.org/sites/default/files/publication/90471/2001288the_evidence_on_recent_health_care_spending_growth_and_the_impact_of_the_afforda
ble_care_act.pdf.
00097
Affordable Care Act market because they were unable to compete with insurers that had been
more successful in projecting a premium rate that would allow them to cover their costs.39
43.
Going into plan year 2017, financial data from insurers demonstrate that the markets were
beginning to stabilize and insurers were gaining their footing.40 Indeed, in 2017 the
Congressional Budget Office concluded that the Affordable Care Act’s insurance markets would
likely be stable in most places if left unchanged.41 Consistent with this projection, 2017 appears
to have been a profitable year for most individual market insurers.42
44.
Unfortunately, my own review of insurers premium rate justifications (referred to as
actuarial memoranda) for plan years 2018 and 2019 found that recent policy changes are putting
the stability of the individual market at risk.43 Specifically:
See e.g., Sprung A, Why Insurers Thrive (Or Dive) in ACA Marketplaces,
healthinsurance.org, Apr. 2016. Available at
https://www.healthinsurance.org/blog/2016/04/28/why-insurers-thrive-or-dive-in-acamarketplaces/.
40
Banerjee D. The ACA Individual Market: 2016 Will Be Better Than 2015, But
Achieving Target Profitability Will Take Longer, S&P Global Ratings, Dec. 2016. See
also Herman B. How some Blues made the ACA work while others failed. Modern
Healthcare. October 15, 2016. Available at
www.modernhealthcare.com/article/20161015/MAGAZINE/310159989.
41
H.R. 1628 American Health Care Act of 2017, Congressional Budget Office,
May 2017. Available at https://www.cbo.gov/system/files/115th-congress-20172018/costestimate/hr1628aspassed.pdf.
42
Cox C, Semanskee A, Levitt L. Individual Insurance Market Performance in
2017, Kaiser Family Foundation, May 2018. Available at
http://files.kff.org/attachment/Issue-Brief-Individual-Insurance-Market-Performance-in2017.
43
See Corlette S. The Effects of Federal Policy: What Early Premium Rate Filings
Can Tell Us About the Future of the Affordable Care Act, CHIRblog, May 2018.
Available at http://chirblog.org/what-early-rate-filings-tell-us-about-future-of-aca/;
Corlette S. We Read Actuarial Memoranda so You Don’t Have to: Trends from Early
Health Plan Rate Filings, CHIRblog, Jun. 2017. Available at http://chirblog.org/we-readactuarial-memoranda-so-you-dont-have-to/; Corlette S. Proposed Premium Rates for
2018: What do Early Insurance Company Filings Tell Us? CHIRblog, May 2017.
Available at http://chirblog.org/proposed-premium-rates-for-2018-what-do-early-filingstell-us/.
39
00098
45.
The Trump administration’s decision in October of 2017 to cut off reimbursement to
insurers for low cost-sharing plans (called cost-sharing reduction or CSR plans) resulted in
significant premium increases in 2018. Additionally, the uncertainty about that decision, which
the President had been threatening for months, was a contributing factor for some insurers to
either exit the marketplaces or reduce their service areas.
46.
For example, in its 2018 rate filing in Virginia, Anthem informed the state: “A lack of
CSR funding introduces a level of volatility which compromises the ability to set rates
responsibly. It has been estimated that lack of CSR funding could increase premium rates for
Silver plans an additional 20 percent…” Anthem went on to say that if CSR reimbursements
were not guaranteed for 2018, it would consider exiting the marketplaces, reducing service areas,
or requesting additional rate increases.
47.
Additionally, although Congress did not zero out the individual mandate penalty until
2019, many insurers increased premiums for 2018 coverage on the expectation that the Trump
administration would not enforce the individual mandate. For example, in its Maryland filing for
2018, CareFirst Blue Cross BlueShield stated: “we have assumed that the coverage mandate
introduced by the ACA will not be enforced in 2018 and that this will have the same impact as
repeal. Based on industry and government estimates as well as actuarial judgment, we have
projected that this will cause morbidity to increase by an additional 20%.”
48.
Other insurers are projecting the effect of the individual mandate repeal to be felt in 2019.
For example, Kaiser Foundation Health Plan projects that premiums will need to increase 32.1
percent in Virginia. “The primary cause,” the company reports, is “related to nonenforcement of
the Individual Mandate.”
49.
Similarly, insurers increased premiums due to the Trump administration’s decision to
decrease spending on marketplace advertising and consumer assistance, which are critical for
educating and enrolling the healthy uninsured. For example, a Cigna filing for 2018 noted that
they expected a smaller and sicker population in their risk pool due to the lower “overall
awareness of individual health insurance products.”
00099
50.
Going into 2019, insurers are also predicting that their risk pools will be smaller and
sicker due to “potential movement into other markets.” These markets include association health
plans and short-term, limited duration insurance, both of which are exempt from many of the
Affordable Care Act’s consumer protections and are being promoted by the Trump
administration as cheaper alternative coverage. For example, insurers such as Optima and
CareFirst in Virginia note that the “availability of association health plans and expanded
availability of short-term medical plans” was affecting their rate projections, with CareFirst
adding 10 percent to its premium increase as a result.
51.
Individuals who are eligible for the Affordable Care Act’s premium tax credits are
largely insulated from these premium increases because the tax credit rises, dollar for dollar, with
the increase in premium for silver level health plans. The people who suffer the most from these
premium increases are the working middle class: entrepreneurs who run their own businesses,
freelancers and consultants, independent contractors, farmers and ranchers, and early retirees
who earn too much to qualify for the Affordable Care Act’s premium subsidies.
52.
Granting the plaintiffs’ request to enjoin the Affordable Care Act amounts to an effort to
repeal the law without any clear public policy to replace it. Congress explicitly rejected repealing
the Affordable Care Act without a replacement last year. This is because uprooting a complex
law that has been in place for over eight years, touches almost every facet of our health care
system, and includes many provisions with widespread bipartisan support (such as allowing
young adults to stay on their parents’ plans until age 26, closing the Medicare drug benefit
“donut hole,” and expanding Medicaid) will inevitably result in dramatic negative consequences,
some of which are predictable, and outlined below.
53.
First, millions of individuals will lose their insurance coverage. In 2017, the
Congressional Budget Office and Joint Committee on Taxation estimated that repealing the
00100
Affordable Care Act without implementing a replacement would result in 32 million people
losing coverage by 2026, with 17 million people losing coverage in the first year after repeal.44
54.
Second, those remaining in the individual market would see their premiums roughly
double. The Congressional Budget Office estimated that individual market premiums would
increase by 25 percent in the first year after repeal, by 50 percent by 2020, and almost double by
2026.45 These premium increases are largely the result in the elimination of the individual
mandate and the Affordable Care Act premium subsidies, resulting in fewer healthy individuals
enrolling in individual market coverage and a costlier risk pool for insurers.
55.
Third, even a partial repeal of the provisions of the Affordable Care Act would primarily
harm working middle class Americans. The majority of people losing coverage – as many as 82
percent – would be in working families. Over half would be non-Hispanic whites, and up to 80
percent would not have college degrees. Thirty-eight percent would be young adults between
ages 18 and 34.46
56.
Fourth, repealing the Affordable Care Act will have significant negative consequences
for public health and safety. For example, the Pennsylvania Budget and Policy Center found that
repealing the Medicaid expansion and Affordable Care Act tax credit subsidies would result in
3,425 premature deaths each year in that state alone.47 Researchers from Harvard and New York
University found that repealing the Affordable Care Act would result in 1.25 million Americans
Congressional Budget Office. Cost Estimate: H.R. 1628, Obamacare Repeal
Reconciliation Act of 2017, Jul. 2017. Available at
https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/52939hr1628amendment.pdf.
45
Id.
46
Blumberg L, Buettgens M, Holahan J. Implications of Partial Repeal of the ACA
Through Reconciliation, Urban Institute, Dec. 2016. Available at
https://www.urban.org/sites/default/files/publication/86236/2001013-the-implications-ofpartial-repeal-of-the-aca-through-reconciliation_1.pdf.
47
Stier M. Devastation, Death, and Deficits: The Impact of ACA Repeal on
Pennsylvania, Pennsylvania Budget and Policy Center, Jan. 2017. Available at
https://pennbpc.org/sites/pennbpc.org/files/Impact_of_ACA_Repeal_Final.pdf.
44
00101
with serious mental conditions losing coverage. They further estimate that 2.8 million Americans
with a substance use disorder, including roughly 222,000 with an opioid-related disorder, would
lose coverage.48
57.
Fifth, repealing the Affordable Care Act will drive insurance companies out of the
individual market. The Congressional Budget Office estimated that legislation repealing the
Affordable Care Act would leave an estimated three-fourths the nation’s population in areas
where no insurers are willing to offer nongroup coverage by 2026.49 These estimates align with
my own research at Georgetown, in which colleagues and I conducted interviews with 13 health
insurance company executives participating in the individual markets in 28 states. In those
interviews, executives told us they would “seriously consider” a market withdrawal; they further
told us that a bill repealing the Affordable Care Act without an immediate replacement would
destabilize the market and create “significant” downside financial risk for those companies
remaining.50
58.
