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  • 1. What’s Next?State Health Care Policy in 2012 2011 State Legislative Conference Salt Lake City, Utah November 5, 2011
  • 2. State GovernmentsWhere the action really happens. …but having money helps.
  • 3. State BudgetsYEAR CUMULATIVE BUDGET GAPFY2002 $40,000,000,000FY2003 $75,000,000,000FY2004 $80,000,000,000FY2005 $45,000,000,000FY2009 $110,000,000,000FY2010 $191,000,000,000FY2011 $130,500,000,000*FY2012 $103,000,000,000*FY2013 $46,000,000,000** $820,500,000,000 Source: Center on Budget and Policy Priorities Source: Center on Budget and Policy Priorities ( (
  • 4. State Governments• Three ways to fill a budget hole: – Use the rainy day fund • Drained – Cut programs • Medicaid payments are a perennial favorite – Raise revenues • Never a popular option• All within the context of health reform implementation
  • 5. What’s in ACA for States?• Public Coverage – Medicaid and CHIP• Private Insurance – Health Insurance Exchanges – Interstate Insurance Commerce – Co-Ops• New Programs and Opportunities – Alternatives to Liability Tort – PC Extensions and Community Health Teams – Demonstration Programs and Other Odds and Ends
  • 6. Medicaid: Eligibility• Eligibility Expansion• About 16 million uninsured, non-elderly citizens expected to qualify • <133% of the Federal Poverty Level – Household Income – $29,326.50 for a family of four • State may file a plan amendment to expand further – Foster children through the age of 26
  • 7. Medicaid: Benefits• Concurrent hospice and curative treatment for children• Smoking cessation – Comprehensive treatment for pregnant women – Prescriptions covered for everyone• Adult preventive services option – 1 point FMAP increase
  • 8. Medicaid: Benefits• Premium assistance for employer- sponsored insurance• Long-Term Care – Remember Willie Sutton? • Dual eligibles are 46% of Medicaid’s costs. – Community First, 1915(i) revision – Money follows the Person Demo – Spousal Impoverishment Protection
  • 9. Medicaid: Quality• Prevention Incentives – $100M in grants to states to implement comprehensive, evidence-based incentive programs in Medicaid for: • Tobacco cessation • Weight loss • Lowering cholesterol or blood pressure, or • Avoiding onset, or improving control, of diabetes – States may apply for grants lasting 3 - 5 years
  • 10. Medicaid: Waste, Fraud, Abuse• Waste, Fraud, Abuse Provisions – Screening of all Medicare, Medicaid, and CHIP providers • Suspension and termination of enrollment • Booted from one, booted from all – Overpayments • Collection period expanded from 60 days to 1 year – Program Integrity • Recovery audit contractors
  • 11. Medicaid: Payment• Primary care physician payment will be brought to parity with Medicare. – Covers E&M codes and immunization codes – Feds pay the difference between Medicare and what your state’s Medicaid program paid on June 30, 2009. • States responsible for any difference between the January 1, 2013 and June 30, 2009 levels – Only lasts for two years: 2013 and 2014
  • 12. Children’s Care• CHIP – Authorization extended through 2019 – Federal funding increased by 23 points • Lowest current Fed Matching Rate: 65% • Feds will pay 95%+ for nearly half of states – Maintenance of effort required by states• Pediatric ACO Demo – Four-year demo (2012-2016) – Allows pediatric providers who meet certain criteria (TBD) to be recognized as ACOs
  • 13. Medicaid: PCMH• New State Option: Health Homes for Patients with Chronic Conditions – 90 percent federal match for first 8 quarters – Focus on patients with asthma, diabetes, heart disease, mental health condition, substance use disorder, or overweight/obesity (BMI over 25) • Patient must have two chronic conditions; • One chronic condition and is at risk of having a second chronic condition; or • A serious and persistent mental health condition – Simpler plan amendment process is all that’s needed
  • 14. Health Insurance Exchanges• States must make choices: – Let the Feds do it or run it ourselves? – Combine individual and small group markets? – “Advanced” exchange planning • Regional Multi-State / Regional Intra-State• Exchanges must become self-sufficient• In 2013, HHS will certify that exchanges are prepared to begin operations
  • 15. Health Insurance Exchanges• What would FPs think an ideal insurance market looks like?• States are responsible for setting guidelines and regulating products offered on the exchange – Get to know your Insurance Commissioner – Get to know your state legislature’s committees with jurisdiction over health insurance
  • 16. Health Insurance Exchanges• Family Medicine’s Principles 1. Fair Representation of Stakeholders 2. Payment for PCMH & Enhanced Access 3. Standardized Contracting 4. Set Primary Care Targets 5. Require Robust PC-Based Essential Benefits 6. Presume Eligibility 7. Reward Quality 8. Protect Consumers & Physicians
  • 17. Interstate Insurance CommerceInterstate Insurance Compacts• Cross-border sale/purchase of insurance• National Association of Insurance Commissioners to develop regulations with HHS• General rules: – Subject to general insurance and contract laws/regs of state where policy is written – Subject to consumer protection laws/regs of state where policy is purchased
  • 18. Interstate Insurance Commerce• Multi-State Qualified Health Plans – Contracts negotiated by Office of Personnel Management (OPM) – At least two multi-state plans to be offered on every state exchange • At least one must be non-profit – Must be considered qualified coverage
  • 19. Co-Ops• Loans and grants to cover start-up and solvency costs of starting Consumer Oriented and Operated Plans (CO-OPs) – Loans paid back in 5 years, grants in 15 years• Non-profits that may not be run by any unit of government, nor by private insurers• Goal of at least one per state• $2.2 billion (of $6B) rescinded in FY11 CR.
