Health Reform Bracketology

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Health Reform Bracketology is a scenario-planning tool that assesses the future of specific policies and provisions within the Patient Protection and Affordable Care Act. This assessment is conducted across a myriad of different political scenarios.

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Health Reform Bracketology

  1. 1. Step 1: Choose a Supreme Court Decision Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Remainder of Law Upheld Split Congress IM Overturned D White House Remainder of Law Upheld Split Congress IM Overturned R White House Remainder of Law Overturned R Congress Start Over
  2. 2. Step 2: Choose a 2012 Election Outcome Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law Remainder of Upheld Law Upheld Split Congress IM Overturned R White House Law Overturned Remainder of Law Overturned R Congress Back Start Over
  3. 3. Step 2: Choose a 2012 Election Outcome Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Mandate Remainder of Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Remainder of Law Overturned R Congress Back Start Over
  4. 4. Step 2: Choose a 2012 Election Outcome Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law Remainder of Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Remainder of Law Overturned R Congress Back Start Over
  5. 5. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law D-Gridlock Remainder of R-Gridlock Upheld Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  6. 6. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law D-Gridlock Remainder of D-Gridlock Upheld Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  7. 7. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law D-Gridlock Remainder of Sweep Upheld Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  8. 8. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Mandate D-Gridlock Remainder of R-Gridlock Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  9. 9. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Mandate D-Gridlock Remainder of D-Gridlock Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  10. 10. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Mandate D-Gridlock Remainder of Sweep Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  11. 11. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law D-Gridlock Remainder of R-Gridlock Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  12. 12. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law D-Gridlock Remainder of D-Gridlock Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  13. 13. Step 3: Click “The Future of Health Reform” Supreme Court 2012 Election Decision Outcomes IM Upheld R White House Law Upheld R-Gridlock Remainder of Law Upheld Split Congress IM Overturned D White House Mandate Overturned Law D-Gridlock Remainder of Sweep Overturned Law Upheld Split Congress IM Overturned R White House Law Overturned Sweep Remainder of Law Overturned R Congress Back Start Over
  14. 14. Scenario: Law Upheld / R Gridlock We believe that Republicans will seek to administratively disrupt and congressionally defund core provisions of PPACA, as well as seek to increase flexibility for other provisions The Breakdown by • Republicans will continue to press for wholesale repeal, though some elements of the law that have already gone into effect will be preserved. Repeal will happen through In this scenario, what tactic will reconciliation. Republicans use to disrupt PPACA? • Major provisions of PPACA will remain in force, but the Secretary will use his/her 70% discretion to implement innovative changes in the Medicaid program that center on state flexibility (e.g., repealing the MOE, Duals initiatives, etc.). • Republicans will try to reform Medicare, likely through a Medicare exchange and increasing the eligibility age, but will be met with opposition from Democrats. IPAB will remain a target for repeal. • Delivery reform will continue at the current pace with some provisions being shelved due to budgetary constraints and HHS capacity. 15% 10% • Exchanges will be implemented as prescribed with additional administrative flexibility granted to states unable to meet the statutory deadline. The Federally Facilitated 0% Exchange will be scaled back. Work w/ Admin Modify Nothing Ds Tactics to Current • Minor modifications will be made to select insurance reform provisions while Slow Imp Regs reforms like guaranteed issue and community rating will stay in effect. • The premium subsidy will likely be reduced to 250%-300% of the FPL. Back Start Over
