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Understanding the affordable care act riportella and meehan strub priester


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Understanding the affordable care act riportella and meehan strub priester

  1. 1. Health ReformPatient Protectionand Affordable Care ActUnderstandingthe Affordable Care ActMary Meehan-Strub, J.D.Professor Department of FamilyDevelopmentDepartment Head/Family Living AgentLa Crosse University of Wisconsin-Extension
  2. 2. Learn how national and state-based ACAprogramming tie togetherTake in-depth look at how ACA is poised tochange the health care landscapeShare examples of Extensions’ responsesShare resourcesAddress unanswered questions
  3. 3. Is ACA here to stay? Passed into law on March 23, 2010 SCOTUS ruled on challenge June 2012 mandate to be insured upheld Medicaid Expansion not upheld As with any law, there may be future challenges orchanges. Some provisions already in effect. Major implementation January 1, 2014THE Public Issues Education Challenge of Our Times
  4. 4. Confused? Here’s why…It’s a big law…with 10 provisions …and implications formost Americans
  5. 5. Provisionsof theAffordableCare;
  6. 6. Timeline;
  7. 7.  Driven by concerns with access, costs and quality of care,ACA is set to changeHow health is created withA balance of personal and social responsibilitiesA balance between the medical care system and other actorsA focus on prevention and primary careHow health care is delivered and by whomHow health care is paid for and how muchHow private insurance is purchased (for many)And its new minimum standardsHow the public insurance systems workSo much more than health insurance reform
  8. 8. What the Law Does forInsurance Modifies current insurance policies to: Improve coverage for those who have it Secure coverage for those who do not Responds (from the legislature) to: Regulate insurers, Protect consumers, and Put in place new insurance entities Leaves the current free market healthinsurance system generally untouched
  9. 9.  Provides new eligibility rules for Medicaidand creates changes in Medicare Offers guidance on: Preventive care Access to care Infrastructure Workforce Cost efficient care New delivery systems, such as: Accountable Care Organizations
  10. 10. What the Law Does: Other Provides grants to various groups andorganizations to improve the overall healthcare system through innovation cross-profession expertise The outreach component is theresponsibility of the Center for Medicareand Medicaid Services (CMS) and theyhave funds to contract with organizationaround educating consumers
  11. 11. What the Law Does (cont’d.) Changes some options for the publicly insured Moves more uninsured individuals toinsurance by: Mandating individual coverage Sharing responsibility of employer-basedcoverage at some levels (business with 50+employees) Removing barriers to current coverage Increasing lower cost group options Online Marketplace (Exchanges) High risk pools
  12. 12. Who Benefits from the Affordable Care Act Coverage Expansions?Percentage of Nonelderly Population With Income Up to Four Times the Poverty LevelWho Were Uninsured or Purchasing Individual Coverage, 2010
  13. 13. TheThree-legged Stool ApproachPublic Programs(Medicaid/CHIP/Medicare)EmployerCoverageOnlineMarketplaceCoverage
  14. 14. 050100150200250300Private Insurance Public Insurance UninsuredNumber(inMillions)TotalEmployerDirect-PurchaseTotalMedicaidMedicareVATotalPrivate InsuranceTotal: 201 millionEmployer: 176.3millionDirect-Purchase: 26.7 millionPublic Insurance (non-exclusive)Total: 87.4 millionMedicaid: 42.6 millionMedicare: 43 million (dual eligibles)Military healthcare: 11.5 millionUninsured: 46.3 millionUS Health Insurance byType
  15. 15. Can I Keep the Insurance I Have? Individuals with insurance through their employer orprivate insurance do not have to change their plan, butcan still compare other options. Individuals who qualify for Medicareor Medicaid will continue to beeligible for these programs.Individuals who don’t haveinsurance will be required(mandated) to purchase it
  16. 16. ACA and the Mandate Jan. 2014 Most individuals will be mandated to have insuranceBUT: Government will provide tax credits to some whocan’t afford it (some exempt) Individuals without access to insurance canpurchase coverage through an online marketplace(intent to be affordable in large purchasing pools) Adults cannot be denied coverage for pre-existingconditions States can choose to cover more individuals byexpanding their Medicaid programs
  17. 17. Will Everyone be Required toHave Insurance in 2014? Some individuals may be exempt, including: Pregnant women Individuals with disabilities American Indians Youth aging out of foster care Individuals with low incomes that causeinsurance to be unaffordable
  18. 18. Does the MandateWork?Massachusetts: Uninsured as % of Population10.20%11.30%9.2%10.4%5.4%2003 2004 2005 2006 2007Source: Current Population Survey, 2003-2008, US Census Bureau2.7%2009
  19. 19. Employer Coverage is a Key toHealth ReformPublic Programs(Medicaid/CHIP/Medicare)EmployerCoverageOnlineMarketplaceCoverage
  20. 20. HowWill ACA Change theEmployer-Based System? Builds on and expands the employer-basedinsurance system instead of limiting it Gives tax incentives to small businesses for insuringemployees Fines large employers for not insuring employees Requires very large employers to insure by providingemployer-sponsored plansCongressional Budget Office (CBO) estimates four different scenarios thatall show a decline in Employer-based coverage; all are due to an increasein enrollment through the online marketplaces and Medicaid, rather thana net loss of insured individuals.