Sixth, an increase in the uninsured will impose significant financial harm on hospitals and
other health care providers. For example, repealing the Affordable Care Act without a
replacement was estimated to cost the nation’s public hospitals $54.2 billion in uncompensated
care charges between 2018 and 2026.51 The Iowa Fiscal Partnership estimated that Affordable
Frank RG, Glied SA. Keep Obamacare to Keep Progress on Treating Opioid
Disorders and Mental Illnesses, The Hill, Jan. 2017. Available at
http://thehill.com/blogs/pundits-blog/healthcare/313672-keep-obamacare-to-keepprogress-on-treating-opioid-disorders.
49
Congressional Budget Office. Cost Estimate: H.R. 1628, Obamacare Repeal
Reconciliation Act of 2017, Jul. 2017.
50
Corlette S, Lucia K, Giovannelli J, Palanker D. Uncertain Future for Affordable
Care Act Leads Insurers to Rethink Participation, Prices, Georgetown University and
Robert Wood Johnson Foundation, Jan. 2017. Available at
https://georgetown.app.box.com/file/127781433019.
51
America’s Essential Hospitals. ACA Replacement Must Protect Vulnerable
People, Communities, Feb. 2017. Available at https://essentialhospitals.org/wpcontent/uploads/2017/02/UCC-policy-brief-February-2017-FINAL.pdf.
48
00102
Care Act repeal would result in a $10 billion increase in the cost of uncompensated care in that
state alone, with most of the burden borne by rural hospitals.52
59.
Seventh, repeal of the Affordable Care Act would lead to significant negative economic
consequences. For example, repealing just the Medicaid expansion and Affordable Care Act tax
credits would result in an estimated loss of 2.6 million jobs across the country.53 State-specific
analyses align with these findings. For example, the University of California at Berkley’s Center
for Labor Research and Education found that just a partial repeal of the Affordable Care Act
would cause California to suffer 209,000 lost jobs, $20.3 billion in lost gross domestic product,
and $1.5 billion lost in state and local tax revenue.54 Arizona State University’s Seidman
Research Institute similarly found that if Arizona lost federal Affordable Care Act funding, it
would leave a $5 billion dent in the state’s economy, cost over 62,000 jobs state wide, and lower
personal income by almost $3.5 billion.55
60.
Eighth, and finally, a full repeal of the Affordable Care Act would not only harm the
individual insurance market. Other programs would be harmed as well. For example, repealing
Fisher P. Repealing ACA: Pushing thousands of Iowans to the brink, Iowa
Fiscal Partnership, Jan. 2017. Available at http://www.iowafiscal.org/wp/wpcontent/uploads/2017/01/170119-IFP-ACA.pdf.
53
Ku L, Steinmetz E, Brantley E, Bruen B. Repealing Federal Health Reform:
Economic and Employment Consequences for States, The Commonwealth Fund, Jan.
2017. Available at http://www.commonwealthfund.org/~/media/files/publications/issuebrief/2017/jan/ku-aca-repeal-job-loss/1924_ku_repealing_federal_hlt_reform_ib.pdf.
54
Lucia L and Jacobs K. California’s Projected Economic Losses under ACA
Repeal, UC Berkeley Center for Labor Research and Education, Dec. 2016.
55
Seidman Research Institute, W.P. Carey School of Business. Economic Impact
on Arizona Of Repeal of Funding Provisions Of the Affordable Care Act, Arizona State
University, Jan. 2017. Available at http://azchildren.org/wpcontent/uploads/2017/05/ACA-Impact-Feb-6-.pdf.
52
00103
i
the law is estimated to accelerate the insolvency of the Medic* Hospital Insurance Trust Fund
(Part A) by five years, from 2026 to 2021. 56
61.
The plaintiff's suggestion that the Affordable Care Actibe enjoined ignores the serious
negative consequences of an action that would be tantamount~ repealing the law without any
clear federal
.
policy to
i
replace
.
it. When such a strategy was pr'W<>sed last year to Congress,
it was
rejected because of the serious economic and public health barbs that would result, including:
millions of Americans losing coverage, premiums doubling, insurers exiting the marke~ and the
costs of uncompensated care putting providers at serious finaJiat risk. Repeal-without-replace
!
would also result in heavy job and productivity losses. These Je serious adverse repercussions
that should not be taken lightly.
I
I declare under penalty of perjury that the foregoing is true and correct and of my own personal
knowledge.
Executed on June 5, 2018 in Washington, D.C.
Committee for a Responsible Federal Budget. Pull Repeal ofObamacare Would
Hasten Medicare's Insolvency, Apr. 2017. Available at http://www.crfb.org/blogs/fullrepeal-obamacare-would-hasten-medicares-insolvency. '
56
1
00104
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS , LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
V.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEAL TH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAYID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAW AIi, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF JAMES DEBENEDETTI IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
I, James DeBenedetti declare:
1.
I am the Director of the Plan Management Division for Covered California. I have worked
for Covered California for three years. The fact stated herein are of my own personal
knowledge, and I could and would competently testify to them.
00105
2.
Covered California is the state agency created to implement the Patient Protection and
Affordable Care Act (ACA)and establish a Health Benefit Exchange in California.
3.
The ACA increased access to affordable coverage in the State of California.
• The ACA expanded coverage through federal health subsidies to purchase coverage
in new health insurance Exchanges for those individuals with low to moderate
incomes. California built its own state-based Exchange, Covered California, for
the individual and small group markets with federal grants in the amount of
1,065,213,056.
• Since its creation, 3,570,000 individuals have gained access to coverage using
Covered California.
• The Exchanges are an important reform made by the ACA. As of March 2018,
1,417,248 individuals were enrolled through Covered California. 1,231 ,166 of
those individuals received federal subsidies, worth an estimated $6.5 billion dollars
for the 2018 plan year alone, to make that coverage more affordable. This equates
to approximately 87% of enrollees receiving a federal subsidy through Covered
California.
• Covered California receives funding from a percent of premium assessment on
health plans participating in Covered California. In 2018, for the individual
market, that fee was 4% percent of premium. In 2019, that fee will be 3.75%
percent of the monthly premium. This assessment helps pay for Covered
California' s operations, including marketing and outreach to consumers. This
assessment also funds the Navigator program to assist individuals with enrolling in
coverage through Covered California.
4.
The loss of federal subsidies available through the ACA would cause consumers to lose
access to affordable health coverage through Covered California.
• Enjoining the ACA would harm Covered California and the consumers that have
gained access to coverage as a result of the ACA. Based on my knowledge and
experience, dismantling the Affordable Care Act (ACA) would cause a loss of
benefits, services and initial grant funds invested to support Covered California,
and would cause severe harm to the State of California, to its residents and to its
economy. Without federal subsidies to lower the cost of health care coverage, the
00106
00107
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
1
2
3
4
5
6
7
8
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA, PAUL
LePAGE, Governor of Maine, Governor Phil
Bryant of the State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA, SOUTH
CAROLINA, SOUTH DAKOTA, TENNESSEE,
UTAH, WEST VIRGINIA, NEILL HURLEY and
JOHN NANTZ,
Plaintiffs,
9
V.
10
11
12
13
14
Civil Action No. 4:18-cv-00167-0
UNITED STAJ'ES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
15
Defendants.
16
17
18
19
20
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAll,
ILLINOIS, KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its Department of
Commerce, NEW JERSEY, NEW YORK,
NORTH CAROLINA, OREGON, RHODE
ISLAND, VERMONT, VIRGINIA and
WASHINGTON,
21
Intervenors-Defendants.
22
23
24
DECLARATION OF ALFRED J. GOBEILLE IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY INJUNCTION
25
I, Alfred J. Gobeille, declare:
26
1.
27
I am the Secretary of the Vermont Agency of Human Services (AHS). I have served
in this position since January 2017. I have either personal knowledge of the matters set forth
28
Deel. of Alfred J. Gobeille in Support of Intervenor States' Opp. to Mot. for Prelim. Injunction (4: l 8-cv-00167-0)
00108
1
below or, with respect to those matters for which I do not have personal knowledge, I have
2
reviewed information gathered from AHS records and other publicly available information. This
3
declaration is submitted in support of the Intervenor-States' Opposition to the Motion for
4
Preliminary Injunction. Based on my knowledge and experience, dismantling the Affordable
5
Care Act (ACA) would cause severe harm to the State of Vermont, to its residents, and to its
6
economy. In addition to loss of benefits and services and federal investments to support
7
Vermont's healthcare system, dismantling or suspending implementation of the ACA would
8
cause Vermont to experience harm and increased costs from the dismantling of the State's own
9
administrative structure and apparatus, created in compliance with, and to work in conjunction
10
11
with, the Affordable Care Act.
2.