  15. 15. Scenario: Law Upheld / D Gridlock We believe that Democrats will view their election triumph as a validation of PPACA and will continue with a full implementation of the law, albeit with some provisions delayed The Breakdown by • Full-scale implementation of PPACA will continue unabated. In this scenario, how will the administration • The Medicaid program will largely remain as envisioned by PPACA. States will change its stance on state flexibility? continue to push for flexibility on the MOE; in response, the administration will grant 1115 Waivers, but with reform elements. 43% • Democrats will continue to introduce Medicare savings through payment 39% adjustments and minimal benefit changes. The savings could be used to offset the SGR-fix; IPAB likely upheld. • Delivery reform will continue at the current pace with some provisions being shelved due to budgetary constraints and HHS capacity. 16% • Many of the hesitant states will move to build exchanges while some will continue to refuse compliance. Many state exchanges will not be operational until 2015. • All insurance reform provisions will remain in effect. • The premium subsidy will move forward uninhibited, though it is possible the FPL More Rigid No Change More level will be reduced to 300-350% for cost savings. in Flexibility Flexible Back Start Over
  16. 16. Scenario: Law Upheld / R SweepWe believe that Republicans will attempt but fail at repealing all of PPACA, but will then pursue a piecemeal repeal approach on targeted, less politically controversial provisions The Breakdown by • Republican repeal-and-replace efforts—a patchwork of various conservative proposals (e.g., Rep. Ryan’s plan)—will primarily target the individual mandate, In this scenario, how will Republicans guaranteed issue, and community rating. pursue a repeal of PPACA? • The Administration will focus on providing state flexibility and innovation through 46% 1115 Waivers rather than full repeal. Budget pressures could reduce the FPL cutoff in the Medicaid expansion. 26% • Republicans will use Rep. Ryans budget as a blueprint for Medicare reform and 21% repeal IPAB. Cuts to hospital payments will stay intact and the SGR fix will likely be offset by defunding portions of PPACA. 3% • Delivery reform will continue at the current pace with more demonstrations/pilot programs being shelved due to budgetary constraints. Innovation Center funding will continue. • Republicans will not completely repeal exchanges due to pressure from the insurance and medical lobby, instead opting to make legislative changes that provide states with additional flexibility and allow private-market distribution. • Republicans will overhaul the insurance reform provisions with few replacements. Republicans will likely replace guaranteed issue. • The premium subsidy will likely be repealed and replaced. Back Start Over
  17. 17. Scenario: Mandate Overturned / R GridlockWe believe that Republicans will administratively disrupt some PPACA provisions and find increased bi-partisan support in Congress to repeal or modify other provisions The Breakdown by • Republicans and Democrats will be unable to agree on a viable replacement for the individual mandate. In this scenario, how will Congress replace the Guaranteed Issue provision? • Major aspects of PPACA will remain intact, but the Secretary will use his/her discretion to implement innovative changes in the Medicaid program that center on state flexibility (e.g., repealing the MOE, Duals initiatives, etc.). 25% • Republicans will try to reform Medicare, likely through a Medicare exchange and increasing the eligibility age, but will be met with opposition from Democrats. Hospital payment cuts will stay intact and IPAB could be repealed. 41% • Delivery reform will be accelerated with an emphasis on cost-cutting programs. 8% • For exchanges, Republicans will seek congressional support for enhanced waiver authority and look to enable public/private partnership development. 7% High Risk Pool • The Congress will ensure that guaranteed issue is repealed, but will not be able to find a bi-partisan replacement, leaving it to the administration. Republicans will Auto Enroll (Employers) administratively weaken other core insurance provisions. Mandatory Enrollment Period No Replacement • The premium subsidy will largely remain intact, but will face a modest decrease on the basis of deficit cutting. Back Start Over
