Stan Dorn's Health Care Reform Rundown


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Stan Dorn presented the ins and out of health care reform to the National Health Journalism Fellows on July 12, 2010.

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Stan Dorn's Health Care Reform Rundown

  1. 1. Health reform passed —now what? Some overlooked stories National Health Journalism Fellowships July 12, 2010 Stan Dorn The Urban Institute [email_address] 202.261.5561
  2. 2. Overview <ul><li>Little-known aspects of health reform legislation </li></ul><ul><li>Health policy outside the new law </li></ul><ul><li>Implementation issues </li></ul>
  3. 3. Part I Little known aspects of the reform law
  4. 4. Introduction <ul><li>Patient Protection and Affordable Care Act (PPACA or ACA) </li></ul><ul><li>Some “early deliverables” </li></ul><ul><li>Main provisions effective in 2014 </li></ul><ul><ul><li>Subsidies </li></ul></ul><ul><ul><li>Exchange </li></ul></ul><ul><ul><li>Shared responsibility </li></ul></ul><ul><ul><li>Insurance reforms </li></ul></ul>
  5. 5. Conservative provisions
  6. 6. Guns <ul><li>Ban on compelled disclosure of gun ownership </li></ul><ul><li>Ban on health plan discrimination based on gun ownership </li></ul><ul><li>History </li></ul>
  7. 7. Health insurance exchange <ul><li>Consumer-driven choice </li></ul><ul><li>Diverse offerings </li></ul><ul><ul><li>AV standard </li></ul></ul><ul><ul><li>Multiple AV levels </li></ul></ul><ul><li>Extensive consumer information to guide choice </li></ul><ul><ul><li>Both plan and provider </li></ul></ul>
  8. 8. Other conservative provisions <ul><li>$500 million in funding for abstinence-only education </li></ul><ul><li>Limited Medicaid benefits for newly eligible adults </li></ul><ul><li>History </li></ul>
  9. 9. New models of health care delivery
  10. 10. Theories of cost control <ul><li>Traditional argument </li></ul><ul><ul><li>From the right, demand-side management </li></ul></ul><ul><ul><li>From the left, supply-side management </li></ul></ul><ul><li>Common assumption: health care is a fixed widget </li></ul><ul><li>Third way: what if we change the widget? </li></ul><ul><ul><li>Intuition: we’re paying for things we don’t need </li></ul></ul><ul><ul><ul><li>The incentives are wrong </li></ul></ul></ul><ul><ul><li>Examples of success: Geisinger, Mayo </li></ul></ul>
  11. 11. But how do we move from TO
  12. 13. CMS Center for Medicare and Medicaid Innovation <ul><li>$10 billion through 2019 </li></ul><ul><ul><li>$5 million in planning money for FY 2010 </li></ul></ul><ul><ul><li>Similar funding thereafter </li></ul></ul><ul><li>Broad mandate - test and expand many models </li></ul><ul><li>Substantively open-ended </li></ul>
  13. 14. Models specified in law <ul><li>Patient-centered medical home (PCMH) </li></ul><ul><li>Move from FFS to comprehensive or salary-based payment </li></ul><ul><li>Care coordination for chronically ill elders </li></ul><ul><li>Preventing hospitalization of high-risk patients through disease registry, care coordination, home telehealth </li></ul><ul><li>Patient decision-making tools </li></ul><ul><li>Fully integrating care and funds for Medicaid/Medicaid dual eligibles </li></ul><ul><li>All-payer payment reform </li></ul><ul><li>Outpatient care where non-physicians determine </li></ul><ul><li>Pharmacist-based medication management </li></ul>
  14. 15. Key concepts of the Patient-Centered Medical Home <ul><li>Care coordination </li></ul><ul><ul><li>Integrated into medical practice </li></ul></ul><ul><ul><li>Manage care transitions </li></ul></ul><ul><li>Patient education </li></ul><ul><li>24/7 availability </li></ul><ul><li>Aided by HIT </li></ul>