AHS was created by the Vermont Legislature in 1969 to serve as the umbrella
12
organization for all human service activities within state government. AHS is led by the
13
Secretary, who is appointed by the Governor. The Secretary's Office is responsible for leading
14
the agency and its departments: the Department for Children and Families; the Department of
15
Corrections, the Department of Disabilities, Aging and Independent Living; the Department of
16
Mental Health; and the Department of Vermont Health Access (DVHA). DVHA is the state office
17
responsible for the management of Medicaid, the State Children's Health Insurance Program, and
18
other publicly funded ~ealth insurance programs in Vermont. As such, it is the largest insurer in
19
Vermont in terms of dollars spent and the second largest insurer in terms of covered lives. DVHA
20
is responsible for administering Vermont Health Connect, which is the State's health insurance
21
marketplace.
22
3.
23
to Vermont.
The Affordable Care (ACA) Act directs hundreds of millions of dollars directly
24
• Specifically; Vermont has received $772 million via Medicaid expansion; $8 million
25
through the Prevention and Public Health Fund; and more than $85 million for
26
federal premium subsidies.
27
4.
The ACA increased access to affordable coverage.
28
2
Deel. of Alfred J. Gobeille in Support oflntervenor States' Opp. to Mot. for Prelim. Injunction (4: l 8-cv-00167-0)
00109
1
• Overall the number of individuals with insurance has increased. In Vermont, the
2
number of covered individuals increased from 583 ,674 in 2012 to 603,400 in 2014,
3
according to the Vermont Household Health Insurance Survey (VHHIS). Over the
4
same period, the number of uninsured Vermonters was nearly cut in half, dropping
5
from 42,760 in 2012 to 23,231 in 2014. This correlates to an uninsured rate of 6.8%
6
in 2012 and 3.7% in 2014. While the next VHHIS won't be completed until the
7
second half of 2018, the U.S. Census has estimated that the number of uninsured
8
Vermonters remained down in the 23,000 range in 2015 and 2016.
9
• The ACA expanded coverage through two key mechanism: Medicaid expansion for
10
those individuals with the lowest incomes, and federal health subsidies to purchase
11
coverage in new health insurance Exchanges, like Vermont Health Connect, for
12
those individuals with moderate incomes.
13
• Medicaid is an important source of healthcare insurance coverage and has resulted in
14
significant coverage gains and reduction in the uninsured rate, both among the low-
15
income population and within other vulnerable populations. Vermont can be
16
described as a "pre-expansion" state in the sense that it offered state health
17
programs- the Vermont Health Access Plan and Catamount Health-to Vermonters
18
with incomes up to 300% FPL years before Medicaid expansion. The change in
19
Medicaid eligibility under the ACA from considering assets to only focusing on
20
income also benefitted farmers and other land rich, cash poor Vermonters who
21
previously could not afford health insurance and did not qualify for benefits but now
22
qualify either for Medicaid or for health insurance subsidies. The uninsured rate for
23
Vermonters with income up to 138% FPL (the expanded Medicaid threshold)
24
dropped from 9.6% in 2012 to 5.0% in 2014, and the state's overall uninsured rate
25
dropped from 6.8% in 2012 and 3.7% in 2014.
26
• Creation of health insurance exchanges is an important reform made by the ACA. In
27
Vermont, 23,554 people have received federally subsidized coverage in 2018 as a
28
result of the ACA.
3
Deel. of Alfred J. Gobeille in Support oflntervenor States ' Opp. to Mot. for Prelim. Injunction (4:18-cv-00167-0)
00110
1
2
3
5. The ACA has positive economic benefits on states.
• Studies have shown that states expanding Medicaid under the ACA have realized
budget savings, revenue gains, and overall economic growth.
4
• In Vermont, $260 million has been saved as a result of Medicaid expansion.
5
6. The ACA expanded programs in Medicaid to provide States with increased
6
opportunities to increase access to home and community-based services.
7
• In 2011, Vermont was awarded a five-year $17.9 million Money Follows the Person
8
(MFP) grant from CMS to help people living in nursing facilities overcome the
9
barriers that have prevented them from moving to their preferred community-based
10
setting. The grant works within the Choices for Care program and provides
11
participants the assistance of a Transition Coordinator and up to $2,500 to address
12
barriers to transition.
13
•
14
services through September 30, 2019.
15
16
Effective April 1, 2016, Vermont received a continued $8 million award for
7. The ACA has allowed States to test and implement reforms to healthcare delivery
system.s that support State policy priorities of increasing efficiency and quality of care.
17
•
The Vermont All-payer Accountable Care Organization (ACO) Model
18
Agreement with CMS is a new test of an alternative payment model in which the
19
most significant payers through Vermont-Medicare, Medicaid, and commercial
20
healthcare payers-incentivize healthcare value and quality, with a focus on health
21
outcomes, under the same payment structure for the majority of providers
22
throughout the state's care delivery system. The model began on January 1, 2017
23
and will span six performance years, concluding on December 31, 2022. The
24
Vermont Medicaid Shared Savings Program (VMSSP) was a three-year program
25
(2014-2016) to test if the ACO models in Vermont could improve health quality
26
while also reducing costs. Upon conclusion of the VMS SP, the Vermont Medicaid
27
Next Generation ACO program began (January 1, 2017). On October 24, 2016,
28
CMS approved a five-year extension of Vermont's Global Commitment to Health
4
Deel. of Alfred J. Gobeille in Support oflntervenor States' Opp. to Mot. for Prelim. Injunction (4: l 8-cv-00167-0)
00111
1
1115 waiver (January 1, 2017-December31, 2021), which specifically allows
2
Vermont Medicaid to enter into ACO arrangements that align in design with that of
3
other healthcare payers in support of the Vermont All-payer ACO Model. The pilot
4
now includes over 5,000 providers.
5
6
7
8
8. The ACA resulted in better quality and more accessible, affordable healthcare for
consumers.
• The ACA created robust consumer protections to help ensure individuals can access
the healthcare system.
9
•
Largely due to the ACA's provision that adult children can be
10
covered by their parents' health plan until age 26, the number of
11
uninsured young adults in Vermont between the ages of 18 and 24
12
was slashed from 10,839 in 2009 to 2,920 in 2014;
•
13
More than 79,000 Vermonters enrolled in qualified health plans as of
14
February 2018 are benefitting from the ACA's mandated preventive
15
services including access to birth control, cancer screenings, and
16
immunizations for children;
•
17
More than 79,000 Vermonters enrolled in qualified health plans as of
18
February 2018 are benefitting from access to essential health benefits
19
such as substance use disorder treatment and cancer screenings.
20
• The ACA has led to improved access to care (39% drop in the number of individuals
21
who needed medical care from a doctor but did not receive it because they could not
22
afford it, 45% drop - n individuals who skipped medications because they could not
i
23
afford it).
24
• The ACA has led to improved financial security for Vermont families. The number of
25
Vermonters who had trouble paying medical bills fell more than 30,000 from 2009
26
to 2014, a 20% drop. In addition, the number of Vermonters who were contacted by
27
a collection agency about owing money for unpaid medical bills fell by 16% over
28
the same period.
5
Deel. of Alfred J. Gobeille in Support oflntervenor States' Opp. to Mot. for Prelim. Injunction (4:18-cv-00167-0)
00112
1
2
• In addition, the ACA created additional consumer protections and rights such as:
•
Under the ACA, no individual can be rejected by an insurance plan
3
or denied coverage of essential health benefits for any health
4
condition present prior to the start of coverage. Once enrolled, plans
5
cannot deny coverage or raise rates based only on the enrollee's
6
health.
7
8
9. The foregoing benefits of the ACA could be removed if Plaintiffs' motion for a
preliminary injunction were granted.
9
10
I declare under penalty of perjury that the foregoing is true and correct.
11
12
Executed on June_.k}_, 2018, in Waterbury, Vermont.
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
6
Deel. of Alfred J. Gobeille in Support oflntervenor States' Opp. to Mot. for Prelim. Injunction (4:18-cv-00167-0)
00113
00114
00115
00116
00117
1
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
· WICHITA FALLS DIVISION
2
3
4
5
6
7
8
9
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA,
GEORGIA, INDIANA, KANSAS,
LOUISIANA, PAUL LePAGE, Governor
of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA,
SOUTH CAROLINA, SOUTH DAKOTA,
TENNESSEE, UTAH, WEST VIRGINIA,
NEILL HURLEY and JOHN NANTZ,
10
Plaintiffs,
11
Civ. Action No. 18-cv-00167-0
v.
12
13
14
15
16
17
18
19
20
21
22
23
24
25
UNITED STATES OF AMERICA,
UNITED STATES DEPARTMENT OF
HEALTH AND HUMAN SERVICES,
ALEX AZAR, in his Official Capacity as
SECRETARY OF HEALTH AND
HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and
DAVID J. KAUTTER, in his Official
Capacity as Acting COMMISSIONER OF
INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT,
DISTRICT OF COLUMBIA,
DELAWARE, HA WAIi, ILLINOIS,
KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its
Department of Commerce, NEW JERSEY,
NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND,
VERMONT, VIRGINIA and
WASHINGTON,
Intervenors-Defendants.
26
27
DECLARATION OF JENNIFER KENT IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY INJUNCTION
28
Deel. of Jennifer Kent in Support of Intervenors-Defendants' Opposition to Application for Preliminary Injunction
·
(4:18-cv-00167-0)
00118
1
I, Jennifer Kent, declare;
2
1.
