Obama & Biden's health reform: ACCESSIBLE HEALTH COVERAGE FOR ALL

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An introduction to USA's health reform, with a overview for the provisions and schedule.

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  • catastrophic
  • Cadillac tax: 對保險公司 23,000 以上保費加徵 40% 貨物稅
  • Federal poverty level
  • Obama & Biden's health reform: ACCESSIBLE HEALTH COVERAGE FOR ALL

    1. 1. BARACK OBAMA AND JOE BIDEN’S PLAN TO LOWER HEALTH CARE COSTS AND ENSURE AFFORDABLE, ACCESSIBLE HEALTH COVERAGE FOR ALL 電子病 期末報告歷 描述美國全民健保法 條與未來實施狀況 P97843012 魏文一 1
    2. 2. (1) INVEST IN ELECTRONIC HEALTH INFORMATION TECHNOLOGY SYSTEMS. (2) IMPROVE ACCESS TO PREVENTION AND PROVEN DISEASE MANAGEMENT PROGRAMS. (3) LOWER COSTS BY TAKING ON ANTICOMPETITIVE ACTIONS IN THE DRUG AND INSURANCE COMPANIES. (4) REDUCE COSTS OF CATASTROPHIC ILLNESSES FOR EMPLOYERS AND THEIR EMPLOYEES. 2
    3. 3. (1) GUARANTEED ELIGIBILITY. (2) NEW AFFORDABLE, ACCESSIBLE HEALTH INSURANCE OPTIONS. (3) TAX CREDITS FOR FAMILIES AND SMALL BUSINESSES. (4) EMPLOYER CONTRIBUTION. (5) REQUIRE COVERAGE OF CHILDREN. (6) EXPANSION OF MEDICAID AND SCHIP. (7) FLEXIBILITY FOR STATE PLANS. 3
    4. 4. (1) EMPLOYERS. (2) SCHOOL SYSTEMS. (3) WORKFORCE. (4) INDIVIDUALS AND FAMILIES. (5) FEDERAL, STATE, AND LOCAL GOVERNMENTS. 4
    5. 5. 描述美國全民健保法條 與未來實施狀況 5
    6. 6. 美國醫療現況 6
    7. 7. 美國醫療系統三大特色 • 全世界醫療費用最貴的國家 (GDP 16.3%(2.2trillion, $7,421 per person) in 2007) • 唯一沒有全民健保的已開發國家 ( 無保險人數達總人口 15%) • 醫療市場資本化,藥價由保險公司與藥廠 協商 7
    8. 8. 現有醫療保險體系 ( 7 成私人、 3 成公立) • 聯邦政府 • 州政府 • 私人保險( 9 成雇主、 1 成私人購買) • 無保險者:地區安全網 ( local safety net ) 收費依個人收入而定 8
    9. 9. 主管機關 -DHHS • 食品藥品監督管理局( FDA ) • 疾病控制及預防中心( CDC ) • 健康照護與品質研究機構( AHRQ ) • 國家衛生研究院( NIH ) • 醫療保險及醫療計畫補助中心( CMS ) 9
    10. 10. 聯邦政府 • 老人( 65 歲以上)健康保險制度 ( MediCare ) – Part A 住院保險 • 可免費享有 – Part B 門診保險 – Part C 額外保險 – Part D 藥費保險 (2006 年實施 ) 10
    11. 11. 州政府 • 低收入戶健康保險制度( MedicAid ) • 兒童( 14 歲以下)醫療保險制度 ( SCHIP ) • 北方福利較南方好 11
    12. 12. 私人保險 ( 9 成雇主、 1 成私人購買) • 管理式照護 (managed care) 1973 HMO act – 健康維護組織( HMO ) • 主動管理,保費較低 • PCP 家庭醫師制度( Primary care physician ) – 優先醫療機構計畫( PPO ) • 特約制、自付費用低 – 獨立醫療執業組織( IPA ) • 醫療儲蓄帳戶( health saving account ) 12
    13. 13. 無保險者:地區安全網 ( local safety net ) • 收費依個人收入而定 • 社區健康中心 • 公立醫院 • 社區醫院 • 慈善門診 13
    14. 14. 衛生及公共服務部( DHHS ) • 食品藥品監督管理局( FDA ) • 醫療保險及醫療計畫補助中心( CMS ) • 國家衛生研究院( NIH ) • 健康照護與品質研究機構( AHRQ ) • 疾病控制及預防中心( CDC ) 14
    15. 15. 公共衛生概況 • 平均餘命( 2008 ) – 男: 78.14 歲 – 女: 83.13 歲 • 成人慢性病盛行( 20 年變化) – 肥胖與體重過重( 22% to 32% ) – 糖尿病 ( 成長 20%) – 高血壓 ( 成長 7%) • 死亡 – 心臟病與惡性腫瘤佔 50% – 黑人死亡率 > 白人死亡率 15
    16. 16. 美國民 費用支付習慣眾 16
    17. 17. 各年齡層就醫次數 17
    18. 18. 為何執行 Health Reform? 18
    19. 19. 美國醫療三大問題 • 醫療費用昂貴 • 無醫藥保險比例過高 • 低效率,高管理費 19
    20. 20. 經濟危機 • 2018 年時總醫療費用可能佔 GDP 的 20.3% 20
    21. 21. MediCare 與 MedicAid 的支出龐 大 • Medicaid 佔州預算 32% • Medicare 較不顯著 21
    22. 22. 美國無保險人口 22
    23. 23. OBAMA 的全民健保 23
    24. 24. HEARA: The Healt hcare and Educat ion Af f ordabilit y Reconciliat ion Act of 2010 • contained tax and budget related changes to the PPACA • passed through reconciliation process 24
    25. 25. • Health insurance market reform • Health insurance market exchanges • MEDICAID and CHIP • Medicare • Workforce and other provisions PPACA: Pat ient Prot ect and Af f ordable Care Act (1) 25
    26. 26. • Health insurance market reform : (1) – High-Risk Health Insurance Pool Program – Health insurance for young adults – Pre-existing medical conditions – Lifetime and annual limits on benefits – Community living assistance services and support program (CLASS act) PPACA: Pat ient Prot ect and Af f ordable Care Act (2) 26
    27. 27. • Health insurance market reform: (2) – Individual responsibility – Employer responsibility – Excise tax on health insurers PPACA: Pat ient Prot ect and Af f ordable Care Act (3) 27
