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  • 1. Health Reform underThe Patient Protection and Affordable Care Act What Does it Mean for Rural Health? Carolyn L. Engelhard, MPA Director, Health Policy Program Department of Public Health Sciences, UVASOM December 7, 2011
  • 2. Health Reform An overview of the impact of thePatient Protection and Affordable CareAct (PPACA) in the United States, signed into law March 23, 2010
  • 3. Q1: Will the health reform law require nearly all Americans to have health insurance by 2014 of else pay a fine?1. No, the law will not do this2. Yes, the law will do this3. Don’t know
  • 4. Q1: Will the health reform law require nearly all Americans to have health insurance by 2014 of else pay a fine?Yes. Starting in 2014, most U.S. citizens and legal residents will be required to obtain health coverage or pay a penalty. Some exemptions will be granted, for example, for those with religious objections of where insurance would cost more than 8% of their income. http://www.kff.org/healthreform/upload/8148.pdf
  • 5. Q2: Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare?1. No, the law will not do this2. Yes, the law will do this3. Don’t know
  • 6. Q2: Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare?No. No such panels exist. While early versions of the law did contain provisions that would allow Medicare to reimburse physicians for voluntary discussion with patient about end-of-life planning, these provisions were dropped from the final legislation. http://www.kff.org/healthreform/upload/8148.pdf
  • 7. Q3: Will the health reform law cut benefits that were previously provided to all people on Medicare?1. No, the law will not do this2. Yes, the law will do this3. Don’t know
  • 8. Q3: Will the health reform law cut benefits that were previously provided to all people on Medicare?No. The law reduces payments to the privately administered Medicare Advantage plans, but they will still be required to provide all benefits that are covered by traditional Medicare. http://www.kff.org/healthreform/upload/8148.pdf
  • 9. Q4: Will the health reform law expand the existing Medicaid program to cover low- income, uninsured adults regardless of whether they have children?1. No, the law will not do this2. Yes, the law will do this3. Don’t know
  • 10. Q4: Will the health reform law expand the existing Medicaid program to cover low-income, uninsured adults regardless of whether they have children?Yes. Medicaid will be expanded to cover nearly all individuals under age 65 with incomes up to 133% of the federal poverty level ($14,484 for an individual or $29,726 for a family of four in 2011). http://www.kff.org/healthreform/upload/8148.pdf
  • 11. Q5: Will the health reform law provide financial help to low and moderate income Americans who don’t get insurance through their jobs to help them purchase coverage? 1. No, the law will not do this 2. Yes, the law will do this 3. Don’t know
  • 12. Q5: Will the health reform law provide financial help to low and moderate income Americans who don’t get insurance through their jobs to help them purchase coverage?Yes. Individuals without access to affordable coverage who purchase coverage through the new insurance Exchanges and have incomes up to 400% of the federal poverty level will be eligible for premium tax credits based on their income. http://www.kff.org/healthreform/upload/8148.pdf
  • 13. Q6: Will the health reform law prohibit insurance companies from denying coverage because of a person’s medical history or health condition?1. No, the law will not do this2. Yes, the law will do this3. Don’t know
  • 14. Q6: Will the health reform law prohibit insurance companies from denying coverage because of a person’s medical history or health condition?Yes. Starting in 2014, all health insurers will be required to sell coverage to everyone who applies, regardless of their medical history or health status. http://www.kff.org/healthreform/upload/8148.pdf
  • 15. Q7: Will the health reform law require all businesses, even the smallest ones, to provide health insurance for their employees? 1. No, the law will not do this 2. Yes, the law will do this 3. Don’t know
  • 16. Q7: Will the health reform law require all businesses, even the smallest ones, to provide health insurance for their employees?No. The law does not require employers to provide health benefits. However, it does impose penalties. In some cases, on larger employers (those with 50 or more workers) that do not provide insurance to their workers or that provide coverage that is unaffordable. http://www.kff.org/healthreform/upload/8148.pdf
  • 17. Q8: Will the health reform law provide tax credits to small businesses that offer coverage to their employees? 1. No, the law will not do this 2. Yes, the law will do this 3. Don’t know
