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ACA: A Step Toward Healthcare For All (Dr. John Cavacece, DO)
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ACA: A Step Toward Healthcare For All (Dr. John Cavacece, DO)


Presented to the American Medical Student Association ( at Michigan State University's College of Human Medicine (MSU CHM) on Tuesday, March 20, 2012

Presented to the American Medical Student Association ( at Michigan State University's College of Human Medicine (MSU CHM) on Tuesday, March 20, 2012

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  • At approximately $8,000 per capita, the U.S. system is the most expensive in the world.   The second most expensive medical system per capita is Norway which insures all citizens in a universal, tax-funded, single-payer health system. Norwegian medical system even covers sick days and spa treatments.   Our Big Three auto makers are at an enormous competitive disadvantage against competitors in countries like Japan ($2,700 per capita) that don’t have to include health benefit costs in the price of their product.
  • The U.S. has the most inefficient healthcare model, by far, in the world According to the World Health Organization, the U.S. ranks 37 th in health systems behind Malta, Cyprus & Costa Rica. The WHO report examines and compares aspects of health systems around the world. It provides conceptual insights into the complex factors that explain how health systems perform, and offers practical advice on how to assess performance and achieve improvements with available resources. This report asserts that the differing degrees of efficiency with which health systems organize and finance themselves, and react to the needs of their populations, explain much of the widening gap in death rates between the rich and poor, in countries and between countries, around the world. Even among countries with similar income levels, there are unacceptably large variations in health outcomes. The report finds that inequalities in life expectancy persist, and are strongly associated with socioeconomic class, even in countries that enjoy an average of quite good health. Furthermore the gap between rich and poor widens when life expectancy is divided into years in good health and years of disability. In effect, the poor not only have shorter lives than the non-poor, a bigger part of their lifetime is surrendered to disability
  • Premium rates went up 76.5 %, while household income went up 5.9% The average family's premium for employer-provided insurance in the state jumped from $6,817 in 2000 to $12,034 in 2009, an increase of 76.5 percent. But median income of Michigan workers rose just 5.9 percent in the period, from $25,910 in 2000 to $27,450 this year. The majority of the uninsured are in working households.  In the uninsured population, 61.6 percent are in families headed by a full‐time or part‐time employee that works the entire year.  Only 21.9 percent of the uninsured are in families headed by non‐workers.  Individuals in families headed by full‐year workers who have experienced periods of unemployment during the year are most likely to be uninsured at 23.5 percent, followed closely by those in families headed by non‐workers at 22.3 percent.  Individuals in families headed by full‐time workers are least likely to be uninsured at 9.3 percent
  • This is just intended as a fun way to kick off a conversation on what the ACA actually does. Ask them to raise their hands if they already knew that members of Congress would have to accept the same insurance as the rest of us (very few will raise their hand) by being required to select their family coverage from available products in their state’s healthcare exchange. Then ask them to raise their hands if they heard about the death panel myth (most will). Have fun comparing and contrasting how many people have heard lies about the ACA, rather than the facts.
  • For Background; Modernizing the system will be by: Encourage widespread adoption and meaningful use of  health information technology  through incentives, grants, and technical assistance; Endorse the active participation of consumers in accessing and engaging with their health information; Inspire confidence and trust in health information technology by ensuring the  privacy and security  of electronic health information; Encourage innovation; support pilots that demonstrate health IT-enabled reform; and develop policies, standards, and services that will enable the appropriate re-use of information to support quality, public health, and research; Support and promote use of telehealth to provide access to modern technology and healthcare specialty resources for tribal, rural, and other underserved communities; Explore the use of mobile technology to provide timely and culturally appropriate health information to vulnerable and hard-to-reach populations; and Enhance communication and support a public awareness campaign  about the value of health information technology for outreach to all healthcare stakeholders, including providers, payers, and consumers of care. Develop and implement  a public awareness campaign  public about the basics, benefits, and privacy implications of health information technology for multiple audiences, including healthcare providers, other professionals, and patients and families. ACA requires HHS to modernize the computer and data systems of the Centers for Medicare & Medicaid Services
  • Insurance companies can’t drop your coverage because you get sick. Insurance companies won’t be able to charge higher premiums because of pre-existing conditions, gender, or occupation, and there will be a limit on how much they can charge based on age. Ask How many would like to be turned down for something like asthma?