3
I am the Director the California Department of Health Care Services (DHCS), which
operates California's version of the federal-state Medicaid program under title XIX of the federal
4 · Social Security Act, known as Medi-Cal. In this capacity, I am responsible for overseeing the
5
administration ofthe Medi-Cal program and the delivery and financing ofcare for over 13.5
6
million beneficiaries. This declaration is in support of the Interveno_r-States' Opposition to the
7
Motion to Intervene. The facts stated herein are of my own personal knowledge, and I could and
8
would competently testify to them.
9
10
2.
Based on my knowledge and experience, dismantling the Affordable Care Act
· (ACA) would cause a loss of benefits, services and federal investments to support Medi-Cal, and
11
would cause severe harm to the State of California, to its residents and to its economy. California
12
would experience harm and increased costs from the dismantling of the state's administrative
13
structure and apparatus, created in compliance with, and to work in conjunction with, the ACA.
14
For example, there would be significant harm and administrative burden associated with: the cost
15
of terminating coverage for millions of Californians and providing alternative options for
16
individuals losing Medicaid coverage; eliminating subsidies and other ACA-authorized services;
17
the cost of delivering health care through more traditional and expensive safety-net health
18
systems; providing appropriate notice and instructions to individuals losing such support;
19
regulatory costs; and the cost of reconstructing the state health exchange in the absence of the
20
ACA.
21
22
3.
The ACA increased access to affordable coverage.
~
The ACA expanded coverage through two key mechanisms: Medicaid expansion for
23
those individuals with the lowest incomes, and federal health subsidies to purchase
24
coverage in new health insurance exchanges for those individuals with moderate
25
incomes.
26
• Due to implementation of the ACA in California, the State has experienced a
27
considerable decrease in the number of tminsured residents. This is predominantly
28
attributable to the expansion of eligibility in the Medi-Cal program, and the
2
Deel. of Jennifer Kent in Support oflntervenors-Defendants' Opposition to Application for Preliminary Injunction
(4: l 8-cv-00167-0)
00119
1
newfound availability of health coverage through the State's exchange marketplace
2
known as Covered California.
3
·•
California's implementation of the Medicaid expansion has enabled more than 3.7
4
million Californians to obtain coverage, and we dramatically reduced the uninsured
5
rate in the State from 17 percent in 2013 to 6.8 percent in 2017.
6
• ·Asa result, the State collectively, including its political subdivisions, its safety net
7
health care providers, and its residents, has begun to realize significant gains from
8
both a public health, and an economic and fiscal standpoint. One of the principal
9
financial benefits has been a meaningful reduction in the level. of uncompensated care
10
costs borne within the State's various health care systems and programs. For
11
example, according to data collected and published by the Office of Statewide Health
12
Planning and Development (OHSPD), California hospitals incurred uncompensated
13
care costs totaling approximately $5.2 billion dollars in 20·13, before full
14
implementation of the ACA. In 2015, after implementation of the ACA, OSHPD
15
data reflects that California hospitals experienced approximately $1. 9 billion dollars
16
in uncompensated care costs, which amounts to nearly a 64 p~rcent decrease in
17
hospital uncompensated care costs over this short period of time.
18
19
4.
The invalidation of the ACA would cost C_alifornia billions annually.
•
20
21
All of the foregoing benefits of the ACA would be removed if the Plaintiffs' motion
forpreliminary injunction were granted.
•
DHCS projects that the elimination of the Medicaid expansion in California would
22
result in an annual loss of $22.2 billion starting in fiscal year 2020, and increasing to
23
a loss of $32.6 billion in 2027. In addition, the elimination of the Community First
24
Choice Option is projected to increase State costs by approximately $400 million in
25
2020, growing annually.
26
•
In addition, if the number of uninsured in California were to increase, the State would
27
incur a significant negative economic impact due to the accompanying increase in
28
U11compensated care costs that would follow. Without any other options for care,
.3
Deel. of Jennifer Kent in Support oflntervenors-Defendants' Opposition to Application for Preliminary Injunction
·
(4:18-cv-00167-0)
00120
those residents finding themselves without coverage would turn to traditional and
2
more costly safety-net sources of care, such as use of hospital emergency rooms, or
3
forego care entirely. This would reintroduce the same type of financial strain on
4
State, local and private health SY.Stems and programs that the ACA was intended to
.
5
relieve.
6
7
8
.
, I declare under penalty of pe1jury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 6, 2018, in Sacramento, California.
9
iL__t_
10
11
Jennifi r ent
Direct r
Department of Health Care Servcies
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
4
Deel. of Jennifer Kent in Support of lntervenors-Defendants' Opposition to Application for Preliminary Injunction
(4: 18-cv-OO167-0)
00121
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UTAH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
V.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his Official
Capacity as SECRETARY OF HEALTH AND
HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, .and DAVID J.
KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HA WAIi, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF MILA KOFMAN IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
I, Mila Kofinan~declare:
1.
This declaration is submitted in support of the Intervenors-Defendants' Opposition
to the Motion to for Preliminary Injunction. This is based on my knowledge and experience on
Deel. of Mila Kofman in Support oflntervenors-Defendants• Opposition to Motion for Preliminary Injunction
(4: 18-cv-00167-0)
00122
private health insurance and federal and state reforms as Executive Director of the DC Health
Benefit Exchange Authority, former Superintendent oflnsurance (Maine), and former research
faculty member at Georgetown University. Dismantling the Affordable Care Act would cause
severe harm to the District of Columbia, to its small businesses, to its residents and to its
economy. In addition to federal investments to support the District of Columbia's individual and
small group marketplaces (exchange), dismantling or suspending implementation of the
Affordable Care Act would cause severe harm to the District of Columbia. District of Columbia
residents received approximately $2.57 million in advanced premium tax credits (APTC) in
2017. The loss of those dollars will likely cause those people to drop coverage as they will not
have the affordability assistance provided under the ACA. That loss of coverage will harm the
risk pool, causing the experience to degrade and premiums to increase for those who remain. The
loss of ACA consumer protections will harm people who need comprehensive and secure health
insurance. Also without Medicaid expansion, the private risk pool would be more expensive
because "Expansion population" (childless adults) are sicker with numerous co-morbidity
factors. The damage to District residents and small businesses would be irreparable, as the lack
of coverage would lead to a lack of care, with fatal or irreversible permanent health conditions
that currently are being prevented and treated because people have health insurance.
2.
I am the Executive Director of the District of Columbia Health Benefit Exchange
Authority. Prior to my appointment, I was on the faculty at Georgetown University Health Policy
Institute as a Research Professor and Project Director. Before that I served as Superintendent of
Insurance in Maine for over three years, and as a federal regulator at the Department of Labor.
3.
The DC Health Benefit Exchange Authority (HBX) was established as a requirement
of Section 3 of the Health Benefit Exchange Authority Establishment Act of 201 1, effective
March 3, 2012 (D.C. Law 19-0094). The mission of the DC Health Benefit Exchange Authority
2
Deel. of Mila Kofman in Support of Intervenors-Defe ndants ' Opposition to Motion for Preliminary Inj unction
(4: 18-cv-OO 167-0)
00123
is to implement an online health insurance marketplace in the District of Columbia in accordance
with the Patient Protection and Affordable Care Act (PPACA), thereby ensuring access to quality
and affordable health care to all DC residents.
4.
The Affordable Care Act (ACA) increased access to affordable coverage in the
District of Columbia.
• Overall the number of individuals with insurance has increased. The ACA has
enabled the District to expand health coverage so that more than 96% of our
residents are now covered (less than 4% uninsured in 2016 compared to 7.2% in
2009). We have the lowest uninsured rate we've ever had and rank between first
and third (depending on the study) among all states in the nation for having the
lowest uninsured rate. As of March 12, 2018, there are 17,808 District residents
enrolled in individual health insurance and more than 76,000 people enrolled in
small group coverage through our marketplace, DC Health Link. A 2016 survey of
our enrolled customers revealed that more than 25,500 people, who were not
previously covered in 2015, gained access to health coverage in 2016 through the
marketplace. 25% of the people who enrolled in individual private health insurance
coverage were previously uninsured. 53% of the people who were determined
eligible for Medicaid were uninsured before applying. 40% of the small businesses
enrolled in DC Health Link did not offer health insurance to their employees prior
to enrollment through DC Health Link.
• The Marketplace is an important reform made by the ACA, for a number of reasons.
The on-line health insurance marketplace has provided access to quality affordable
health insurance, and has created transparency, encouraged market competition,
simplified the purchase of insurance. Many residents have benefitted from reduced
premiums for health insurance. There are approximately 4,187 District residents
who have received APTC; this does not include residents who received premium
tax credits when they filed their taxes. Tens of thousands of residents have
3
Deel. of Mila Kofman in Support oflntervenors-Defendants' Opposition to Motion for Preliminary Injunction
(4: I 8-cv-00167-0)
00124
benefited from having access to comprehensive health insurance that includes
prescription drug coverage, hospitalization, specialists, and mental health coverage.
