The document provides an overview of the key components and reforms of the Affordable Care Act (ACA). It explains that the ACA aims to expand health insurance coverage, increase choice of providers, and mandate affordable health insurance for all Americans by 2014. Major reforms include establishing health insurance exchanges, expanding Medicaid eligibility, and enacting essential health benefits. The ACA also focuses on payment and delivery system reforms like accountable care organizations to improve quality and reduce costs.

1. HEALTH CARE REFORM 101
22 May 2012

2. WHAT IS THE ACA?
 The Patient Protection and Affordable Care Act (ACA) was signed into law
in March of 2010
 A governmental policy that changes the delivery of health care services in
a given place
 Major Changes:
 All Americans must have health insurance by 2014
 More emphasis on community-based services and less reliance on
institutional care
 Disease prevention and wellness are major themes

3. REFORMS IN THE ACA ATTEMPT TO:
 Broaden the population that receives health care coverage through
employment, or public sector insurance companies (e.g. DPW)
 Increase the number of health care providers people may choose from
 Improve the referral process and the right to be seen by a specialist
 Mandate health insurance by reducing the cost and making it affordable
for everyone

4. A NEW VOCABULARY
 Accountable care organization
(ACO)
 Basic health programs
 Carve-out
 Centers for Medicare and
Medicaid Services
 Community health centers
 Federally Qualified Health Center
 Electronic Health Record (EHR)
 Health care homes
 Health information technology
(HIT)
 Health information privacy and
security
 Health Insurance Portability and
Accountability Act (HIPAA)
 Home and Community-Based
Services
 Information transparency
 Meaningful User
 Medicaid
 Medical home
 Patient Protection and Affordable
Care Act

5. KEY COMPONENTS
Insurance Reform (Jan 2014)
Coverage Reform (Sept 2010)
Quality Reform (Jan 2011 – Dec 2013)
Payment Reform (Mar 2010 – Mar 2020)
HIT Reform (Jan 2011 – Dec 2013)

6. INSURANCE REFORM
Core feature of the ACA
Includes:
 Individual Mandate provision
 Expanding Medicaid eligibility
 Establishing Health Insurance Exchanges
 Establishing the Essential Health Benefits package
 Providing tax incentives to purchase insurance
An estimated 32 million individuals will become
insured by 2019

7. INDIVIDUAL MANDATE
Most controversial provision of the ACA
Requires individuals to obtain health insurance or
pay a penalty
Penalties increase each year
 Exemptions include:
 Religious
 Incarceration
 Undocumented status

8. MEDICAID EXPANSION
Individuals and families with incomes up to 133% of
the Federal Poverty Level (FPL) will be eligible
 Appx. $14,850 for an individual
 Appx. $30,650 for a family of four
Expected to enroll 11.6 million people in 2014

9. HEALTH INSURANCE EXCHANGE
States must establish by January 2014 or default to the
Federal government
Several requirements:
 User Friendly
 Must screen and enroll public & private coverage
 Must establish “navigators”
 Transparency
 Self-financing by 2015

11. ESSENTIAL HEALTH BENEFITS
WHAT IS ESSENTIAL?
Ambulatory patient
services
 Emergency services
Hospitalization
 Maternity and
newborn care
 Mental health and
substance use disorder
services, including
behavioral health
treatment
Rehabilitative and
habilitative services and
devices
Laboratory services
Preventive and wellness
services and chronic
disease management
Pediatric services,
including oral and vision
care
Prescription drugs

12. COVERAGE REFORM
Many provisions are already in effect:
 Pre-Existing Condition Coverage to age 19
 Family Coverage to age 26
 No Annual or Lifetime Limits
 Closing the Medicare Donut Hole
 No co-pays/deductibles for prevention/ promotion
interventions
 Medical loss ratios now at 85 and 80 %

13. QUALITY REFORM
Patient Centered Medical
Homes (PCMH) and Health
Homes
Accountable Care
Organizations
Establishment of National
Quality Measures

14. ACCOUNTABLE CARE ORGANIZATIONS
(ACO)
 Providers collectively take responsibility
for the quality and costs of
treatment
 If providers can reduce costs while
providing high quality care they receive
a share of the cost savings
 Can be operated by health systems,
health plans, hospitals, large physician
practices or other medical service
organizations
 Population health approach = not just
taking care of the sick but keeping
people healthy

15. PAYMENT REFORM
Payment reform involves moving whole
sectors of the health care field from encounter
payment systems to case and capitation
systems
Lead work in this area will be done by the
Center for Medicare & Medicaid Innovation:
 Medicare ACO Pioneer project
 CMMI Innovation Challenge
 Medicaid Emergency Psychiatric Demonstration
This is a 10 year undertaking

16. HEALTH INFORMATION TECHNOLOGY
REFORM
HIT is the use of computers as a means of exchanging
medical information from doctor to doctor, or provider to
provider
Currently, behavioral healthcare is not receiving financial
incentives to implement needed EHRs for the field
The Behavioral Health Information Technology Act of 2011,
S.B.39, is currently in Congress
 Would expand Federal incentives to implement HIT in
physical health care to behavioral health care

17. HEALTH EQUITY PROVISIONS
§10334: Elevates
Office of Minority Health
(OMH) to HHS and
requires six HHS
agencies to establish
offices of minority health
§4302: Mandates
federal health care
programs to collect and
report data on sex, race,
ethnicity, language and
disability status
§5306: Behavioral
health workforce
development grants
§5313: Community
health workforce grants
to promote culturally and
linguistically appropriate
services
§3509: Establishes an
Office of Women’s Health

18. CONSTITUTIONAL CHALLENGES
Kaiser Family Foundation. Available at: http://www.kaiserhealthnews.org/Supreme-Court-DecidesHealth-Law.aspx

19. ACA BENEFITS TO PENNSYLVANIANS
Insurance Reform
 7.7 million residents are without lifetime limits on coverage
 32,100 young adults received coverage through parent’s plans
 657,000 children can not be denied coverage due to preexisting conditions
Medicare Provisions
 2.3 million Medicare beneficiaries receiving primary care services with no
copay
 Currently, Medicare beneficiaries receiving 50% discount on brand name
drugs in donut hole
 By 2020 donut hole will be closed

20. ADVOCACY OPPORTUNITIES
 Essential Health Benefits inclusion of behavioral health services
 HHS has given States the discretion to craft the EHB Package
 While Mental Health/Substance Use is defined as an essential health
benefit, state determines at what level
 Health Insurance Exchange Design & Implementation
 Transparency & Governance
 Use of Navigators
 Other State Legislation
 S.B. 10: Amending the PA Constitution
 Maintenance of Effort (MOE) Waiver Request

21. QUESTIONS?