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03 13 Coverage Estimates

03 13 Coverage Estimates

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Published by Peggy Satterfield

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Published by: Peggy Satterfield on Mar 13, 2013
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Updated Estimates for the Insurance CoverageProvisions of the Affordable Care Act
M
ARCH
2012
In preparing the March 2012 baseline budget projections, the CongressionalBudget Office (CBO) and the staff of the Joint Committee on Taxation (JCT)have updated estimates of the budgetary effects of the health insurance coverageprovisions of the Affordable Care Act (ACA).
1
That legislation comprises thePatient Protection and Affordable Care Act (Public Law 111-148) and the healthcare provisions of the Health Care and Education Reconciliation Act of 2010(P.L. 111-152).The insurance coverage provisions of the ACA establish a mandate for most legalresidents of the United States to obtain health insurance; create insurance
“exchanges” through which certain individuals and families may receive federal
subsidies to substantially reduce the cost of purchasing health insurance;significantly expand eligibility for Medicaid; impose an excise tax on certainhealth insurance plans with relatively high premiums; establish penalties oncertain employers who do not provide minimum health benefits to theiremployees; and make other changes to prior law.
2
 CBO and JCT now estimate that the insurance coverage provisions of the ACAwill have a net cost of just under $1.1 trillion over the 2012
 – 
2021 period
 — 
about$50
 billion less than the agencies’ March 2011 estimate for that 10
-year period(see Table 1, following the text).
3
The net costs reflect:
 
Gross additional costs of $1.5 trillion for Medicaid, the Children’s Health
1
See Congressional Budget Office, 
(March 2012).
2
For more information on the insurance coverage provisions of the ACA, see CongressionalBudget Office, cost estimate for H.R. 4872, the Reconciliation Act of 2010 (March 20, 2010).
3
The budgetary effects of the ACA discussed in this report are its effects on federal revenues andmandatory spending; they do not include federal administrative costs, which will be subject tofuture appropriation action. CBO has previously estimated that the Internal Revenue Service willneed to spend between $5 billion and $10 billion over 10 years to implement the law, and that theDepartment of Health and Human Services and other federal agencies will have to spend at least$5 billion to $10 billion over that period. In addition, the ACA included explicit authorizations forspending by a variety of grant and other programs; that funding is also subject to futureappropriation action.
 
2
 
U
PDATED
E
STIMATES FOR THE
C
OVERAGE
P
ROVISIONS OF THE
A
FFORDABLE
C
ARE
A
CT
M
ARCH
2012
 
Insurance Program (CHIP), tax credits and other subsidies for the purchase of health insurance through the newly established exchanges and related costs,and tax credits for small employers,
 
Offset in part by about $0.4 trillion in receipts from penalty payments, thenew excise tax on high-premium insurance plans, and other budgetary effects(mostly increases in tax revenues).Those amounts do not encompass all of the budgetary impacts of the ACAbecause that legislation has many other provisions, including some that will causesignificant reductions in Medicare spending and others that will generate addedtax revenues, relative to what would have occurred under prior law. CBO and JCThave previously estimated that the ACA will, on net, reduce budget deficits overthe 2012
 – 
2021 period; that estimate of the overall budgetary impact of the ACAhas not been updated.
4
 The current estimate of the
gross
costs of the coverage provisions ($1,496 billion
through 2021) is about $50 billion higher than last year’s p
rojection; however, theother budgetary effects of those provisions, which partially offset those gross
costs, also have increased in CBO and JCT’s estimates (to $413 billion), leading
to the small decrease in the
net 
10-year tally. Over the 10-year period from 2012through 2021, enactment of the coverage provisions of the ACA was projectedlast March to increase federal deficits by $1,131 billion, whereas the March 2012estimate indicates that those provisions will increase deficits by $1,083 billion.The net cost was boosted by an additional $168 billion in estimated costs forMedicaid and CHIP and $8 billion less in estimated revenues from the excise taxon high-premium health insurance plans. But those increases were more thanoffset by a reduction of $97 billion in the projected costs for the tax credits andother subsidies for health insurance provided through the exchanges and relatedspending, a reduction of $20 billion in the projected costs for tax credits for smallemployers, and a reduction of $107 billion in deficits from the projected revenueeffects of changes in taxable compensation and penalty payments and from othersmall changes in estimated spending.This report also presents estimates through fiscal year 2022, because the baselineprojecti
on period now extends through that additional year. The ACA’s
provisions related to insurance coverage are now projected to have a net cost of $1,252 billion over the 2012
 – 
2022 period (see Table 2, following the text); thatamount represents a gross cost to the federal government of $1,762 billion, offsetin part by $510 billion in receipts and other budgetary effects (primarily revenuesfrom penalties and other sources). The addition of 2022 to the projection periodhas the effect of increasing the costs of the coverage provisions of the ACA
4
See the statement of Douglas W. Elmendorf, Director, Congressional Budget Office, before theSubcommittee on Health, House Committee on Energy and Commerce, 
 (March 30, 2011). For the provisions of the ACA unrelated to insurance coverage, most of which involve ongoing programs or revenuestreams, separating the portion of the updated projections for those programs or revenue streamsthat is attributable to the ACA from the portion that would have existed under prior law is verydifficult.
 