Because of the requirements for essential health benefits, prohibitions on benefit
limits, medical underwriting, and gender and health. based discrimination,
thousands of District residents and small businesses have benefitted. Furthermore,
easy apples-to-apples comparison of plans have enabled thousands of residents to
make more informed decision about which health plan is best for them. Robust online consumer decision support tools have made the purchase of health insurance
easier for thousands of residents. Small businesses have the type of market power
only large employers had in the past and are able to offer their employees not just
one insurance plan but plans from all carriers. Residents and small businesses - and
their employees - can see in one place all of the different products, compare benefit
packages side-by-side, and compare prices for all products. With the purchasing
power of thousands, DC's small businesses now have insurers competing for their
business. HBX advocates for the lowest possible rates. HBX hires independent
actuaries to review proposed rates and challenge the assumptions made by carriers.
HBX provides actuarial analysis to insurance regulators advocating for lower rates.
DC Health Link also has on-line portals for brokers and General Agencies/TPAs.
There are more than 800 brokers supporting more than 65,000 people covered
through small businesses through DCHealthLink.com.
5. The ACA has positive economic benefits on the District of Columbia.
• the ACA have had a significant positive effect on states. Slates realized budget
savings, revenue gains, and overal] economic growth. A Commonwealth study
modeled the effects of ACA repeal, and shows the deleterious economic impact
such an action would have. See The Commonwealth Fund, Repealing Federal
Health Reform: Economic and Employment Consequences/or States, (Jan. 20 17),
4
Deel. of Mila Kofman in Support oflntervenors-Defendants' Opposition to Motion for Preliminary Injunction
(4: 18-cv-00167-0)
00125
http://www.commonwealthfund.org/publications/issue-briefs/201 7/jan/repealingfederal-health-refonn.
• Further, the decline in uncompensated care in hospitals by 60% from 2010 to 2015
has led to decreased spending as a. result of the ACA. See
https://hbx.dc.gov/sites/default/files/dc/sites/hbx/event_content/attachments/Uncom
pensated_ care_ updated_ IO_ l l _ 15.pdf.
6. The ACA resulted in better quality and more accessible, affordable healthcare for
consumers.
• The ACA created robust consumer protections to help ensure individuals can access
the healthcare system by pennitting covered dependents to access coverage on their
parents' plans until age 26, mandating preventive services including access to birth
control, cancer screenings, and immunizations for children, and providing essential
health benefits, such as substance use disorder treatment and cancer screenings.
The ACA's consumer protections prohibiting medical underwriting, preexisting
conditions exclusions, rating based on gender, health factors, industry and
employer size have helped District residents and small businesses have private
health insurance that was not available before. Also, ACA restrictions on ahnual
and lifetime limits and required essential health benefits have resulted in many
District residents and small businesses having financial security and access to
medical care that was not available before the ACA.
• The District has built on the consumer protections under the ACA. The District
prohibits premiums based on tobacco use. The District also prohibits benefit
substitutions in the essential health benefits categories, protecting residents' access
to all essential health benefits. HBX requires carrier to offer standard benefit plans,
in addition to carrier designed plans. The standard plan designs have the same
benefits and out-of-pocket features, e.g., co-pays, deductibles, co-insurance, within
a metal level. Networks, premiums, and quality are the major differences. This
5
Deel. of Mila Kofman in Support oflntervenors~Defendants' Opposition to Motion for Preliminary Injunction
(4: 18-cv-00167-0)
00126
makes shopping even easier. Importantly, enrollees can receive many medical
services such as specialist visits, urgent care visits, primary care visits, mental
health services, and prescription medication before meeting deductibles, even with
bronze plan coverage. In addition, HBX has invested in strong consumer shopping
tools so that people can make informed choices. The DC Health Link Plan Match
tool enables customers to compare plans based on expected annual out-of-pocket
costs; search a doctor directory which enables consumers to see which plans their
doctors participate in; and a prescription drug formulary tool that enables customers
to compare their medication costs across plans.
• In addition, the District requires all small group and individual health insurance to be
sold only through the DC Health Link. This has created significant competition
among health insurers. For example, in 2013, one carrier refiled their proposed
rates twice, lowering the proposed rates to be more competitive. Another carrier
refiled their rates proposing lower premiums and filed additional products for sale.
Another carrier refiled their rates proposing lower premiums. This product and
price competition continues, and each year carriers offer new products and offer
products with reduced premiums or no or almost no increase in premiums
compared to the prior year. Small businesses in the District have 151 different
health plans offered by 3 United Health Care companies, 2 Aetna companies,
Kai~er Permanente, and Care First Blue Cross Blue Shield.
7.
All of the foregoing benefits of the Affordable Care Act would be removed if the
Plaintiffs' preliminary injunction were granted.
6
Deel. of Mila Kofman m Support of lntervenors-Defendants' 5)pposilion to Motion for Preliminary Injunction
(4: J8-cv-00167-0)
00127
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 6, 2018 in Washington, Dist · t
1 a Kofman
Executive Director
District of Columbia Health Benefit
Exchange Authority
7
Deel. of Mila Kofman in Support of lntervenors-Defendants' Opposition to Motion for Preliminary Injunction
(4: l 8-cv-00167-0)
00128
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA, PAUL
LeP AGE, Governor of Maine, Governor Phil
Bryant of the State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA, SOUTH
CAROLINA, SOUTH DAKOTA, TENNESSEE,
UTAH, WEST VIRGINIA, NEILL HURLEY and
JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
v.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAII,
ILLINOIS, KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its Department of
Commerce, NEW JERSEY, NEW YORK,
NORTH CAROLINA, OREGON, RHODE
ISLAND, VERMONT, VIRGINIA and
WASHINGTON,
Intervenors-Defendants.
DECLARATION OF DR. JENNIFER LEE IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
00129
I, Dr. Jennifer Lee, declare:
1.
I am the Director of the Department of Medical Assistance Services (DMAS), which
is the agency responsible for administering Medicaid and the State Children's Health Insurance
Program (CHIP) in Virginia. Before becoming the Director of DMAS, I served as Deputy
Secretary of Health and Human resources for Governor Terence McAuliffe from 2014 until
2016. I have also previously served on the Virginia Board of Medicine from 2008 until 2011,
and I served as the Deputy Under Secretary for Health for Policy and Services, and Senior
Advisor to the Secretary at the U.S. Department of Veterans Affairs. I have a bachelor's degree
in biophysics and biochemistry from Yale University, a medical degree from Washington
University School of Medicine, and completed my residency at Johns Hopkins. I am a boardcertified, practicing emergency physician and a fellow of the American College of Emergency
Physicians.
2.
This declaration is submitted in support of the Intervenor-States' Opposition to the
Motion for a Preliminary Injunction. Based on my knowledge and experience, dismantling or
suspending the Affordable Care Act (ACA) would cause severe harm to the Commonwealth of
Virginia, to its residents, and to its economy. Virginia would experience harm and increased
costs from the dismantling of the state's administrative structure and apparatus, created in
compliance with, and to work in conjunction with, the ACA. In particular, the Commonwealth
would experience significant costs associated with unwinding changes that were made to
Medicaid eligibility determination by the ACA.
3.
With a budget of $10 billion, DMAS's mission is to provide a system of high quality
and cost effective health care services to qualifying Virginians and their families. Today, DMAS
00130
provides health care coverage to more than 1 million Virginians through the Medicaid program
and CHIP.
4.
Virginians receive billions of dollars directly as a result of the ACA. For example, in
2017, Virginians received an estimated $1,148,490,000 in total annual premium tax credits.
Moreover, Virginia has received more than $25,320,000 through the Public Health and
Prevention Fund. The Public Health and Prevention Fund has funded grants for programs that
include, in part, "Making a Healthier Virginia the Priority" (more than $2,600,000), "Affordable
Care Act - Maternal, Infant and Early Childhood Home Visiting Program - Expansion" (more
than $7,600,000) "Preventive Health Services" (more than $3,170,000), "Immunization and
Vaccines for Children" (more than $2,130,000), and "Immunization PPHF Supplemental" (more
than $4,900,000).
5.
In addition to direct funds, the ACA has increased Virginians access to affordable
health care coverage. Since the ACA was enacted, the overall number of individuals with
insurance in Virginia has increased. In 2009, prior to the implementation of the ACA, Virginia's
uninsured rate for non-elderly adults (ages 19-64) was 16.4%, representing 779,000 non-elderly
adults in Virginia who lacked health insurance. By 2016., after the ACA was in effect, Virginia's
uninsured rate for non-elderly adults dropped to 12.4%, representing 621,000 non-elderly adults
in Virginia who lacked health insurance. Moreover, the ACA expanded coverage in Virginia
through the federal health subsidies that enabled individuals with moderate incomes to purchase
health insurance in the Exchanges. In 2017, 410,726 Virginians purchased health insurance on
the Federally Facilitated Marketplace (FFM). Of those individuals purchasing coverage on the
FFM in 2017, 334,942 individuals received a federal premium subsidy. Finally, Medicaid is an
important source of healthcare insurance coverage.