  • The law requires an “Essential Health Benefits” or EHB which will essentially provide a floor of benefits that all health insurance plans must offer. Any plan sold inside or outside the Exchange must include this essential package of services.   Each state must decide for itself what will be in their EHB but the federal government has provided guidelines.
  • The prohibitions against lifetime limits took effect in 2011. No annual limits allowed by 2014. Out of pocket caps for consumers: set at current HAS limits, $5,950 for individuals and $11,900 for families
  • “ An Exchange is where individuals and small businesses pool themselves together to create economies of scale and thereby help drive down costs.” People got very confused about the “Health Insurance Exchange.” They got it mixed up with the “public option.” Some folks called it “socialism.” A health insurance exchange is a marketplace where the insurance companies have to provide plans that follow the new rules. They had to have the essential benefits package, can’t charge more in premiums because we are women or because we have preexisting conditions. They can’t have annual caps on what they will pay, etc. The only insurance plans allowed in the exchange are those that follow the new rules. Also [read slide]
  • Refundable and advance-able
  • Eliminates deductibles and co-payments for preventive care , provides free annual wellness checkups (2011) Improves quality of care by creating incentives to reward providers that meet quality goals (2011) Extends the viability of the Medicare program for an additional 9 years (to 2026). Medication Coverage (Medicare Part D Prescription Drug Coverage): - Provides a $250 rebate for “Donut Hole” for one year in 2010. Discounts increase until the donut hole is gone in 2020. The established Medicare Part D Co-pay still applies after 2020. - Provides discounts up to 50% for drug prices in 2011. The donut hole refunds begin June 15 this year and continue every month to people who hit the donut hole. Participants do NOT need to fill out any forms. Be vigilant against con artists asking for personal information and report any incidents to 800-MEDICARE.
  • The Community First Choice Act is a state option. The states do get an enhanced federal match (an increase of 6 percentage points). Income eligibility can go up to 150% of FPL. The systems design includes a requirement that individual/representative select, manage and dismiss workers. Services are controlled “to the maximum extent possible” by the individual/representative regardless of employer of record.
  • 2010 Tax credits of 35% of the premium will be available to businesses with fewer than 25 employees and average wages less than $50,000. (Increases to 50% by 2011.) 2014 Small businesses will be able to purchase coverage in the Exchange as part of a large pool and the tax credit will increase.
  • Bonuses for services furnished by primary care physicians; higher bonuses for practice in underserved areas (2011) Increases Medicaid reimbursement to equal Medicare rates for primary care providers (2013) Cuts bureaucracy by simplifying and standardizing paperwork (2013) Invests in outcome research (2013) and primary care models (2012) Increases National Health Service Corps funding (2010) Increases scholarships and loan repayment programs (2010)
  • 2010: For new plans, no out-of-pocket costs for preventive care: mammograms, immunizations, and screenings for cancer and diabetes. 2012: Contraceptive care to be included as preventive care with no out-of-pocket cost. 2014: No more “gender rating.” An insurer will no longer be able to charge women more than men for the same coverage. Insurance companies will no longer be able to deny coverage due to a pre-existing condition such as: breast or cervical cancer, pregnancy or C-section domestic abuse
  • We should include some Michigan Specific numbers here.
  • You can insert you own organizations information on this slide as well.
  • These slides from here on out are only to be shown if people have questions about these programs and need additional resources.