  21. 21. The ProblemSmall businesses haven’t always been able toafford to provide health insurance to theiremployees. Sometimes, even when insuranceoptions are provided, they are limited and tooexpensive for employees to access.The SolutionThe ACA makes providing insurance moreaffordable for many small business employers,expands options in some cases, and limits cost fortheir employees.
  22. 22. How ACA Works for Small Businesses Small businesses with fewer than 50 employees are notmandated to provide insurance coverage. Employees of small businesses maybe eligible for tax credits topurchase insurance on their own inonline marketplace if theiremployers do not to provide it. Small businesses with fewer than 25employees are eligible for tax credits ifthey do decide to offer healthinsurance to their employees.
  23. 23. How Does the Tax Credit Work? A small business can qualify for a tax credit if theyhave: Less than 25 FTE* Wages that average less than $50,000 Not counting the owner and his/her familymember The employer pay 50% or more of the healthcare costs They can receive tax credits by filling a Form 8941on with their accountant.* FTE is counted at 30 hours a week
  24. 24. What Are the Penalties for Businesses? A small business with less than 50 FTE* will notbe penalized for not offering health insurance totheir employees Employers with more than 50 FTE can be penalizedtwo ways: Not offering health insurance $2,000/employee minus 30 first employees Not offering affordable health insurance $3,000/employee that receives tax subsidythrough the health insurance marketplace* FTE is counted at 30 hours a week
  25. 25. Online Marketplace Coverage is aKey to Health ReformPublic Programs(Medicaid/CHIP/Medicare)EmployerCoverageOnlineMarketplaceCoverage
  26. 26. 2014: A New Online MarketplaceStarting January 1, 2014:Individuals and smallbusinesses can shop in anew health insurancemarketplace featuring:• Standardized insuranceproducts (and better peaceof mind);• Tools for comparingoptions and finding thebest plans; and• Strong insurer oversight
  27. 27. Kaiser Family Foundation; Choice is UpTo the States
  28. 28. Online MarketplaceCurrent Decision Making How insurers will participate What types of plans and how many What types of assistance will be available tohelp people enroll Navigators (federal) Navigators/Assistors (state) Building IT infrastructure
  29. 29. Purchasing through the OnlineMarketplace Individual pays 2-9.5% of premium, government givestax credit to cover balance of premium, determined attime of online enrollment Policies will at least meet essential benefit packagecoverage though other features may vary and OOPSmay vary No one can be turned down for insurance, minimalrating system (max 3X for age, group/geographic,single/family, NO MEDICAL HISTORY FORMS)
  30. 30. Medicaid Expansion is a Key toHealth ReformPublic Programs(Medicaid/CHIP/Medicare)EmployerCoverageOnlineMarketplaceCoverage
  31. 31. Medicaid 101 Began 1966 after Medicare First came elderly, then poor Always a state-federal partnership, federal share varies bystate Minimum eligibility limits set by feds to participate Variation by state on eligibility criteria from generous to not Under-market payment to providers always impacts poolof willing providers ACA’s stool depended upon states participating in puttingALL population under 138% of FPL in their Medicaidprograms.