00131
Although Virginia has not yet expanded Medicaid coverage under the ACA, the Virginia
General Assembly adopted a budget on May 30, 2018 that expands Medicaid in the new state
fiscal year that begins July 1, 2018. Many Virginians see this as a strategic opportunity to expand
access to care, improve Virginians overall health, and bolster the economy. DMAS is currently
in the planning and implementation phase of expanding the Virginia Medicaid program, and
expects that expanded coverage will be available in early 2019. Eliminating the ACA would
result in the elimination of the opportunity to provide health care coverage to up to 400,000
Virginians beginning in 2019. In addition to the harm caused to individuals losing the promise of
health care coverage, the Commonwealth estimates that it would lose $458 million in federal
funds in FY 2019 and $1.9 billion in federal funds in FY 2020.
6.
The ACA also expanded various Medicaid programs to provide States with increased
opportunities to increase access to home and community based services. For example, in 2008,
Virginia launched its Money Follows the Person (MFP) program. MFP provides extra support
and services to Virginians choosing to transition from long-term care institutions to the
community. MFP has helped Virginia move closer to a rebalanced long-term support system
that promotes choice, quality, and flexibility. Under the ACA, funding for MFP was extended
from 2012 through 2016. Over 1,000 Virginians have been discharged from a facility to the
community since 2012 with assistance from MFP.
7.
All of the foregoing benefits of the ACA would be removed if the Plaintiffs' motion
for preliminary injunction were granted.
00132
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 6, 2018, in Richmond, Virginia.
r..TennliLee
'
Director
Virginia Department of Medical
Assistance Services
00133
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA, ARKANSAS,
ARIZONA, FLORIDA, GEORGIA, INDIANA,
KANSAS, LOUISIANA, PAUL LePAGE,
Governor of Maine, Governor Phil Bryant of the
State of MISSISSIPPI, MISSOURI , NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA, SOUTH
DAKOTA, TENNESSEE, UT AH, WEST
VIRGINIA, NEILL HURLEY and JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
V.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAW All, ILLINOIS,
KENTUCKY, MASSACHUSETTS, MINNESOTA
by and through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF KIMBERLEY LUFKIN IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY
INJUNCTION
I, Kimberley Lufkin, declare:
00134
l.
I am 37 years old and a resident of Fairfax, Virginia. I work with international health
nonprofits that focus on issues ranging from reproductive health to HIV/AIDS.
2.
I was diagnosed with type-I diabetes at five years old. For my most of my life, I
have been in a constant battle with insurance companies that repeatedly denied me
coverage and care for a pre-existing medical condition. Even though I have
maintained continuous employer-sponsored coverage, I often experienced
discrimination or difficulties receiving care because of my diagnosis.
3.
The Affordable Care Act eliminated any discrimination based on my diabetes. I no
longer needed to fill out paperwork or prove continuous coverage before insurance
companies would cover my care every time I started a new job or had a change in
employer-sponsored coverage. When the law went into effect, I felt like a huge and
constant worry in my life had been lifted.
4.
This was made all the more pressing for me and my family in 2016, when my 18month-old son was diagnosed with type- I diabetes. My husband and I were shocked,
worried, and scared for three days after his diagnosis in the ICU, and we knew that
our son' s childhood would be forever be impacted. With all the fears we had as
parents of a young child with a chronic condition, I was at least relived that because
of the protections under the ACA, my son wouldn't face the same struggles I did
with insurance coverage.
5.
I'm terrified that that efforts to overturn the ACA will cause people like me and my
son to lose the protections we have. My family will now have to constantly worry
about our ability to access lifesaving health care. We shouldn't have to worry if we
can afford insulin for my three-year-old son, or if he'll miss out of medical
innovations because of our inability to pay. We shouldn't have to fight with
insurance companies to cover care for a medical condition he developed at just 18
months old.
00135
6.
I support the Intervenor-Defendants' defense of the ACA. Elimination of the ACA
would hurt me and my family.
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 1, 2018, in Fairfax, VA.
SA2018100536
00136
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS,
WISCONSIN,
ALABAMA,
ARKANSAS, ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA, PAUL
LeP AGE, Governor of Maine, Governor Phil
Bryant of the State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA, SOUTH
CAROLINA, SOUTH DAKOTA, TENNESSEE,
UTAH, WEST VIRGINIA, NEIL HURLEY and
JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
V.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAVID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT
OF COLUMBIA, DELA WARE, HA WAIi,
ILLINOIS, KENTUCKY,
MASSACHUSETTS, MINNESOTA by and
through its Department of Commerce, NEW
JERSEY, NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenors-Defendants.
DECLARATION OF CHRIS MALEY IN SUPPORT OF INTERVENORSDEFENDANTS' OPPOSITION TO APPLICATION FOR PRELIMINARY INJUNCTION
I, Chris Maley, declare:
Deel. of Maley ISO Intervenors-Defendants' Opposition to Preliminary Injunction (18-cv-167)
Page I
00137
1.
This declaration is submitted in support of the Intervenors-Defendants' Opposition to
the Application for Preliminary Injunction.
2.
My name is Chris Maley. I am employed by the Office of the Illinois State
Comptroller as the Director of Research and Fiscal Reporting.
3.
Susana A. Mendoza is the Illinois State Comptroller. The Comptroller is the chief
fiscal control officer for Illinois government, charged by the Constitution with maintaining the
state's central fiscal accounts and ordering payments into and out of the appropriate funds. The
Illinois Constitution empowers the Comptroller to record transactions, pre-audit expenditures
and contracts, issue financial reports and provide leadership on the fiscal affairs of the state. The
office processes more than 16 million transactions annually and serves as a "fiscal watchdog" to
ensure all state payments meet the requirements of the law. The office provides current and
accurate fiscal information to the Governor, the General Assembly, local governments and the
public. Financial Impact analyses and other studies are published to assist the Governor and
lawmakers in making informed budget decisions. As part of its responsibility to ensure the
operations of state government are transparent, the Illinois Comptroller's Office collects
information from participating state agencies about the programs they administer and reviews
financial resources allocated to those programs.
4.
As Director of Research and Fiscal Reporting, one of my responsibilities is to
oversee the assembly of several reports produced by the Office of the Illinois Comptroller that
provide facts, figures and analysis of various aspects of the State of Illinois' fiscal condition and
economic outlook. As paii of my duties, I am responsible for the preparation of the Public
Accountability Report, a compilation of data reported by State government agencies addressing
agency initiatives, effectiveness, program administration, goals and objectives.
5.
The Illinois Department of Healthcare and Family Services (HFS) is responsible for
administering the Medical Assistance Programs under the Illinois Public Aid Code, the
Children's Health Insurance Program Act, the Covering All Kids Health Insurance Act, the
Veterans Health Insurance Program Act, other provisions of state law, and Title XIX and XXI of
Deel. ofMaley ISO Intervenors-Defendants' Opposition to Preliminary Injunction (18-cv-167)
Page 2
00138
the federal Social Security Act. Specifically, HFS is the Illinois state agency responsible for
providing healthcare coverage for adults and children who qualify for Medicaid, including those
who qualify for Medicaid through the Medicaid expansion. As part of its review of state agency
programs, the Illinois Comptroller's Office receives and reviews info1mation from HFS about
the resources allocated to the medical assistance program (Medicaid).
6.
In 2013, Illinois adopted what is commonly known as the Medicaid expans10n
pursuant to the Patient Protection and Affordable Care Act. 42 U.S.C. § 1396a(a)(I0(A)(i)(VIII).
Beginning January 1, 2014, Illinois law required that individuals aged 19 or older, but younger
than 65, with incomes at or below 133% of the federal poverty level, be eligible for coverage
under Illinois' Medicaid program. 305 ILCS 5/5-2(18). Illinois law also provides that if Illinois'
federal medical assistance percentage is reduced below 90% for persons eligible for medical
assistance through the Medicaid expansion, coverage for such persons shall terminate no later
than the end of the third month following the month in which the reduction takes effect. Id.
7.
I have reviewed data regarding HFS' financial operations provided by HFS to the
Comptroller's Office for publication in the fiscal year 2017 Public Accountability Report.
According to that data, Illinois received approximately $9,553,600,000 from the federal
Department of Health and Human Services for Illinois' Medicaid expansion population for the
years FY 2014 through FY 2017. Illinois is projected to receive $3,740,400,000 in FY 2018 for
the Medicaid expansion population.
8.
Additional data provided by HFS indicates that more than 673,000 individuals in
Illinois are projected to be enrolled in an Affordable Care Act health insurance exchange plan in
FY 2018. Enrollment by individuals in an Affordable Care Act health insurance exchange plan
in Illinois has continued to increase since enrollment began in 2014: 457,000 enrollees in
FY 2014; 642,000 enrollees in FY 2015; 651,747 enrollees in FY 2016; and 639,418 enrollees
in FY 2017. In total, that amounts to 2,390,165 unique enrollments from FY 2014 through
FY 2017.
Deel. of Maley ISO Intervenors-Defendants' Opposition to Preliminary Injunction (18-cv-167)
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00139
9.
Any of the foregoing financial contributions received under the Affordable Care Act
would be terminated if the Plaintiffs' motion for preliminary injunction were granted.
I declare under penalty of perjury that the foregoing is true and correct and of my own
personal knowledge.