    28. 28. • Health insurance market exchanges: – Health insurance exchanges – Premium assistance credits, caps on out-of- pocket costs for health plans – Health care choice compacts PPACA: Pat ient Prot ect and Af f ordable Care Act (4) 28
    29. 29. • MEDICAID and CHIP: – Medicaid expansion – CHIP – Medicaid medical home pilot – Medicaid emergency psychiatric demonstration – Medicaid community-based services – Medicaid accountable care organization pilot program PPACA: Pat ient Prot ect and Af f ordable Care Act (5) 29
    30. 30. PPACA: Pat ient Prot ect and Af f ordable Care Act (6) • Medicare: – Specialized Medicare advantage plans for special needs individuals – Medicare Part D – Medicare medical home pilot program – Medicare accountable care organization 30
    31. 31. PPACA: Pat ient Prot ect and Af f ordable Care Act (7) • Workforce and other provisions: (1) – Co-location of primary and specialty care in community-based behavioral health settings – National health service corps – Training for behavioral health professionals – Loan repayment for pediatric behavioral health specialists in underserved areas 31
    32. 32. PPACA: Pat ient Prot ect and Af f ordable Care Act (8) • Workforce and other provisions: (2) – Educating primary care providers about behavioral health – Community transformation grants – Community health workforce grants – National health care workforce commission – Federal definition of community mental health centers 32
    33. 33. The Promise • All Americans guaranteed affordable, high quality healthcare • The freedom to choose whatever doctor or health plan you want • all that a savings of some $2,500 per family 33
    34. 34. Feat ures • individual mandate • sufficient coverage • elimination of underwriting • tax equity, subsidy (indiv vs group) • public plan to compete • emphasis on prevention and wellness • elimination of waste • electronic data keeping • comparative effectiveness 34
    35. 35. I mpact on st akeholders-1 • Employer – Eliminate and reduce the favored tax of healthcare expense ($194.2B a year) – less control over plan designs offered to employees • Carriers – Competition from ''public plan'' – inability to underwrite – increased regulation – shift to individual policies 35
    36. 36. I mpact on st akeholders-2 • TPAs (Third party administration) – potential loss of FSA( 財務監管局 )/HRA(Health reimbursement account) admin – potential gain of FSA substitution – shift from groups to individuals • Broker and agents – Competition from connectors – shift to individual market – relief from underwriting 36
    37. 37. I mpact on st akeholders-3 • individuals – requirement to purchase insurance – Tax credits and subsidy – Reduced the tax advantage of HSAs, FSAs and itemized deduction of medical expense – New ''sin taxes'' on products such as alcohol and sugary soft drinks 37
    38. 38. I mpact on st akeholders-4 • providers – Reduced Medicare spending on home healthcare, durable medical equipment, medical imaging and prescription drugs – increased demand for services, especially primary care – 5% bonus payment for office visits and other ''primary care services'' – Medicare 38
    39. 39. Medicare policies • increase payments to doctors who regularly exceed ''national benchmarks'' for the quality of care • Bonuses to hospitals that provide superior care for heart attack, pneumonia and selected other conditions • Doctors could receive extra payments if they hire nurses to manage follow-up care for chronic cases 39
    40. 40. Medicare policies • Government set national standards for the appropriate use of CT scans, MRI and other diagnostic imaging techniques • Make single bundled payment for all services provided to a hospital patient. (Bad for nursing homes, home care, hospice, etc.) 40