  32. 32. What Happened to the MedicaidExpansion after SCOTUS DecisionACA does not provide an affordable alternative toMedicaid coverage• The subsidies are not available for this population tohelp purchase health insurance in the onlinemarketplacesThis leaving many likely to still be uninsured (6 million)• The new “donut hole” of health reformSource: Merrill Goozner, The Fiscal Times; July 24, 2012
  33. 33. Who Benefits from the Affordable Care Act Coverage Expansions?Percentage of Nonelderly Population With Income Up to Four Times the Poverty LevelWho Were Uninsured or Purchasing Individual Coverage, 2010
  34. 34. How Else Does ACA Affect Medicaid? Increases primary care provider payments Gradually reduces disproportionate share hospitalpayments Requires a maintenance of eligibility (MOE)compliance that states maintain their eligibilitystandards in place as of March 23, 2010 until theSecretary of the Department of Health and HumanServices (HHS) certifies state’s online marketplacereadiness
  35. 35. What are States Doing for Medicaid? All modernizing and streamlining enrollment systems Almost all participating in “Money follows theperson” restructuring of long term care Moving from institutional to community-basedcare 10 states creating “Health Homes” for those withchronic disease or serious mental illnesses Comprehensive care management Health promotion Transitional care
  36. 36. ACA and Insurance Reforms Preventive Aspects Free preventive care for those with insurance, includingMedicare (effective as of new policy year) Financial Aspects Financial assistance for seniors for prescription drugs No lifetime limits on coverage of essential benefits Tax breaks for small businesses to provide coverage(2010-2016) Access to insurance Young adults can stay on parent’s private insurance plansuntil age 26 Children cannot be denied coverage for having pre-existing condition (Adults Jan 2014)
  37. 37. ACA and Insurance Reforms Medical loss ratio Insurance companies held to 80-85% standard ofpremium dollars to direct medical care $1 Billion already returned to policyholders Standardized easy to read summary of benefits andcoverage
  38. 38. Personal and SocialResponsibilities Personal responsibility: Making healthy choices for oneself Social responsibility: Responsibility of government, communities, andcorporations Considers health of whole population
  39. 39. Rewarding Responsibility Rewards Medicare and Medicaid enrollees forcompleting behavior modification programs Requires Medicaid coverage of smoking cessationservices for pregnant women Gives free annual wellness visits for those onMedicare Prevention plan services and health risk assessment Free preventive services for all on insurance (July2012)
  40. 40. Federal & State HealthPromotion Efforts Creates a National Council to coordinatefederal prevention, wellness, and public healthactivities Offers new prevention research and healthscreenings, education and outreach
  41. 41. Promoting Health At Work Gives grants to employers for up to 5 years forwellness programs Funds grants for employers to reward employees forentering wellness programs Requires chain restaurants to state nutrition contenton all items Employers must provide a break time and also offera separate location (other than bathroom) forbreastfeeding
  42. 42. Making Communities Healthier Community Transformation Grants Competitive state grants for preventive services toreduce disease and address health disparities Grants for more community health workers Individualized Wellness Plan Project Pilot program giving wellness plans to at-riskpopulations using health centers
  43. 43. 48Joel Diringer, JD, MPHDiringer and Associates2475 Johnson AvenueSan Luis Obispo, CA
  44. 44. 49AgriculturalworkerLegalauthorization toworkAnnual incomebelow 138%FPL (app$26,600 familyof 3)Eligible forMedicaidEmployersuppliedinsurance (ESI)for largeemployers whenworkingAnnualincome above138% FPL (app$26,600family of 3)Large employercoverage whenworkingInsurance throughExchange if noemployercoverageForgo insurance;individual payspenalty ifaffordableinsurance isavailableNo legalauthorization toworkEmployersuppliedinsuranceReliant onsafety net andemergencyMedicaidPrivateinsuranceFarmworker Health Coverageunder the Affordable Care Actin 2014
  45. 45. Summary• Farmworkers will continue to face difficulties in securing health coverageand paying for care• The Medicaid expansion will primarily benefit documented individuals(undocs will receive emergency coverage only)• The Large Employer mandate will benefit those full-time workers whowork for a single employer for more than 90 days• The Marketplaces will benefit documented individuals with subsidizedpremiums, but potentially large out of pocket expenses• Some safety net providers will see increased income, while others maybecome financially unstable• Critical to health reform is immigration reform.50
  46. 46. Covering Kids & Families (CKF)● Based at UW-Madison, affiliated with UW-Extension● Statewide coalition● Key project: School based outreach to supportBadgerCare+ assistance in schools and share health careresources with school staff● More recently, CKF has been collaborating with UW-Extension to build an Affordable Care Act (ACA)curriculum for UW-Extension county faculty to use intheir communities
  47. 47. • PowerPoint slides with talking notes-Presentations—different audiences, different lengths-Train theTrainer• Sub-population specific factsheets• Small group activities• Poster board displays• Press release templates• And more… social media….ACA UW-Extension CurriculumAlong with professional development workshops specific toUW-Extension faculty, CKF is developing resources for withUW-Extension and other community partners to use:
  48. 48. Health Care Reform ResourcesCKF website, blog, and listserv:
  49. 49. sheets andresources can be foundon the new CKFAffordable Care ActWebpage!