Executed on June 5, 2018, in Springfield, Illinois.
Chris Mal
Director of Research and Fiscal Re
Office of Illinois State Comptroller
Deel. of Maley ISO Intervenors-Defendants' Opposition to Preliminary Injunction (I 8-cv-167)
Page4
00140
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA, GEORGIA,
INDIANA, KANSAS, LOUISIANA, PAUL
LePAGE, Governor of Maine, Governor Phil
Bryant of the State of MISSISSIPPI, MISSOURI,
NEBRASKA, NORTH DAKOTA, SOUTH
CAROLINA, SOUTH DAKOTA, TENNESSEE,
UTAH, WEST VIRGINIA, NEILL HURLEY and
JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-0
V.
UNITED STATES OF AMERICA, UNITED
STATES DEPARTMENT OF HEALTH AND
HUMAN SERVICES, ALEX AZAR, in his
Official Capacity as SECRETARY OF HEALTH
AND HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and DAYID
J. KAUTTER, in his Official Capacity as Acting
COMMISSIONER OF INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT, DISTRICT OF
COLUMBIA, DELAWARE, HAWAll,
ILLINOIS, KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its Department of
Commerce, NEW JERSEY, NEW YORK,
NORTH CAROLINA, OREGON, RHODE
ISLAND, VERMONT, VIRGINIA and
WASHINGTON,
Intervenor-Defendants.
DECLARATION OF THEA MOUNTS IN SUPPORT OF IN SUPPORT OF
INTERVENORS-DEFENDANTS' OPPOSITION TO APPLICATION FOR
PRELIMINARY INJUNCTION
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (18-cv-167)
Page 1
00141
I, Thea Mounts, declare:
1.
I am over the age of 18 years and make this declaration based on my
personal knowledge of the matters stated below.
2.
I am a Senior Forecasting and Research Manager/WA-APCD Program
Director at the Washington State Office of Financial Management. My responsibilities
include supervising a team that provides analytic and research support for budget and
policy development of the state's health and human service programs. We analyze and
monitor data related to trends in the state's health care coverage, service utilization,
quality, costs and workforce capacity, in addition to producing the state's Medicaid
expenditure forecast.
3.
The Washington State Office of Financial Management is the Governor's
office for vital information, fiscal services and policy support that the Governor,
Legislature and state agencies need to serve the people of Washington.
4.
This declaration is submitted in support of the Intervenor-States '
Opposition to the Motion for Preliminary Injunction. Based on my knowledge and
experience, dismantling the Affordable Care Act would cause severe harm to the state of
Washington, to its residents and to its economy. In addition to loss of benefits and
services and federal investments to support Washington's health care system as stated
below, Washington would experience harm and increased costs from the dismantling of
the state's administrative structure and apparatus created in compliance with, and to work
in conjunction with, the Affordable Care Act. For example:
a. The state would have to rebuild the eligibility and enrollment system for
Medicaid, which would have a significant cost associated with it.
b. The state would have to take on the costs of the call center for Medicaid.
c. The state would have to pick up outreach, marketing, and other functions
for Medicaid currently performed by the Exchange.
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (18-cv-167)
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00142
d. The state would have to revert to the law related to individual market
coverage in place prior to the ACA's enactment. Under those provisions, all
applicants for individual health insurance would be required to complete a
standard health questionnaire, which would be used to determine whether
an individual meets a health cost/risk threshold sufficient to allow the
catTier to deny coverage and trigger the individual's eligibility for the
Washington State Health Insurance Pool (WSHIP), the state's high risk
pool program. The substantial cost impacts of reversion to this system
would include:
1.
WSHIP is funded by a combination of enrollee premiums and
assessments on health carriers and stop loss insurers doing business
in Washington State. WSHIP coverage would be more costly for
consumers, especially those who would be eligible for an APTC
payment under cuITent law, directly harming those consumers.
11.
CatTiers and stop loss insurers in Washington state would be
required to fund the difference between WSHIP enrollee claims
costs and premiums paid by enrollees, through as assessment
formula. After implementation of the ACA, WSHIP enrollment was
closed because consumers have guaranteed access to coverage.
Carriers would be confronted with the additional costs of the
assessment.
m. The Office of the Insurance Commissioner would face substantial
administrative costs associated with major regulatory changes,
modifications to individual and small group health plan filing
requirements and other administrative changes required to return to
the rules and policies that were in place prior to ACA
implementation.
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (18-cv-167)
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00143
A.
The Affordable Care Act Directs Billions of Dollars Directly to Washington
State
5.
Washington received $10 .1 billion in additional funds from the federal
government to support its Medicaid expansion between January 2014 and June 2017.
6.
Washington has spent $48.7 million in Center for Medicare and Medicaid
Innovation grant dollars between February 2015 and February 2018.
B.
The Affordable Care Act Increased Access to Affordable Coverage
7.
Overall, the number of individuals with health insurance has increased. In
Washington State in 2016, 6.9 million people had coverage. The State' s total uninsured
rate declined by 61 % between 2013 and 2016, falling from 14.0% to 5.4%.
8.
The Affordable Care Act (ACA) expanded coverage through two key
mechanisms: Medicaid expansion for those individuals with the lowest incomes, and
federal health subsidies to purchase coverage in new health insurance Exchanges for
those individuals with moderate incomes.
9.
Adults ages 18-64 experienced the largest reduction in the number of
uninsured and the uninsured rate, declining from 877,000 (19.8%) in 2013 to 352,000
(7.9%) in 2016 .
10.
Medicaid is an important source of health coverage and has resulted in
significant coverage gains and reduction in the uninsured rate, both among the lowincome population and within the vulnerable populations. In the first year of Medicaid
expansion, the increase in Medicaid accounted for at least 93% of Washington State' s
total coverage gains. In turn, low-income non-elderly adults accounted for 92% of the net
increase in the state's Medicaid enrollment in 2014.
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (I 8-cv-167)
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00144
11.
The State's Exchange is an important reform made by the ACA that has
had a major impact on access to affordable health insurance. In Washington State, over
132,500 residents·currently receive federally subsidized coverage as a result of the law.
12.
In 2017, an average of 156,000 people per month received tax credits
totaling over $342 million dollars.
13.
In 2017, an average 101,000 people per month received cost-sharing
reductions totaling over $56 million dollars.
C.
The Affordable Care Act Has Positive Economic Benefits on States
14.
Our State's experience shows that expansion of Medicaid under the ACA
has resulted in budget savings, revenue gains, and overall economic growth.
15.
In 2015, an estimated 51,196 jobs were saved or created as a result of the
ACA Medicaid expansion in Washington State.
· 16.
The amount of uncompensated care in Washington State's community
hospitals declined by $1.332 billion, or two-thirds (66.7%), in FY 2016, when compared
to the level seen in FY2013.
17.
The state budget benefited by nearly $1.14 billion through June 2017
thanks to refinancing health programs that were previously all or partially funded by the
State-General Fund (Basic Health, Medical Care Services, Presumptive SSI, state only
behavioral health programs, Medically Needy, etc.). These programs served vulnerable
populations who were not previously eligible for federally funded Medicaid prior to the
ACA.
D.
The Affordable Care Act Has Allowed States to Test and Implement Reforms
to Healthcare Delivery Systems That Support State Policy Priorities of
Increasing Efficiency and Quality of Care
18.
Washington State continues to benefit from the infusion of resources for
health reform and innovation that has catalyzed higher quality, safer and better
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (18-cv-167)
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00145
coordinated care delivery, smaiier spending and the realization of savings to public
programs, more engaged providers, and healthier populations.
19.
Successes to date that have been achieved pursuant to ACA authority or
funding include:
a. Developed, implemented, and managed the Washington State Common Measure
Set, which sends aligned signals to providers.
b. Launched fully-integrated Managed Care contracts aligning the financing for
physical and behavioral health, resulting in better patient outcomes.
c. Created a value-based plan option called UMP Plus for state employees and their
families, starting in 2016. Over 25,000 state employees and their families are
emolled in the plan. Year 1 (2016) results show state employee received high quality
care for chronic and preventive services, and the State spent $2.7M less for UMP
Plus members (compared to benchmark) or roughly 1% less than if non-UMP Plus
providers had been caring for this same population.
d. Stood up nine Accountable Communities of Health to link clinical and community
supp01is in service to the whole person.
e. Matured the State's analytic and data capabilities, to include data aggregation
infrastructure and overall improvement of data and reporting quality and
consistency.
20.
Funding available under the ACA supp01ied the design and development
work that created the Health Home program, a care management strategy for high risk
clients. This is the first program in the state to offer such services to Medicare-Medicaid
dual eligible clients. Under an ACA supported demonstration agreement with CMS has
brought tens of millions of dollars in savings to the state.
21.
Amidst the success of the Medicaid expansion, leaders in Washington state
and nationwide recognize access to coverage is just the beginning, and barriers remain to
improved health and wellbeing of individuals and families. The innovation opp01iunities
offered through ACA-facilitated models like SIM, Partnership for Patients, Transforming
Clinical Practice Initiative and more help ensure we are not expanding access to a system
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (l 8-cv-167)
Page 6
00146
that is unsafe, fragmented and wasteful. One success story from these opportunities is
that the Washington State Hospital Association's leadership in the state for the
Partnership for Patients program led to a reduction in hospital-acquired conditions and
avoidable readmissions. Through the first r.ound of this program, 23,000 patients were
saved from harm and saw a reduction of $336 million in health care spending.