3
 
U
PDATED
E
STIMATES FOR THE
C
OVERAGE
P
ROVISIONS OF THE
A
FFORDABLE
C
ARE
A
CT
M
ARCH
2012
 
relative to those projected in March 2011 for the 2012
 – 
2021 period because thatchange adds a year in which the expansion of eligibility for Medicaid andsubsidies for health insurance purchased through the exchanges will be in effect.CBO and JCT have not estimated the budgetary effects in 2022 of the otherprovisions of the ACA; over the 2012
 – 
2021 period, those other provisions werepreviously estimated to reduce budget deficits.
CBO and JCT’s projections of health i
nsurance coverage have also changed sincelast March. Fewer people are now expected to obtain health insurance coveragefrom their employer or in insurance exchanges; more are now expected to obtaincoverage from Medicaid or CHIP or from nongroup or other sources. More areexpected to be uninsured. The extent of the changes varies from year to year, butin 2016, for example, the ACA is now estimated to reduce the number of peoplereceiving health insurance coverage through an employer by an additional 4million enrollees relative to the March 2011 projections. In that year, CBO andJCT now estimate that there will be 2 million fewer enrollees in insuranceexchanges. In the other direction, CBO and JCT now estimate that, in 2016, theACA will increase enrollment in Medicaid and CHIP slightly more thanpreviously estimated (but considerably more in 2014 and 2015), and it will reducethe number of people with nongroup or other coverage by 3 million less and thenumber of uninsured people by 2 million less than previously estimated.Compared with prior law, the ACA is now estimated by CBO and JCT to reducethe number of nonelderly people without health insurance coverage by 30 millionto 33 million in 2016 and subsequent years, leaving 26 million to 27 millionnonelderly residents uninsured in those years (see Table 3, at the end of thisreport). The share of legal nonelderly residents with insurance is projected to risefrom 82 percent in 2012 to 93 percent by 2022. According to the currentestimates, from 2016 on, between 20 million and 23 million people will receivecoverage through the new insurance exchanges, and 16 million to 17 millionpeople will be enrolled in Medicaid and CHIP. Also, 3 million to 5 million fewerpeople will have coverage through an employer compared with the number underprior law.
5
 
Reasons for Changes in Estimates Since March 2011
 
The major sources for the differences between the March 2011 and March 2012projections are the following:
5
Some observers have expressed surprise that CBO and JCT
’s previous estimates
did not show amuch larger reduction in the number of people receiving employment-based health insurance.CBO and
JCT’s estimates take account of 
the expanded eligibility for Medicaid and the subsidiesto be provided through the insurance exchanges, but they also recognize that the legislation leavesin place substantial financial incentives for firms to offer health insurance coverage and alsocreates new financial incentives for firms to offer such coverage and for many people to obtain itthrough their employers. Shortly, CBO will release an extensive analysis conducted with JCT of the incentives for firms to offer or not offer health insurance under the ACA, as well as a range of estimates of sources of coverage and federal budgetary outcomes that would result from the ACAunder alternative assumptions
about employers’ behavior.
 

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