  18. 18. Scenario: Mandate Overturned / D Gridlock We believe that Democrats will work to salvage the public image of the law, quickly implementing the remaining provisions while negotiating alternatives as necessary The Breakdown by • Democrats will search for a mandate replacement, but will be unable to move anything through the Congress, limiting their response to administrative action. In this scenario, how will Congress • The Medicaid program will largely remain as envisioned by PPACA. States will replace the Guaranteed Issue provision? continue to push for flexibility on the MOE; in response, the administration will grant 1115 Waivers, but with reform elements. 21% • Democrats will continue to introduce Medicare savings through additional payment adjustments and minimal benefit changes. Hospital payment cuts likely will stay intact, and IPAB likely upheld. 5% • Delivery reform will continue as outlined in PPACA and will be consistent with the 52% current administration’s pace of implementation. 11% • Exchanges will be implemented as prescribed by PPACA, with few states establishing their own exchanges in the short term; additional states will come online after 2015. The Federally Facilitated Exchange will serve an important role. High Risk Pool • Both parties will ensure that guaranteed issue is overturned while all other insurance Auto Enroll (Employers) provisions will continue unimpeded. A congressional replacement for guaranteed Mandatory Enrollment Period issue is unlikely. No Replacement • The premium subsidy will be scaled back slightly from 400% of FPL on the basis of deficit concerns. Back Start Over
  19. 19. Scenario: Mandate Overturned / R Sweep We believe that Republicans will succeed in a partial repeal of the law, focusing on entitlement and insurance reforms The Breakdown by • Republicans will not pursue a replacement to the individual mandate. In this scenario, how will Republicans • The Administration will focus on providing state flexibility and spurring innovation pursue a repeal of PPACA? through 1115 Waivers rather than full repeal. Budget pressures could reduce the FPL cutoff in the Medicaid expansion. 54% • Republicans will use Rep. Ryans budget as a blueprint for Medicare reform and repeal IPAB. Cuts to hospital payments will stay intact and an SGR fix will likely be offset by defunding portions of PPACA. 36% • There will be a new emphasis on delivery reform as HHS’ focus shifts away from insurance provisions. • Republicans will immediately seek repeal of exchanges and allow private exchanges to distribute modified premium subsidies. 3% • Republicans will repeal most insurance market provisions without replacement while furthering the work done on high-risk pools to offset the loss of guaranteed issue. Repeal Not Pursue Targeted Entire Law Repeal Provisions • The current premium subsidy is likely to be repealed and replaced with a means- for Repeal tested program. Back Start Over
  20. 20. Scenario: Law Overturned / R GridlockWe believe that Republicans and Democrats will not come together on a comprehensive replacement plan, but will moderately reform entitlement programs The Breakdown by • A minimalist approach will be taken vis-à-vis Medicaid reform, although additional flexibility will be provided to states in eligibility determination. Block grants will not In this scenario, what health reforms would be a policy option. the Congress & White House be able to pass? • Republicans will try to reform Medicare through a Medicare exchange. A greater focus will be placed by the administration on Medicare Advantage programs. Minor Public/Private Exchange Funding 33% adjustments will be made to FFS. Consumer-Focused 47% • The Administration and Congress will re-institute some of the payment reform Insurance Reforms provisions but cut funding to demonstrations without proven records. Modified Guaranteed Issue 30% • Republicans and Democrats will be unable to find a bi-partisan alternative to the Modified Premium premium subsidy, leaving the middle-class uninsured without redress. Subsidies 33% • Private exchanges will emerge, expanding in popularity while focusing primarily on Employer Penalty 7% the group market. Rate Banding 10% • Given the popularity of guaranteed issue, Congress will look to guaranteed issue-like solutions to the coverage dilemma—e.g., high-risk pools. MLR Restrictions 15% • Republicans will pursue portability and med-mal reforms as health policy options. Substitute For Mandate 15% • Republicans may be in favor of working with Democrats to re-institute some of the insurance provisions found in PPACA. Medicaid Expansion 8% Block Grants (Medicaid) 25% Back Premium Support (Medicare) 20% Start Over