  • 20. Liability: Tort Alternatives Demos• Supposed to begin October 2010• Grants for demonstration programs – Grants made to states• Similar to 2009 HHS-initiated program• Funding would be nice, though…
  • 21. Primary Care Extensions• Grants to states or multi-state entities• Creates upper-level hubs and local-level extension agencies – Hubs: State health department, Medicaid, state Medicare administrator, departments of at least one school training in primary care • May also include professional societies• Funding would be nice, though…
  • 22. Community Health Teams• Help states/state-designated entities to establish community-based, inter- professional, interdisciplinary teams to support primary care physicians and patients – A model used very successfully in North Carolina and Vermont, for example• Funding would be nice, though…
  • 23. Odds and Ends• Medicaid Global Payment Demo• Affordable Care Access 10-State Demo• Reimbursement Data Collection/Analysis• Community Transformation Grants• School-Based Health Centers• Increased Funding for Territories• Consumer Information Office Grants• State Innovation Waiver
  • 24. But Wait, There’s More!• ACA isn’t all that happened in 2011… …nor will it be all that happens in 2012.• States continue to deal with – Scope of Practice – Workforce – Public Health – Liability …and much, much more
  • 25. Scope of Practice• Nurse Practitioners • Pharmacists – Independence – Immunizations• Psychologists • Lay Midwives – Rx Authority – Independence• Chiropractors • Naturopaths – Rx Authority – Licensure• Optometrists – Surgery
  • 26. Scope of Practice• Truth in Advertising – Model legislation and supporting materials available from Scope of Practice Partnership – Legislation passed in… • California • Illinois • Oklahoma • Texas
  • 27. Workforce and Public Health• Workforce – Student Loan Repayment Programs – Rural Training Programs• Public Health – Pseudoephedrine by Rx – Clean Indoor Air – Anti-Obesity
  • 28. Liability• The Wheel in the Sky (Keeps on Turnin’) – Courts continue to strike down non-economic damages caps – 2010: Arkansas, Georgia, Illinois• Damage Caps – Utah lowered by $30k• PC No-Fault Compensation Fund – Failed in Vermont
  • 29. 2012 Outlook• More Budget Cuts = More Pain – Medicaid provider payments – Cuts to optional Medicaid/CHIP services – Cuts to enrollment? – New taxes/fees – Programs (PCMH, workforce, medical school, residency) may go un- or under-funded
  • 30. 2012 Outlook• Health Reform (not just ACA) Continues – Health Insurance Exchanges – Co-Operatives – Accountable Care Organizations – Public Options – Single-Payer
  • 31. AAFP State Government Affairs• New Reports, One-Pagers – ACOs, Co-Ops, Exchanges – FP Education & Training versus • NP, DNP and Naturopaths• State Legislative Tracking –• Government Affairs Weekly Reports – Submissions always welcome and wanted
  • 32. AAFP State Government Affairs• Chapter-Supported Legislation• Ad Hoc Research• Grassroots Advocacy for State Legislation – Speak Out – Legislator-Member Matching• Scope of Practice Partnership – Research and Reports – Grant Applications
  • 33. Thank You!• Questions?Greg Martin Manager, State Government Affairs American Academy of Family Physicians 888.794.7481, x.2552