22.
Also as a result of the innovation opportunities offered through ACA-
facilitated models, five Transforming Clinical Practice Initiative sites statewide are set up
to help clinicians achieve large-scale health transformation through comprehensive
quality improvement strategies.
E.
The ACA Resulted in Better Quality and More Accessible, Affordable
Healthcare for Consumers
23.
The ACA created robust consumer protections to help ensure individuals
can access the health care system.
24.
Between 2009 and 2016, nearly 100,000 young adults aged 18-26 in
Washington State gained access to private coverage. Many of these young adults were
able to stay on their parents' coverage policy as a result of the ACA.
25.
Since January 2014, more than 27,000 adults in Washington State have
been treated for cancer while enrolled under the ACA's Med.icaid expansion.
26.
Since January 2014, more than 90,000 new adult Medicaid enrollees
received substance use disorder services as a result of the ACA.
27.
The ACA has led to improved access to care in Washington State: between
2013 and 2016, the share of adults with a doctor increased 3 .2 percentage points; and
between 201 J and 2014, the percent of adults who skipped medications because of cost
declined 1.5 percentage points.
28.
The ACA led to improved financial security for over 90,000 adults in
Washington State in 2014. The share of adults carrying medical debts declined from
19.5% in 2013 to 17.7% in 2014.
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (18-cv-167)
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00147
29.
The ACA has resulted in improved health outcomes. The share of adults in
Washington state reporting fair or poor health dropped by 1.4 percentage points between
2013 and 2016.
30.
The number of adults in Washington state delaying care due to costs
dropped from 15 .5% in 2013 to 10.1 % in 2016.
31.
All of the foregoing benefits of the Affordable Care Act would be removed
if the Plaintiffs' motion for preliminary injunction were granted.
I declare under penalty of perjury under the laws of the United States of America
and the State of Washington that the foregoing is true and conect.
Executed on this _5__ day of June, 2018, at Olympia, Washington.
~ / 7. /J?~
THEA N. MOUNTS
Senior Forecasting and Research Manager/
WA-APCD Program Director
Washington State Office of Financial
Management
Deel. of Thea Mounts in Opp. To Motion for Preliminary Injunction (l 8-cv-167)
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00148
IN THE UNITED STATES DISTRICT COURT
FOR THE NORTHERN DISTRICT OF TEXAS
FORT WORTH DIVISION
TEXAS, WISCONSIN, ALABAMA,
ARKANSAS, ARIZONA, FLORIDA,
GEORGIA, INDIANA, KANSAS,
LOUISIANA, PAUL LePAGE, Governor of
Maine, Governor Phil Bryant of the State of
MISSISSIPPI, MISSOURI, NEBRASKA,
NORTH DAKOTA, SOUTH CAROLINA,
SOUTH DAKOTA, TENNESSEE, UTAH,
WEST VIRGINIA, NEILL HURLEY and
JOHN NANTZ,
Plaintiffs,
Civil Action No. 4:18-cv-00167-O
v.
UNITED STATES OF AMERICA,
UNITED STATES DEPARTMENT OF
HEALTH AND HUMAN SERVICES,
ALEX AZAR, in his Official Capacity as
SECRETARY OF HEALTH AND
HUMAN SERVICES, UNITED STATES
INTERNAL REVENUE SERVICE, and
DAVID J. KAUTTER, in his Official
Capacity as Acting COMMISSIONER OF
INTERNAL REVENUE,
Defendants.
CALIFORNIA, CONNECTICUT,
DISTRICT OF COLUMBIA,
DELAWARE, HAWAII, ILLINOIS,
KENTUCKY, MASSACHUSETTS,
MINNESOTA by and through its
Department of Commerce, NEW JERSEY,
NEW YORK, NORTH CAROLINA,
OREGON, RHODE ISLAND, VERMONT,
VIRGINIA and WASHINGTON,
Intervenor-Defendants.
DECLARATION OF NELI PALMA IN SUPPORT OF OPPOSITION TO
APPLICATION FOR PRELIMINARY INJUNCTION
00149
I, Neli N. Palma, declare:
1.
I am an attorney at law licensed to practice in all Courts of the State of
California. I have been appointed and currently serve as a Deputy Attorney General in
the California Office of the Attorney General. In this capacity, I have been assigned to
appear on behalf of the Intervenor-Defendants in this matter.
2.
I have reviewed the exhibits listed and attached hereto, and if called upon
could testify that each document is a true and correct copy downloaded from the
referenced web address on June 6, 2018:
Exhibit A – Glied, Sherry A., et al., “Access to Coverage and Care for People with
Preexisting Conditions: How it Has Changed Under the ACA?,” The Commonwealth
Fund, June 22, 2017. http://www.commonwealthfund.org/publications/issuebriefs/2017/jun/coverage-care-preexisting-conditions-aca.
Exhibit B – Maine Equal Justice Partners Consumers for Affordable Health Care,
et al. v. Ricker Hamilton, Commissioner Maine Department of Health and Human
Services, Order on M.R. Civ. P. 80C Appeal of Agency Action, Business and Consumer
Court Civil Action, Doc. No. BCD-AP-18-02, June 4, 2018.
http://www.courts.maine.gov/news_reference/high_profile/equal-justice-partners/orderon-mrcivp80c-appeal-of-agency-action.pdf.
Exhibit C – Kaiser Family Foundation, “Medicaid Expansion Spending,” FY 2015.
https://www.kff.org/medicaid/state-indicator/medicaid-expansion-spending.
00150
Exhibit D – Kaiser Family Foundation, “High-Risk Pools for Uninsurable
Individuals,” February 22, 2017. https://www.kff.org/health-reform/issue-brief/high-riskpools-for-uninsurable-individuals/.
Exhibit E – Congressional Research Service “Legislative Actions in the 112th,
113th, and 114th Congresses to Repeal, Defund, or Delay the Affordable Care Act,”
February 7, 2017. https://fas.org/sgp/crs/misc/R43289.pdf.
Exhibit F – Internal Revenue Serv., Affordable Care Act Provision 9010 - Health
Insurance Providers Fee (Rev. Mar. 2018).
https://www.irs.gov/businesses/corporations/affordable-care-act-provision-9010.
Exhibit G – Internal Revenue Serv., U.S. Department of the Treasury, Pub. No.
1304, Individual Income Tax Returns 2015 26 (Rev. Sept. 2017) [portion].
Exhibit H – Congressional Budget Office, “Repealing the Individual Health
Insurance Mandate: An Updated Estimate,” November 2017.
https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53300individualmandate.pdf.
Exhibit I – Internal Revenue Service, “Federal Tax Compliance Research: Tax Gap
Estimates for Tax Years 2008–2010,” Publication 1415, May 2016.
https://www.irs.gov/pub/irs-soi/p1415.pdf.
Exhibit J – Congressional Budget Office, “Federal Subsidies for Health Insurance
Coverage for People Under Age 65: 2018 to 2028,” May 2018.
https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53826healthinsurancecoverage.pdf.
00151
Exhibit K – Congressional Budget Office, “The Effects of Terminating Payments
for Cost-Sharing Reductions,” August 2017. https://www.cbo.gov/ system/files/115thcongress-2017-2018/reports/53009-costsharingreductions.pdf.
Exhibit L – Centers for Medicare & Medicaid Services “Health Insurance
Exchanges 2018 Open Enrollment Period Final Report,” April 3, 2018.
https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2018-Fact-sheetsitems/2018-04-03.html.
Exhibit M – Miller, Thomas P., “Examining the Effectiveness of the Individual
Mandate under the Affordable Care Act: Statement before the House Committee on
Ways and Means Subcommittee on Oversight,” January 24, 2017.
https://waysandmeans.house.gov/wp-content/uploads/2017/01/20170124-OS-TestimonyMiller.pdf.
Exhibit N – Tricia Brooks et al., Medicaid and CHIP Eligibility, March 2018
Enrollment, Renewal, and Cost Sharing Policies as of January 2018: Findings from a 50State Survey, Kaiser Family Foundation, March 2018.
https://www.kff.org/medicaid/report/medicaid-and-chip-eligibility-enrollment-renewaland-cost-sharing-policies-as-of-january-2018-findings-from-a-50-state-survey/.
Exhibit O – Texas Health and Human Services, Community First Choice.
https://hhs.texas.gov/services/health/medicaid-chip/programs/community-first-choice.
Exhibit P – Texas Health and Human Services Commission, “Report on the CostEffectiveness of Community First Choice in Star+Plus,” February 2017.
https://hhs.texas.gov/services/health/medicaid-chip/programs/community-first-choice.
00152
I declare under penalty of perjury under the laws of the United States that the
foregoing is true and correct and that this declaration was signed on this date in
Sacramento, California. Executed on this 7th day of June, 2018, at Sacramento,
California.
/l/v~
NELIPALMA
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