Understanding Healthcare Reform


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The Supreme Court's decision to uphold the Affordable Care Act (ACA) is expected to provide millions of Americans access to health insurance. While this is perhaps the most widely recognized part of the law, there are other key elements that will affect patients and physicians, as well as evolving system-wide implications that are important to these groups.

This material, presented by Julie Barnes, director of health policy at the Bipartisan Policy Center (BPC), explains:
* How the ACA will change health care delivery and access
* How to effectively communicate key elements of the law to constituents
* How to become involved in implementing the law

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Understanding Healthcare Reform

  1. 1. HEALTH REFORM:Post-SCOTUS Decision LandscapeJ U L I E B AR N E S , D I R E C T O R O F H E AL T H P O L I C Y
  2. 2. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 2Health Reform Basics: Access/Affordability – Access to Care: • Individual mandate • State-based insurance exchanges • Medicaid Expansion • Consumer protections – No Rescissions, Restrictions on Lifetime/Annual Limits, Standardized Appeal Process – Affordable Coverage: • Exchange Premium Subsidies • Premium Rate Review • Medical Loss Ratio (MLR) requirements
  3. 3. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 3Health Reform Basics: Care Quality & Efficiency – Pilots and Demonstration Projects • Medicare Accountable Care Organizations • Pioneer ACOs • Bundled payment demo • Value-based purchasing – Accountability • Data reporting & transparency • No reimbursement for avoidable “never events,” such as: – Infections – Wrong site surgery
  4. 4. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 4Supreme Court Outcomes – PPACA is constitutional – Individual mandate constitutional as a TAX – Medicaid expansion is OPTIONAL
  5. 5. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 5Impact of Decision – New Medicaid “donut hole” for non-expansion states – Under 100% FPL, in non-expansion states: • No access to federal subsidies in exchange • No access to Medicaid • Exempt from mandate – Continued uncompensated care for hospitals – Alters exchange enrollment • 3M more people will enroll in exchange that previously would have been Medicaid eligible (greater burden on federal govt. thru premium subsidies) • 2% higher premiums in exchanges – Continued uncertainty about sustainability of Medicaid Program
  6. 6. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 6Access Concerns – Optional expansion = no guarantee of access to Medicaid – 13 States Planning to Expand: • WA, OR, CA, MN, HI, AR, IL, NY, MD, MA, CT, VT, RI – 15 States Unlikely or Unwilling to Expand: • NV, NE, KS, TX, IA, MO, LA, WI, IN, VA, MS, AL, GA, SC, FL • Some interest in partial expansion: IN, NM, WI
  7. 7. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 7States Ready to Implement? – Status: • Established State Exchange, Moving Forward (16) • Studying options/Haven’t ruled out state exchange (9) • Default Federal/Decision Not to Create State Exchange (7) • Leaning Toward or Likely Federal (6) • Planning for Partnership Exchange (4) • Waiting on election outcome (9) – Many waiting for November election • Most state legislative sessions over by June
  8. 8. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 8States Ready to Implement? – Deadlines/Timing • RFPs and RFIs • Nov 16: notify HHS of intent to be state/FFE/partnership exchange • Jan 1, 2013: HHS will approve state readiness to run exchange (can get conditional approval) • Oct 1, 2013: exchanges must be operationally ready for enrollment • Jan 1, 2014: exchange up and running
  9. 9. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 9State Exchanges – State, Federal or Partnership? – Interaction with Medicaid (churning of low-income population) – Core Functions • Consumer assistance • Plan management • Enrollment and Eligibility determination • Financial management
  10. 10. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 10Rules & Regulations (Insurance) – Final/partially final: – Less recent: • Exchange establishment/eligibility • Standardized benefit summary • Medicaid and exchange interaction • Contraception coverage • RR&R • College student health plans • Blueprint (state vs. federal exchange) • Consumer protections (high risk • Premium Tax Credits pools, etc.) • EHB data collection • Medical Loss Ratio • Accreditation of QHPs – Bulletins: – HIT/DSR: • Essential health benefit plan selection • Final Medicare ACO Rule • Actuarial value • State Innovation Waiver • ESI verification • Meaningful Use (Stage II) • Reinsurance • Section 1115 Medicaid waiver • Federally-facilitated exchange transparency • Partnership exchange
  11. 11. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 11Implementation Unknowns – Continued uncertainty for states and stakeholders • Many PPACA deadlines approaching • Waiting on regulation and guidance for key aspects of law – States pressing HHS for more guidance • Federally-facilitated exchange • Partnership model • Essential health benefits (after 2016)
  12. 12. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 12Implementation Unknowns – Outcome of election • Four scenarios – Republican Sweep – Obama White House + Republican Senate – Status Quo – Romney White House + Democrat Senate Majority
  13. 13. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 13Engagement Strategy – Encourage state to expand Medicaid program • No deadline for agreement or withdrawal – Attend listening sessions (if open) • CCIIO often tours states – Work with state leaders – many decisions to be made at state level • Selecting essential health benefit packages • Insurance exchange consumer interaction • Navigator program • Participation of brokers and agents
  14. 14. HEALTH REFORM: POST-SCOTUS DECISION LANDSCAPE 14Health Care Cost Containment Initiative – Leaders • Senator Tom Daschle • Senator Pete Domenici • Senator Bill Frist • Dr. Alice Rivlin – Many opportunities to reduce cost growth and enhance quality and value • Alternative models of payment and care delivery • Prevention and disease management • Medicare/Medicaid delivery and design reform • Administrative simplification • State flexibility and incentives • Supply of professionals and services • Tax reform