  50. 50. covering kids & familiesHow can Extension Educators programaround the Affordable Care Act?• Traditional programs– Special interest educational sessions– Train-the-trainer, Volunteers– Health Insurance Fair– Hands- on experiential session – computer lab- sign up forprogram– Fact Sheet– Media Series – newspaper, television, radio• NewerTraditional programs– Website content- fact sheets, video training**– Facebook pages– Blogs– Twitter
  51. 51. covering kids & familiesWhy Do Educational Programs on ACA?• Extension Perspective– Local faculty/specialists - pulse on theircommunity– Unbiased educational resource – responsive tolocal needs– Build community capacity– Empower individuals and families to makeinformed decisions– National issue – potential impact on everyone-2013 --Teachable year
  52. 52. covering kids & familiesUW-Extension faculty in all 72Wisconsin counties• Community, Natural ResourceDevelopment• Agriculture• 4-HYouth Development• Family LivingWork with community partners toact as an ACA resource to:• Businesses, including Farmers• Government Agencies• Community Agencies• Providers• ConsumersACA UW-Extension Curriculum
  53. 53. covering kids & familiesCreating Health: BuildingCommunity Capacity throughPartnerships and Collaborations• Comprehensive systems approach to helpingindividuals, families and communities createhealth– County: Health, Human Services, Aging Depts.,Health Educators, Aging Benefit Specialists,Special Committees and Coalitions– State: Dept. of Financial Institutions– Federal Reserve Board: Money SmartWeek– Community organizations:AARP, Chambers ofCommerce, Farm Organizations– Medical institutions, providers
  54. 54. covering kids & familiesPivotal and Teachable Moment forCommunity Educators!• Consumers, community leaders, businessowners—variable understanding of the ACA,its provisions, and its affects on them• Concerns for costs and benefits• Health Insurance Literacy – Direct ConsumerEducation• Unbiased educational resource• Building community capacity throughpartnerships and collaborative efforts• Creating personal and community health
  55. 55. • Health Reform Hits Main StreetHenry J. Kaiser Family Foundation Presents• Easy-to-Use SummaryKaiser Family Foundation
  56. 56. 1) Present unbiased information about health reformlegislation;2) Set forth implementation issues;3) Help people understand legislation4) Help federal and state legislative and public agencystaff, private organizations and interest groupsinvolved in implementation, health policyresearchers, and the press.Robert Wood Johnson Foundation
  57. 57. http://w
  58. 58.
  59. 59. • Roberta Riportella, Ph.D.• Kansas Health Foundation Professorof Community Health• K State Research and Extension• Emerita Professor• University of Wisconsin-Madison• 343 Justin Hall• Kansas State University• Manhattan, KS 66506• 785-532-1942•
  60. 60. • Mary Meehan-Strub, J.D.• Professor Department of FamilyDevelopment• Department Head/Family LivingAgent• La Crosse University of Wisconsin-Extension• 400 4th Street North, Rm 3140• La Crosse, WI 54601• 608-785-9593•
  61. 61. Molly Vetter-Smith, Ph.D.State Health Education SpecialistOffice of Continuing Medical EducationUniversity of Missouri
  62. 62. Questions, Discussion