Affordable Care Act March 2013 Janlee Wong, MSW NASW
Learning Objectives• Basic Health Care Policy Elements and the Affordable Care Act• Who is covered• What is covered• Who pays for coverage• How to get covered• Social worker role• Resources
Health Care Policy• Universal, single payer health care• ACA provides universal coverage (except for the unauthorized)• ACA does not provide single payer• Elements of the ACA are state electives – Medicaid expansion – Health Benefits Exchanges
Affordable Care Act (ACA)• Healthcare Reform or Obamacare• Signed into law March 2010, full implementation 2014 GOALS• Universal healthcare (excludes undocumented)• Affordable health plans – minimum benefit• Cost control through wellness, prevention, competition
Court and State Decisions• US Supreme Court upheld the “individual mandate” of the ACA (July 2012)• Struck down sanctions against states that fail to expand Medicaid
Who Is Covered• All are eligible (excluding the unauthorized)• Includes those with pre‐existing conditions• All required to have or purchase health insurance or pay a fine
California has the eighthlargest proportion ofuninsured in the nationand the largest totalnumber of uninsured. Onlythree states (Massachusetts,Hawaii, and Minnesota) haveuninsured rates under 10%.*All numbers reflect the non‐elderly population, under age 65.Source: Employee Benefit Research Institute estimates of the 2009 – 2011 Current Population Survey, March Supplements.
The Uninsured Unauthorized (5)A recent report by the UC‐Berkeley Center for Labor Research and Education and the UCLA Center for Health Policy Research on California residents who will remain uninsured after the ACA takes effect found that:• 66% of the remaining uninsured will be Latino;• 60% of the remaining uninsured will have limited English proficiency; and• 62% of the remaining uninsured will live in Southern California.
Poor Outreach• The report also found that about 50% of those still uninsured five years after the ACA takes effect will qualify for coverage under the Medi‐Cal expansion or for health benefit exchange subsidies, but they will not be aware that they qualify because of poor outreach. Medi‐Cal is Californias Medicaid program (5)
Clues (6)• Uninsured about 18.5% of CA Population• Uninsured immigrants with native born children: 27.9%• Uninsured natives with children: 12.9%
What is covered Essential Health Benefits1. Ambulatory patient services2. Emergency services3. Hospitalization4. Maternity and newborn care5. Mental health and substance use disorder services, including behavioral health treatment6. Prescription drugs7. Rehabilitative and habilitative services and devices8. Laboratory services9. Preventive and wellness services and chronic disease management10. Pediatric services, including oral and vision care
Plans• Standardized plans ‐ Bronze, Silver, Gold, Platinum (from 60‐40 to 90‐10 Premium‐ Copay)• No Rescissions, No Lifetime Limits & Restricted Annual Limits• Medical Loss Ratio, Consumers rebates, 80‐ 85% on healthcare and quality• Elimination of the Medicare Part D doughnut hole ($2,700 to $6,154)
Who Pays?• Insurance model: the high cost of the sick offset by low cost of the healthy• Young adults (up to age 26) covered by parents• Emphasizes and pays for prevention• Sets minimum benefit levels so health plans compete with each other on cost and quality• Creates a state run health benefit exchange market structure for individuals and business
Reducing Healthcare Costs While Expanding Coverage• Cover the healthy as well as the sick• Wellness and prevention, early diagnosis• Reductions in unnecessary testing and referrals• Reductions in preventable emergency room visits and hospitalizations• Reductions in infections and adverse events in hospitals• Reductions in preventable readmissions, • Use of lower‐cost treatments, settings, and providers
Plans are Income Tested• Households earning less than 250 percent of the federal poverty level can receive financial help if they enroll in a Silver plan; the less income they earn, the more financial assistance they can receive. • For example, individuals earning between 150 to 250 percent of the federal poverty level can expect to pay $20 to see their primary care physician, while those earning 100 to 150 percent would pay $4.