  • MCH is Foundation funded and non-partisan Some of the coalition members include: AARP Adult Well Being Services Albion Volunteer Service Organization American Cancer Society, Great Lakes Division American Heart Association American Indian Health and Family Services  The Arc of Livingston County The Arc of Muskegon Area Agencies on Aging Association of Michigan Baraga County Regional Interagency Consumer Committee Bethlehem Temple Church Outreach Bridging Communities Capital Area Center for Independent Living Center for Collaborative Leadership in Healthcare Center for Civil Justice Central Michigan Health Department Chadsey Condon Community Organization Citizens for Better Care Community Health Care Connections Community Living Services, Inc. Corinthian Baptist Church Detroit Wayne County Health Authority DETIPTV Disability Advocates of Kent County Disability Network/Michigan Disability Network of Mid-Michigan Downriver Marriage Resource Center Empower Outreach (Teach 4 Impact) Epilepsy Council of West Michigan The Ezekiel Project Free Clinics of Michigan Grand Rapids African American Health Institute Greater Detroit Area Health Council Greater Lansing African American Health Institute Health Disparities Program, American Cancer Society Healthy Asian American Project Healthy Neighborhoods Detroit The HUDA Clinic (Health Unit on Davison Ave) Ingham County Health Department  Interfaith Health/Hope Coalition ISAAC Disability Network of Mid-Michigan JONAH Kalamazoo County Health Plan Kent Regional Interagency Consumer Committee Lansing Latino Health Alliance L&S Associates, Inc . League of Women Voters of Michigan Legal Services of South Central Michigan Medical Care Access Coalition Micah Center Mid Michigan District Health Department MI Voice/Gamaliel of Michigan Michigan AFSCME Council 25 Michigan Campaign for Quality Care Michigan Catholics for the Common Good Michigan Council for Maternal and Child Health Michigan County Health Plan Association Michigan Developmental Disabilities Council Michigan Disability Rights Coalition Michigan League for Human Services Michigan Legal Services Michigan Minority Health Coalition Michigan Poverty Law Program Michigan Primary Care Association Michigan Primary Care Consortium Michigan Protection and Advocacy Service Inc. Michigan Public Health Association Michigan Unitarian Universalist Social Justice Network MichUHCAN MOSES Muslim Family Services Mustard Seed Shelter Muskegon Regional Interagncy Consumer Committee National Multiple Sclerosis Society, Michigan Chapter Network 180 NJS & Associates Northern Michigan Plan NorthWest Initiative Occupational Planning and Placement Inc. People for a Healthy Muskegon PHI (formerly Paraprofessional Healthcare Institute) Plymouth Congregational United Church of Christ SEIU Healthcare Michigan School Community Health Alliance of Michigan Social Justice Area Team, United Church of Christ  So What? Planning and Evaluation Sunrise Ministries Susan G Komen Detroit Race for the Cure TENCON Health Plan Traverse Health Clinic True Love Missionary Baptist Church The ARC - Kent County The Disability Network (Flint) United Cerebral Palsy of Michigan Urban Health Resource/Urban Health Outreach,LLC Urban League of Battle Creek Washtenaw County Health Plan Wayne County Metro Community Action Agency We Are The People Western U.P. Healthcare Access Coalition World Medical Relief
  • The “father” of the individual mandate is a conservative economist and former policy advisor to former President George Bush Sr. Pauly urged Republicans, as far back as the early 90s, to develop a market-based alternative to the single payer system (e.g. Canadian model) where the government pays for healthcare rather than individuals and private insurance. Pauly argued that if conservatives didn’t develop a market-based alternative, a single payer system in America would become inevitable. Was he right? When Democrats took control of Congress and the White House the existence of functional, market-based model in Massachusetts prevented a focus on a single-payer model.
  • The ultra-conservative Heritage Foundation was one of the leading early advocates for an individual mandate that would require “heads of households” to purchase insurance. The called for a “social contract” where government would make private health insurance more affordable in exchange for mandating “by law” that individuals purchase insurance. Many conservative leaders have previously expressed strong support for the individual mandate concept as an alternative to the Canadian style single payer system. It is only after a Democratic controlled Congress adopted the model that leading conservative leaders began to reverse themselves. Just recently former Massachusetts Governor and GOP Presidential nominee Mitt Romney reiterated that the individual mandate is a “fundamentally conservative principle.”
  • 60% of those individuals buying insurance on the exchange had no previous insurance Premium costs went down an average of 18% on the state’s individual market exchange. Some policies went down as much as 40% within the individual market.
  • Establishes demonstration programs to promote new, innovative models of healthcare which are tribally-driven Directs the IHS to establish comprehensive behavioral health, prevention and treatment programs for Native Americans.