    41. 41. I mpact on st akeholders-5 • Pharmaceuticals – Reduce government spending on prescription drugs – Re-importation of drugs from other countries to lower costs – Shift insurance coverage toward prevention, could increase sales for heart, diabetes and other drugs that patients take long-term – Increased Rx spend by $15~$18B 41
    42. 42. I mpact on st akeholders-6 • Wellness – Tax credits or other subsidies it employers who offer wellness programs that meet federal criteria – Make it easier for employers to use financial rewards or penalties to promote healthy behavior among employees 42
    43. 43. I mpact on st akeholders-7 • Health IT providers – $20B in Stimulus money – Electronic Health Records • Marketing communications – Need to communicate new programs • Benefits attorneys – Need to interpret new regulations 43
    44. 44. 期待 • additional information and guidance from the DHHS, Congress, IRS, insurance industry • Repeal and replace • Reduce costs • Will employers eliminate coverage when the Exchanges are implemented? • What happens in 2018 when the Cadillac Tax become effective? 44
    45. 45. 未來實施時程規劃 45
    46. 46. Early implement at ion • Small business tax credits • Temporary retiree medical reinsurance pool to help employers lower costs for early retirees (2010~2014) • insurance market reforms • 10% excise tax on indoor tanning services (July1) • Health & Human Services (HHS) to develop informational website portal (July1) • Relief begins for retirees in the Medicare Part D coverage gap ''donut hole'' 46
    47. 47. Six mont hs af t er enact ment • eliminate lifetime limits and annual limit restrictions • eliminate pre-existing condition limitations for children • expand dependent coverage • cover preventive care • require nondiscrimination testing • New coverage appeals processes • emergency services must be covered as in-network services • designate any in-network doctor as a primary care physician 47
    48. 48. 2011 • spending account restrictions • new W-2 reporting requirements • CLASS Act (Community Living Assistance Services and Supports Act) • Uniform standards developed by HHS for communicating benefit provisions 48
    49. 49. 2012 & 2013 • implement uniform standards for communicating benefit information with $1000 fine for each failure • Salary reduction to FSAs are limited to $2,500, with annual index (2013) • Employers must notify employees plan benefits and Exchanges • Annual comparative effectiveness research fee of $2 per member assessed on fully insured plans • Individuals with earnings greater than $200,000 and households with earnings greater than $250,000 subject to additional taxes • eliminate the tax reduction for employers who receive Medicare D retiree drug subsidy payments • New taxes on the industry providers and manufactures 49
    50. 50. 2014 • Requires U.S. citizens and legal residents to have insurance or pay penalty • State based Exchanges established for individuals and small groups to purchase coverage with required benefit plans being offered • Employers with 50+ employees are required to coverage or pay a penalty • minimum essential benefits must be offered to individuals and small groups outside the exchange- Grandfathered and large employers plans are exempt • Premium and cost sharing credits for low-income individuals (up to 400% of FPL) • Employers with 200+ employees must automatically enroll employees (out-put) • Maximum waiting period limited to 90 days 50
    51. 51. Beyond 2014 • Insurance industry taxes begin which impact fully insured plans • eliminate pre-existing condition limitations and annual limits • Cadillac Tax becomes effective in 2018 51
    52. 52. 待釐清問題 52
    53. 53. 53
    54. 54. 54
    55. 55. Thank youThank you 55

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