How to Get Coverage• Many employers will simply continue plans for employees• Employers with 50 or more FTE workers required to provide health insurance or pay a penalty• Expands Medicaid (Medi‐Cal) up to 133% of poverty ($14,404 indiv to $29, 327 family of 4)• Health Benefits Exchange (Covered California)• Accountable Care Organizations (ACOs)
Employers• For employers without employee plans: – For businesses with 50 or fewer full time employees, qualified plans available in Exchange – No penalties for 50 or less employers if health coverage not offered• Reactions
Employers With Over 50 FT Workers• May have to pay a penalty if not providing health insurance• Doesn’t apply to employees working 30 hours a week or less• Reactions
Business Incentives• Small Business Tax Credits: 2 million workers get their insurance from an estimated 360,000 small employers • Early Retiree Reinsurance Program (ERRP) partially reimburses employment‐based plans for health benefits for early retirees and their spouses, surviving spouses and dependents• Health Care Exchanges Available to Small Business
Sole Proprietors• Health care reform ends discrimination by insurance companies based on pre‐existing conditions and gender. The new law also eliminates lifetime caps, restricts annual caps and ends the practices by which health insurance companies retroactively end a policy when someone becomes sick. (1)
Sole Proprietors• Premium Subsidies and Cost Sharing Credits (Starting in 2014) – Subsidies and credits to lower premiums and cost‐sharing requirements are available to individuals and families with incomes below 400 percent of the federal poverty line (below $88,000 a year for a family of four) who purchase coverage in the newly established exchanges. (1)
Health Benefits Exchange “Covered California”• Quasi‐governmental organization, specifically an "independent public entity not affiliated with an agency or department.“• Contracting with Plans: Contract with carriers so as to provide health care coverage choices that offer the optimal combination of choice, value, quality, and service.”
Health Benefits ExchangeEssential Health Benefits: Legislation introduced in January 2012, would select the Kaiser small group HMO plan as the state’s benchmark plan (AB 1453/SB 951)Exchange to offer Insurance Companies’ Bronze, Silver, Gold and Platinum plans
Health Benefits ExchangeBasic Health Program (BHP): Optional bridge program allows states to use federal funding to offer subsidized health insurance to adults with incomes between 139 and 200% of the federal poverty level (FPL) who would otherwise be eligible to purchase subsidized coverage through an Exchange. Legislation creating a BHP was initially introduced in 2011, but in August 2012 the bill was held inCommittee, effectively tabling the legislation (SB 703)
Health Benefits ExchangeConsumer Assistance and Outreach: Employ Navigators to assist with education and enrollment activities. CA will use two distinct types of Assisters registered and certified by the Exchange. Certified enrollment Assisters (Navigators) will be compensated by the Exchange and at a minimum will include, non‐profit organizations, community clinics, County Social Services offices employing Eligibility Workers, and labor unions. Direct Benefit Assisters, will not be paid by the Exchange and will include health insurance agents, hospitals, and providers.
Health Benefits ExchangeInformation Technology: Requires the creation of a single statewide application that will be available on paper and electronically for all systems and entities accepting and processing applications and eligibility. It also requires a simplified citizenship and identity verification at application and renewal and increased coordination with other public programs.
Accountable Care Organizations (ACOs)• ACO is a network of hospitals, clinics, physician practices and other providers who work together to provide coordinated, integrated care for an assigned population of individuals and who receive financial compensation for meeting specific patient outcomes.• Goal: Reduce or control the growth of healthcare costs while maintaining or improving the quality of care
Accountable Care Organizations (ACOs)• The core is effective primary care delivered through a “medical home”• Primary care organizations can transform• Integrated coordinated care similar to the HMO model• Not surprising Kaiser picked as essential benefit plan
ACO Characteristics• a strong primary care/medical home foundation• multidisciplinary health care teams• targeted care coordination interventions (focused especially on individuals with multiple chronic conditions)• integration with behavioral health and substance use treatment• sophisticated information systems that include electronic medical records • formal partnerships with “medical neighbors”
Role of Social Worker• Social workers should be included in the interdisciplinary care teams across a broad array of health care settings• Social workers are likely the only professionals devoted to meeting the psychosocial needs of patients and families• Social workers extend the team to allow members to participate at the top of their licenses
Roles of Social Worker• Clinical social workers – mental and behavioral health services• Medical social workers – care coordination and case management, medically related social services, patient and family education, discharge planning, advance care planning, community outreach and engagement
Roles of Social Worker• Be a voice for social work in the health care plan’s development of ACOs• Advocate for comprehensive benefits including psychosocial services• Advocate for horizontal integration of health and human services benefits• Serve as a resource for identifying hard to reach populations
Social Work AdvocacyNASW and California Deans and Directors got a social worker included on the California Workforce Investment Board, Health Workforce Development Council (8)• Standardize, strengthen and expand curricula and training programs to increase access and consistent competencies for Community Health Workers/Promotores, Medical Assistants, Social Workers, Nurses, Direct Care Workers and other workers.• Change regulations to allow the services of Community Health Workers/Promotores to be reimbursable with government and private payers.• Develop supportive payment structure and policies targeted at increasing the attractiveness of primary care as a career path and retention of primary care providers. • Ensure adequate payment for primary care and preventive services with appropriate adjustments in payment incentives.
ACA Is Changing• Check various websites for up to date changes http://www.healthcare.gov/ http://www.chcf.org/publications/2010/05/the‐ affordable‐care‐act‐in‐california• Continued political turmoil: – 27 states are expanding Medicaid, 16 are not and 8 are undecided (Feb 2013) – 17 states have set up exchanges, 27 have not – Some continue to seek repeal or delay