  • The healthcare reform bill would mandate that most US citizens and legal residents purchase “minimal essential coverage” for themselves and their dependents. They can get this either through their employer, or, if their employer doesn’t offer health insurance, they can buy it through new marketplaces that will sell policies to individuals. Those marketplaces would be called “exchanges.” We’ll talk more about them in a later story. (We’ll also cover subsidies for health insurance, when it all would take effect, how it would be paid for, and what it means for businesses.) Exemptions are not yet fully defined but will include: People with religious objections Undocumented immigrants cannot participate in the ACA at all Financial Hardship (to be defined through regulation) Native Americans who participate in the Bureau of Indian Affair’s Health Service People who make so little they do not have to file taxes People who would have to pay over 8% of family income for health coverage
  • The ACA: $5 billion to employers who continue to cover early retirees (2010) State-based Health Exchanges so those who retire early can purchase affordable health insurance (2014) Access to free preventative services (2010) Limitations on your out-of-pocket expenses Prohibits insurance companies from denying coverage or charging more based on a person’s medical history (2014) . Limits what an insurance company can charge based on age (2010) Prohibits lifetime limits on coverage, and regulates the use of annual limits until 2014 (when annual limits are prohibited)


  • 1. Affordable Care Act: A Step TowardHealthcare for All.
  • 2. We have the best healthcare in the world! Right?
  • 3. The Problem• Most expensive health care in the world. – >$2 trillion/yr. (17% of GDP) – >$8 thousand per capita/yr.• Double any other nation.• 50 million or more have no health coverage.• >80 million are underinsured.• Health care quality in US lower than most other developed countries.
  • 4. Administrators Physicians2500%2000%1500%1000%500% 0% 1970 1975 1980 1985 1990 1995 2000
  • 5. U.S. Spending on Healthcare Each Year U.S. $8,000 Norway $5,000 Canada $4,000 U.K. Japan $3,000 $2,700 Spending per capita/per year on health care
  • 6. What do we get out of our investment?
  • 7. Problem of Access: A Moral Issue• Census data: 50.4 Million Americans without health insurance.• Estimated 50 thousand deaths per year attributable to lack of insurance!• Will diminish over next 9 years to estimated 23 million without insurance.• Therefore, only 23 thousand unnecessary deaths due to lack of insurance.
  • 8. Is this the best we can do?1.3 million Michiganders have Michigan workers family no healthcare coverage. health care premiums rose 13 times faster than earnings. 50.7 million Americans have no health insurance and no access to a family physician.
  • 9. Moral and Practical• WHO statistics- U.S. 54/191 in world for “fairness” in providing access to care (slightly ahead of Rwanda).• Patients with curable diseases go untreated until too late>> costs everyone more.• Lack of coverage or affordability for basic preventive health care.• Patients end up requiring more expensive life saving care.
  • 10. Quality of Care• “Avoidable mortality”- deaths before age 75 from conditions that are treatable with effective care. – U.S. ranks dead last of 19 developed countries. – Twice as many deaths from curable disease before age 75 than France, Japan, and Spain.• “Healthy life expectancy at age 60”- last of 23 developed nations.• Infant mortality- last of 23 nations.
  • 11. Patient Protection and Affordable Care Act• Individual Mandate – By 2014, all are required to purchase health insurance. – $695 penalty if not done, maximum $2085 per family. – Also if cost of plan exceeds 8% of income, won’t be required to buy. – Problem: Forces people to choose from group of ineffective plans.
  • 12. “Did you Know?” Quiz• All members of Congress must buy their insurance from their state’s healthcare exchange. • How many of you knew that?• Medical Loss Ratio: 20/80 – 80 cents out of every dollar in premiums must be paid out for policyholders medical care. – If the full 80% is not paid out for medical care, the insurance company must send you a refund check every year. • How many of you knew that?
  • 13. Health care legislation is designed to:• Reduce health care cost growth for families, employers and the government.• Provide Americans access to affordable quality health coverage.• Strengthen and protect Medicare and Medicaid.• Modernize our health care delivery system.
  • 14. Here’s how…
  • 15. Security and Control • Insurance companies won’t be able to turn people down because of pre-existing conditions. • This took effect in 2010 for children and in 2014 for everyone.
  • 16. Essential Health Benefits CoveragePreventive care Habilitation services Hospitals Physicians Substance abuse Prescription drugs Dental and vision care for childrenMental healthRehabilitation Maternity care
  • 17. Financial Protections• No annual or lifetime limits• Spending caps will limit the amount consumers pay out of pocket each year.• Insurance companies have to spend at least 80-85% of premiums on medical care.• Eligible for tax credits• Insurers must justify premium increases
  • 18. Easier to Buy Insurance• New Insurance Exchanges allow people to compare plans, apples to apples• The ACA limits insurance company overhead costs (administrative and marketing) so more of our premiums go to our health care• Allows individuals and small businesses to get better rates because they are in a bigger pool
  • 19. Moderate-Income Americans• Families and individuals will receive tax credits to help pay for health insurance, depending upon income.• Tax credits will be available to families earning between 133-400% of the Federal Poverty Level ($29,327-88,200 for a family of four).• Tax credits are designed to keep premium costs between 2%-8% of income, on a sliding scale.