  • 18. Q8: Will the health reform law provide tax credits to small businesses that offer coverage to their employees?Yes. Beginning in 2010, businesses with fewer than 25 full time equivalent employees and average annual wages of less than $50,000 that pay at least half of the cost of health insurance for their employees are eligible for a tax credit. http://www.kff.org/healthreform/upload/8148.pdf
  • 19. Q9: Will the health reform law create a new government run insurance plan to be offered along with private plans?1. No, the law will not do this2. Yes, the law will do this3. Don’t know
  • 20. Q9: Will the health reform law create a new government run insurance plan to be offered along with private plans?No. The law does not create a new government-run health insurance plan. The existing Medicaid program will be expanded to cover more low- income people, government regulation of the health insurance industry will be increased, and tax credits will be provided to make private health insurance more affordable for people. http://www.kff.org/healthreform/upload/8148.pdf
  • 21. Q10: Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance? 1. No, the law will not do this 2. Yes, the law will do this 3. Don’t know
  • 22. Q10: Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance?No. Undocumented immigrants are not eligible to receive financial help from the government to buy health insurance, nor are they eligible for Medicaid or to purchase insurance with their own money in the new Exchanges. http://www.kff.org/healthreform/upload/8148.pdf
  • 23. Less than 1 percent of surveyed Americans* responded to all 10 questions correctly* Nationally representative random sample of 1207 adults ages 18 and up http://www.kff.org/healthreform/upload/8148.pdf
  • 24. Estimated changes in health coverage after health reform Individual mandate would require most people to purchase coverage MILLIONS Establishes insurance “exchanges” with standardized benefits to compare and buy plans and prohibits insurance companies from excluding anyone based on health status Provides subsidies for low- to moderate-income to purchase insurance* Expands Medicaid coverage to cover some people who don’t quality now (e.g. poor childless adults) Reduce number of uninsured by * 9 million currently uninsured would be ineligible for subsidies; illegal immigrants not eligible for subsidies or the expanded Medicaid program 32 million by 2019Source: Adamy and Weisman WSJ October 8, 2009, http://online.wsj.com/article/SB125494356104171425.html?mod=djem_jiewr_HC
  • 25. Health Reform: Perils, challenges, and wild cards  Gap period < 2014 – Republican Congress may slow down implementation  Payment and delivery system pilots & demonstrations – stakeholder concerns  State capacity and resistance to implement reforms – broke, mad, and suing feds
  • 26. Is the ACA Constitutional? Judicial scoreboard so far… Nov. 8 FOR LAW Court rules 2- 1 that individual mandate is constitutional FLORIDA + 25 STATES VIRGINIA The Supreme Court is expected to issue ACA rulings by next June on 3 issues: individual mandate, Medicaid expansion, and Anti-Injunction Act
  • 27. Health Reform: Perils, challenges, and wild cards  Gap period < 2014 – Republican Congress may slow down implementation  Payment and delivery system pilots & demonstrations – stakeholder concerns  State capacity and resistance to implement reforms – broke, mad, and suing feds  Building up primary care workforce – coverage without access?  Post “super-committee” failure and possible cuts to GME, SGR “fix,” and Medicare  2012 elections and repealing/defunding
  • 28. What’s Ahead for Rural Health under the ACA? PROBLEM ACA Rural Americans are uninsured at  Guaranteed issue and other regulation of higher rates than urban Americans insurance companies Rural Americans are sicker with  Prohibits lifetime limits on benefits and cost- higher rates of chronic illness sharing for preventive services Rural America is already  Investment in NHSC, rural physician training experiencing a health care grants; reallocation of GME slots workforce crisis  Extension of many rural programs: Rural Rural hospitals struggle financially Community Hospital Demonstration Program; because of low reimbursement Medicare Dependent Hospital Program; rates and low patient volume Payment Adjustment for Low-volume hospitals; Medicare Rural Hospital Flexibility Program; unclear if ACO demos will help/hurt Q: WILL THE MONEY BE THERE ?????
  • 29. What do Americans want? This?
  • 30. Unlike citizens in many other industrializedcountries, Americans mistrust a strong centralized authority like the federal government, preferring pluralism and individual rights
  • 31. Or This?AP Photo http://www.politico.com/news/stories/0910/42588.html
  • 32. Questions?