  21. 21. Scenario: Law Overturned / D GridlockWe believe that Democrats will try to salvage some elements of PPACA, but no major health reform legislation will make it through Congress The Breakdown by • Improving state budgets and an illusion of flexibility in Medicaid will reduce the impetus for major reform. Congress may relax some state requirements, especially In this scenario, what health reforms would with respect to eligibility determination. the Congress & White House be able to pass? • No fundamental changes to the current FFS system are anticipated. The administration will continue to support the current path of Medicare Advantage, Public/Private Exchange Funding 44% potentially through provisions similar to PPACA. Consumer-Focused 61% • Delivery reforms will continue with less funding for some programs. Insurance Reforms Modified Guaranteed • State-based exchanges will be implemented in some states with existing funds while Issue 31% slow group private exchange development will continue. Modified Premium Subsidies 36% • Republicans and Democrats will be unable to find a bi-partisan alternative to the premium subsidy, leaving the middle-class uninsured without redress. Employer Penalty 31% • Democrats will find an administrative replacement for guaranteed issue, possibly by Rate Banding 22% developing high-risk pools. MLR Restrictions 25% • A handful of states will implement their own versions of PPACA-style reforms, including mandates, subsidies, and insurance reforms. Substitute For Mandate 31% • The administration will attempt to salvage disparate portions of PPACA administratively. Medicaid Expansion 25% Block Grants (Medicaid) 14% Back Premium Support (Medicare) 14% Start Over
  22. 22. Scenario: Law Overturned / R SweepWe believe that Republicans now “own” health care reform and will be under pressure to find a solution, but will take a minimalist approach with respect to federal government involvement The Breakdown by • Increasing economic pressures will be an impetus for Medicaid reform, resulting in the Administration and Congress loosening constraints on states. Block grants will In this scenario, how will Republicans likely not be a policy option. pursue major health system reform? • Medicare Advantage will grow while premium support will be a viable policy option with an opt-out trigger. Republicans will use Rep. Ryans budget as a blueprint for 39% Medicare reform. 28% • We will see the re-institution of some delivery reform provisions while the general 23% FFS transition progress will be slowed. 10% • Republicans will introduce an alternate premium subsidy program that will have a distribution channel through both public and private exchanges. • State-based exchanges will be implemented in some states with existing grant funding while Republicans may actively look to fund private exchange development. • High-risk pools will be the Republican solution to pre-existing conditions exclusions. • Republicans will push for tort reform and insurance portability and re-instate the more popular insurance reform provisions. Back Start Over
  23. 23. FAQs What is Health Reform Bracketology? Bracketology is a scenario-planning tool that examines the various Supreme Court and election outcomes and their impact on key health reform policies. What is FuturePanel? FuturePanel™ brings together former senior executives from the Centers for Medicare and Medicaid Services, national leaders in health information technology, veterans of state- level health care policy, clinical experts, great economists and legal minds to vet assertions and tease out the implications of the various scenarios. What is LP Health Watch? LP Health Watch is a survey tool used to gather the opinions of a distinguished group of industry executives and Washington DC insiders. Start Over
  24. 24. General Assumptions Six Fiscal Train Wrecks Regardless of the Supreme Court decision and election outcomes, the next Congress will have to deal with sun-setting tax provisions that, if mishandled, invite economic destabilization and political brinkmanship. These fiscal “train wrecks” include: • Expiration of the Bush Tax Cuts • Expiration of the Payroll Tax • Expiration of the Alternative Minimum Tax Patch • The enactment of the Sequestration Economic Performance • Required raising of the Debt Ceiling We assume that the outcome of the Presidential (and to some extent Senate) elections will be largely influenced by the • Cuts to Medicare due to the Sustainable Growth Rate economy. Therefore, we make the following implicit assumptions in our scenarios: • If Republicans win the White House, then it is likely that the economic recovery has stalled or the economy is slipping back into recession. Gubernatorial Pressures • If Democrats retain the White House, then it is likely that We assume that the majority of state governors will be Republican. the pace of economic recovery has either maintained or As of now, it is projected that 34 governors will be Republican, quickened in the weeks and months prior to the election. creating immense pressure from states on congressional delegations and the White House to cede further state flexibility. Start Over

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