  15. 16. More nudges towards a new health care approach <ul><li>Quality standards in the exchange </li></ul><ul><ul><li>Care coordination, including PCMH </li></ul></ul><ul><ul><li>Effort to prevent hospital readmission </li></ul></ul><ul><li>Medicaid PCMH option </li></ul><ul><li>Community health teams </li></ul><ul><li>Primary care extension centers </li></ul><ul><li>Medicare reimbursement reforms </li></ul><ul><ul><li>Value-based payments for hospitals and doctors </li></ul></ul><ul><ul><li>Penalties for hospitals with high rates of readmission, hospital acquired infection </li></ul></ul><ul><ul><li>ACOs </li></ul></ul><ul><li>Conflict-of-interest disclosures </li></ul>
  16. 17. Covering the low-income uninsured
  17. 18. 21 st -century enrollment <ul><li>Traditional public benefits </li></ul><ul><li>PPACA streamlining </li></ul><ul><ul><li>One form, one eligibility determination process for all programs </li></ul></ul><ul><ul><li>Data warehouse </li></ul></ul><ul><ul><li>Potential for eliminating traditional application forms </li></ul></ul><ul><ul><li>Key question: will Medicaid come along? </li></ul></ul>
  18. 19. Medicaid revolution <ul><li>Shift from categorical to income-based eligibility </li></ul><ul><li>Radical simplification </li></ul><ul><li>Hints at reimbursement equity </li></ul>
  19. 20. Part II Health policy outside PPACA
  20. 21. Waiting for 2014 <ul><li>Why the delay? </li></ul><ul><ul><li>Cost </li></ul></ul><ul><ul><li>Implementation </li></ul></ul><ul><li>Bad news in the meantime </li></ul><ul><ul><li>Economic downturn causes cuts to need-based health programs </li></ul></ul><ul><ul><li>Health costs continue to rise </li></ul></ul><ul><ul><li>Employer-sponsored insurance (ESI) continues to fray </li></ul></ul><ul><ul><li>Health insurers continue to discriminate </li></ul></ul><ul><ul><li>Politics: who gets the blame when things go wrong? </li></ul></ul><ul><li>Some potentially good news: HIT investments </li></ul>
  21. 22. Part III Implementation of national health reform
  22. 23. “Early deliverables” that have gone largely uncovered <ul><li>Coverage and access </li></ul><ul><ul><li>Small employer tax credits </li></ul></ul><ul><ul><li>Reinsurance for early retirees </li></ul></ul><ul><ul><li>Community health center expansion </li></ul></ul><ul><ul><li>Health consumer assistance programs </li></ul></ul><ul><li>Insurance reforms </li></ul><ul><ul><li>Preexisting condition exclusions for children </li></ul></ul><ul><ul><li>Rescissions </li></ul></ul><ul><ul><li>Lifetime and annual limits </li></ul></ul><ul><ul><li>Premium review </li></ul></ul><ul><li>Delivery system changes do not wait for 2014 </li></ul>
  23. 24. Preparing for 2014 <ul><li>States </li></ul><ul><ul><li>Extraordinary chance to reform health care </li></ul></ul><ul><ul><li>Daunting duties to expand health coverage </li></ul></ul><ul><ul><li>Great money-saving opportunities </li></ul></ul><ul><ul><li>Very limited administrative capacity </li></ul></ul><ul><ul><li>Specific question: the exchange </li></ul></ul><ul><ul><ul><li>State or federal operation? </li></ul></ul></ul><ul><ul><ul><li>What basic philosophy towards insurers? </li></ul></ul></ul><ul><li>Federal administrative capacity </li></ul>
  24. 25. Conclusion <ul><li>Huge changes under way </li></ul><ul><li>Enormous potential </li></ul><ul><li>How much of the potential will be realized? </li></ul>