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

1. Affordable Care Act: A Step Toward
Healthcare 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 Physicians
2500%
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 Coverage
Preventive care Habilitation
services
Hospitals
Physicians Substance abuse
Prescription
drugs Dental and vision
care for children
Mental health
Rehabilitation 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 Homes
Elder 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 Services
The Community First Choice option that allows
states to make community-based services
mandatory. 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. Women
nsurance 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
n insurer will no longer be
ble to charge women more
han 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
medicine
Enhanced 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 Responsibility
Federal 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 Responsibility
Individuals
• 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 Responsibility
Businesses
• 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 Do
Join MCH’s email list, find us on Twitter @MIChealthcare
or http://Facebook.com/consumersforhealthcare
Use the Legislative Action Center at
www.consumersforhealthcare.org
Visit
www.healthreformtruth.org

50. JOIN OUR MOVEMENT!
www.consumersforhealthcare.org

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 www.hipmichigan.com
• To apply, contact PHP of Mid-Michigan at 877-459-3113 or
• www.hipmichigan.com
51

52. How do I apply for...
MEDICAID:
• Contact “Michigan Enrolls” at 1-888-367-6557
• Fill out form and print online from:
http://www.michigan.gov/documents/dhs/DHS_Information_Booklet_a
• Contact your local DHS office
MiChild, Healthy Kids, Plan First and MOMS:
• Online at https://healthcare4mi.com/michild-web/
• 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
http://www.mmapinc.org/, or
1-800-803-7174
53

54. How do I apply for MiRx?
• Online at www.mihealth.org 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 www.IRS.gov
55

56. How do I use the health insurance
exchange?
Exchanges will not be active until 2014.
Visit www.healthcare.gov for more information.
How do I check the quality of my hospital?
www.hospitalcompare.hhs.gov
www.healthcare.gov
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.

61. “We did it because we were
concerned about the specter of
single 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

62. The Heritage Foundation was
one of the strongest early
backers 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.”

63. 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 FactCheck.org

65. The Facts According to FactCheck.org
• 98.1 percent of the citizens of Massachusetts now have
healthcare coverage (contrasted with a national uninsured
rate of 15.4%)
• FactCheck.org: “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

66. Native Americans
The 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

67. 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

68. 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.)

69. 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.

70. 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.

71. 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.

74. Individual Mandate
The healthcare reform bill mandates that most
US citizens and legal residents purchase
“minimal essential coverage” for themselves
and their dependents if they can afford it.

75. Early Retirees
Federal funds are currently available to help
businesses afford the cost of health insurance
for early retirees (ages 55-64).