  • 20. Medicare • Closes the “donut hole” in drug coverage and lowers cost of brand name drugs • Provides incentives for better coordinated care and use of evidence based medicine
  • 21. Medicare• No co-pays for preventive services in 2011• Medicare Advantage plans cannot charge higher co-pays than traditional Medicare.• Enhanced payments for primary care physicians and general surgeons• Medicare Trust Fund solvency is extended by 9 years
  • 22. Caretakers and Young Adults People in the sandwich generation and caretakers will have guaranteed coverage and affordable choices. Young adults can stay on their parents plans until age 26.
  • 23. Nursing HomesElder Justice Act: – Authorizes new criminal background checks on long-term care workers – Requires better information about the quality of nursing care and improves complaint process.
  • 24. Home and Community-Based ServicesThe Community First Choice option that allows states to make community-based servicesmandatory. There are no cost caps or waiting list restrictions.
  • 25. Small Businesses• Premium subsidies to employers Employers with up to 25 employees and annual wages that average less than $50,000 who purchase health care for their employees get a tax credit• Affordable choices Employees of small businesses may purchase insurance through the Exchange
  • 26. Health Care Workforce• The ACA will provide loan repayments and scholarships for students who work in underserved areas.• The ACA gives grants to health programs at colleges and universities to increase the racial diversity of the health-care workforce.
  • 27. Womennsurance companies will no longer be able to denycoverage due to a pre-existing condition such as: – Breast or cervical cancer – Pregnancy or C-section – Domestic abusen insurer will no longer beble to charge women morehan men for the same coverage.
  • 28. Expand State Health Insurance Programs• State health insurance programs under Medicaid will cover all families and individuals with incomes up to 133% of the Federal Poverty Level – $24,348 for a family of three.• For the first time ever, childless adults without a disability can qualify for Medicaid.
  • 29. Expansion of Public Programs• 133% of federal poverty level (14K for individual, 29K for family of four).• Eliminates limitation of Medicaid for adults w/o dependent children.• If income above 133%, can obtain coverage thru health insurance Exchanges.• Medicaid payments to primary care doctors will be increased to 100% of Medicare payment.• Problem: program will still miss millions.
  • 30. Prevention and Wellness• No deductibles or copayments for preventive services.• Grants for community wellness programs• National standards for restaurant nutrition labeling• Incentives for doctors to improve patients’ health
  • 31. Children• Insurance companies can’t deny children insurance because of a pre-existing condition (will also apply to adults in 2014)• No yearly or lifetime limits on coverage• No co-pays for preventive care• All insurance plans will cover kids’ dental and vision care• Young adults can stay on their parents’ plan until age 26
  • 32. People with Medical Conditions• People with a disability or mental illness can work part-time and still qualify for Medicaid.• Mental health parity – mental health care must be covered just like physical health care.• Insurance companies won’t be able to refuse or charge more to cover people with pre-existing conditions.• A new, temporary high-risk pool will help people with pre-existing conditions gain immediate access to insurance, HIP MICHIGAN.
  • 33. Delivery System Doctor incentives for better coordinated care Pilot projects in evidence-based medicineEnhanced payments for primary care physicians and general surgeons
  • 34. Patients and Doctors Have Control• Insurance plans will have to cover essential services: preventive care, hospitals, physicians, prescription drugs, mental health, substance abuse, dental and vision care for children, maternity care, and other services.• Clear appeals process if your claim is denied
  • 35. Sounds great – but how do we pay for it?
  • 36. How is it paid for?• Multiple funding mechanisms are built into the Legislation. ACA does NOT add to the deficit! – Congressional Budget Office: $143 Billion in Savings this decade.• Examples of funding mechanisms: – $2,000 per employee fines for large businesses (50+ employees) who do not provide insurance for workers – Higher taxes will be imposed on those earning more than $200,000 individual/$250,000 couple – Medicare Advantage plans will be reimbursed at the regular Medicare rate
  • 37. Shared Responsibility Costs and responsibilities are shared among state and federal government, businesses and individuals
  • 38. Shared ResponsibilityFederal Government• Pays for 100 percent of Medicaid expansion from 2014-2016• Pays for 90-95 percent of Medicaid expansion in 2017 and beyond• Shares in cost of tax credits and premium subsidies
  • 39. Shared ResponsibilityIndividuals• U.S. citizens and legal residents must purchase health insurance or pay a penalty• Penalties are phased in for those who do not• Exemptions granted for financial hardship, religious objections, those without coverage for less than 3 months, undocumented workers, incarcerated individuals, or if the lowest cost plan exceeds 8% of income• Tax changes for some high-income individuals
  • 40. Shared ResponsibilityBusinesses• Large employers (50+ employees) may have to pay a penalty if they do not provide coverage and one or more of their employees receives an insurance premium subsidy.• Taxes on insurance companies that offer very high cost plans• Fees or taxes on producers of some medical equipment and pharmaceuticals
  • 41. NOW WHAT???
  • 42. Answer-Medicare for All• Simple and efficient.• The most fiscally responsible option.• Releases employers from worry of health insurance.• All are covered.
  • 43. Medicare for All• Patients have free choice of doctor and hospital.• Publicly funded, privately distributed.• We already fund 60% of total costs with tax dollars.
  • 44. Myths• Single payer means “Socialized Medicine” – FALSE!! – Social insurance like Medicare.• Canadians dislike their system. 88% of Canadians would choose to keep their present system.• Insured pay more to cover uninsured. Opposite is true, besides we already pay more
  • 45. Myths about Single payer• “Market” is the solution. Private better than public. – Not in health care!• We can’t afford it! Actually, would be much less costly.• Innovation would suffer, longer waits for procedures. – Equal number patents per capita in other nations.• Government can’t do anything right! Gross generalization.
  • 46. Who Wants It• Public (>2/3)• Business- makes much more sense. No need to cover employees, therefore, more competitive in market.• Labor- would be free to negotiate for wage increases.• Physicians, nurses, etc. (59% of physicians)
  • 47. Who Doesn’t Want It• Health Insurance Companies- would lose obscene profits and would have to restructure (auto industry?).• Pharmaceutical companies- become unable to charge outrageous prices for meds (one customer).• AMA- not on board yet.
  • 48. Health Care Bill: A Fair Process?• Health Care Industry spent $1.4 million per day lobbying. (6 lobbyists per member of Congress)• 50 are former employees of the Senate Finance Committee and Chairman, Max Baucus (D-MT)• Baucus received $1,434,625 from health care and insurance companies for barely contested race.• $13 million of contributions from health care sector to 23 members of finance committee.
  • 49. What You Can DoJoin MCH’s email list, find us on Twitter @MIChealthcare or Use the Legislative Action Center at Visit
  • 51. So how do I Apply for the Pre-existing Condition Program (PCIP). .• You must have a pre-existing condition.• You must have been uninsured for 6 months.• You must provide: – Proof of US citizenship and Michigan residency – Letter from a physician (issued in the last 6 months) that you have a qualifying condition, OR – Denial letter stating that, for health reasons, you were denied coverage in the last six months• Qualifying conditions are listed at• To apply, contact PHP of Mid-Michigan at 877-459-3113 or• 51
  • 52. How do I apply for...MEDICAID:• Contact “Michigan Enrolls” at 1-888-367-6557• Fill out form and print online from:• Contact your local DHS officeMiChild, Healthy Kids, Plan First and MOMS:• Online at• Call 1-888-988-6300• Health Departments• Some Federally Qualified Health Centers (FQHCs)• Contact your local DHS office 52
  • 53. How do I apply for Medicare?Contact the Michigan Medicare/Medicaid Assistance Program at, or 1-800-803-7174 53
  • 54. How do I apply for MiRx?• Online at or 1-866-755-6479• The MiRx (My Prescription) Card is a prescription drug discount program for Michigan residents who do not have any prescription drug coverage.• The MiRx Card program is free. Card holders take their prescription and their MiRx card to a local participating pharmacy. Card holders are charged the MiRx discounted price for any medicine the pharmacist stocks and your doctor prescribes.• Over-the-counter drugs are not covered even if they are prescribed by your doctor. 54
  • 55. Small Business Tax Credit• Employers with fewer than 25 full-time employees and pay wages averaging less than $50,000 per employee per year may qualify.• Employers with more than 25 employees may also qualify if some of their workers are part-time.• Small businesses can claim the credit as part of the general business credit starting with the 2010 income tax return they file in 2011.• To find out more, visit 55
  • 56. How do I use the health insurance exchange? Exchanges will not be active until 2014. Visit for more information.How do I check the quality of my hospital? 56
  • 57. Health Care Reform:Understanding the Affordable Care Act What’s really in the new law? Presented by: Michigan Consumers for Healthcare
  • 58. Michigan Consumers for Healthcare• Working collaboratively with a diverse alliance of consumers, partners and policymakers to attain affordable, accessible, quality healthcare for all Michiganders• Foundation funded and non-partisan.
  • 59. Consumer Input Key to Meeting Consumer Needs • Bringing the consumer voice to health care reform in Michigan. • Partnering with policymakers and a diverse coalition. • Education, outreach and advocacy.
  • 60. “We did it because we were concerned about the specter ofsingle payer insurance, which isn’t market-oriented, and we didn’t think was a good idea.” ― Mark Pauly, Policy Advisor to President George H. W. Bush
  • 61. The Heritage Foundation was one of the strongest earlybackers of an individual mandate The “central element in the Heritage proposal is a two-way commitment between government and citizens. Under this ‘social contract’ the federal government would agree to make it financially possible… for every American family to purchase at least a back package of medical care including catastrophic insurance. In return, government would require, by law, every head of household acquire at least a basic health plan for his or her family.”
  • 62. About the Massachusetts Model… • There has been a lot said about the Massachusetts model- some true, much false. • Finding a reliable source for data can be a challenge • We use
  • 63. The Facts According to• 98.1 percent of the citizens of Massachusetts now have healthcare coverage (contrasted with a national uninsured rate of 15.4%)• “Any way you want to look at it, premium costs went down.”• 60% of those individuals buying insurance on the exchange had no previous insurance
  • 64. Native AmericansThe ACA permanently authorizes the Indian Health Care Improvement Act and:• Improves access to health care for the 1.9 million Native Americans served by the Indian Health Services.• Updates the Indian Health Service scholarship program.• Authorizes the transfer of funds and equipment for use in the construction or operation of Indian Health Service (IHS) funded facilities. 66
  • 65. Legal Immigrants Legal immigrants are eligible for: • Purchasing health insurance from the state Exchanges (2014) with no waiting periods. • Premium tax credits, cost-sharing reductions, temporary high-risk pools and “basic health plans” offered by a state. 67
  • 66. Private Insurance Company Restrictions• Prohibits denial of coverage for health status, gender, etc.• Must have minimum set of services, caps on oop spending, no cost sharing for preventive care, no lifetime limits.• Cannot rescind coverage except in cases of fraud.• Young adults stay on parents coverage till age 26.• Existing plans remain the same except for above exceptions.• Problems: Allows for insurance industry creativity to find ways to deny coverage (fraud investigations will increase, ways to maintain profit margin, etc.)
  • 67. Employer Requirements• Employers with >50 employees assessed a fee of $2000/employee if they do not offer coverage.• Must supply voucher to employees < 400% poverty income to enable them to enroll in an Exchange.• Employers offering free choice vouchers, will not be subject to above penalty.• Must automatically enroll employees in lowest premium plan in employee doesn’t sign up.• Problem: May incentivize employers to pay penalties and not offer coverage if less expensive.
  • 68. Health Benefit Exchanges• U.S. citizens, legal immigrants, small businesses with <100 employees eligible.• Have to offer multi-state plans and at least one non-profit entity.• Premium subsidies provided for families 133%-400% of the poverty level (will have limits to cost of premiums).• Problems: No public option, adds more complexity to an overly complex system.
  • 69. Reasons for High costs• Management of health insurance – “medical loss”,marketing, administration, profit. – 20-30% of health care expenditures.• Complexity of system- hundreds of different plans (no one else like this).• Unnecessary care- xrays, lab, procedures.• Malpractice• Medical education.
  • 70. Individual MandateThe healthcare reform bill mandates that mostUS citizens and legal residents purchase“minimal essential coverage” for themselvesand their dependents if they can afford it.
  • 71. Early Retirees Federal funds are currently available to helpbusinesses afford the cost of health insurance for early retirees (ages 55-64).