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Riportella priester 2013 the affordable care act
This document provides an overview of the Affordable Care Act (ACA). It discusses key provisions of the law including expanding Medicaid eligibility, establishing health insurance marketplaces, mandating individuals have health insurance, and enforcing employer responsibilities. The document outlines how the ACA aims to increase access to health insurance through a combination of public programs, employer coverage, and online marketplace coverage. It also addresses ongoing implementation challenges and debates around the law.
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Riportella priester 2013 the affordable care act
- 1. Health Reform Patient Protection andAffordable Care Act An Overview of the Affordable Care Act
- 2. Understand basics ofintent of ACA Understand some of the provisions of the law Share resources Answer questions
- 3. Is ACA hereto 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 or changes. Some provisions already in effect. Major implementation January 1, 2014 THE Public Issues Education Challenge of Our Times
- 4. Confused? Here’s why… It’sa big law… with 10 provisions … and implications for most Americans
- 5. Provisions of the Affordable Care Act Healthcare.gov;http://www.healthcare.gov/law/full/index.html
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- 7. Driven byconcerns 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 work So much more than health insurance reform
- 8. What the LawDoes for Insurance 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 health insurance system generally untouched
- 9. Provides neweligibility rules for Medicaid and 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. What the LawDoes: Other Provides grants to various groups and organizations to improve the overall health care system through innovation cross- profession expertise The outreach component is the responsibility of the Center for Medicare and Medicaid Services (CMS) and they have funds to contract with organization around educating consumers
- 11. What the LawDoes (cont’d.) Changes some options for the publicly insured Moves more uninsured individuals to insurance by: Mandating individual coverage Sharing responsibility of employer-based coverage at some levels (business with 50+ employees) Removing barriers to current coverage Increasing lower cost group options Online Marketplace (Exchanges) High risk pools
- 12. Who Benefits fromthe Affordable Care Act Coverage Expansions? Percentage of Nonelderly Population With Income Up to Four Times the Poverty Level Who Were Uninsured or Purchasing Individual Coverage, 2010
- 13. TheThree-legged Stool Approach PublicPrograms (Medicaid/CHIP/Medicare) Employer Coverage Online Marketplace Coverage
- 14. 0 50 100 150 200 250 300 Private Insurance PublicInsurance Uninsured Number(inMillions) Total Employer Direct- Purchase Total Medicaid Medicare VA Total Private Insurance Total: 201 million Employer: 176.3million Direct-Purchase: 26.7 million Public Insurance (non-exclusive) Total: 87.4 million Medicaid: 42.6 million Medicare: 43 million (dual eligibles) Military healthcare: 11.5 million Uninsured: 46.3 million US Health Insurance byType
- 16. Can I Keepthe Insurance I Have? Individuals with insurance through their employer or private insurance do not have to change their plan, but can still compare other options. Individuals who qualify for Medicare or Medicaid will continue to be eligible for these programs. Individuals who don’t have insurance will be required (mandated) to purchase it
- 17. ACA and theMandate Jan. 2014 Most individuals will be mandated to have insurance BUT: Government will provide tax credits to some who can’t afford it (some exempt) Individuals without access to insurance can purchase coverage through an online marketplace (intent to be affordable in large purchasing pools) Adults cannot be denied coverage for pre-existing conditions States can choose to cover more individuals by expanding their Medicaid programs
- 18. Will Everyone beRequired to Have 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 cause insurance to be unaffordable
- 19. Does the MandateWork? Massachusetts:Uninsured as % of Population 10.20% 11.30% 9.2% 10.4% 5.4% 2003 2004 2005 2006 2007 Source: Current Population Survey, 2003-2008, US Census Bureau 2.7% 2009
- 20. Employer Coverage isa Key to Health Reform Public Programs (Medicaid/CHIP/Medicare) Employer Coverage Online Marketplace Coverage
- 21. HowWill ACA Changethe Employer-Based System? Builds on and expands the employer-based insurance system instead of limiting it Gives tax incentives to small businesses for insuring employees Fines large employers for not insuring employees Requires very large employers to insure by providing employer-sponsored plans Congressional Budget Office (CBO) estimates four different scenarios that all show a decline in Employer-based coverage; all are due to an increase in enrollment through the online marketplaces and Medicaid, rather than a net loss of insured individuals.
- 23. The Problem Small businesseshaven’t always been able to afford to provide health insurance to their employees. Sometimes, even when insurance options are provided, they are limited and too expensive for employees to access. The Solution The ACA makes providing insurance more affordable for many small business employers, expands options in some cases, and limits cost for their employees.
- 24. How ACA Worksfor Small Businesses Small businesses with fewer than 50 employees are not mandated to provide insurance coverage. Employees of small businesses may be eligible for tax credits to purchase insurance on their own in online marketplace if their employers do not to provide it. Small businesses with fewer than 25 employees are eligible for tax credits if they do decide to offer health insurance to their employees.
- 25. How Does theTax Credit Work? A small business can qualify for a tax credit if they have: Less than 25 FTE* Wages that average less than $50,000 Not counting the owner and his/her family member The employer pay 50% or more of the health care costs They can receive tax credits by filling a Form 8941 on www.irs.gov with their accountant. * FTE is counted at 30 hours a week
- 26. What Are thePenalties for Businesses? A small business with less than 50 FTE* will not be penalized for not offering health insurance to their employees Employers with more than 50 FTE can be penalized two ways: Not offering health insurance $2,000/employee minus 30 first employees Not offering affordable health insurance $3,000/employee that receives tax subsidy through the health insurance marketplace * FTE is counted at 30 hours a week
- 27. Online Marketplace Coverageis a Key to Health Reform Public Programs (Medicaid/CHIP/Medicare) Employer Coverage Online Marketplace Coverage
- 28. 2014: A NewOnline Marketplace Starting January 1, 2014: Individuals and small businesses can shop in a new health insurance marketplace featuring: • Standardized insurance products (and better peace of mind); • Tools for comparing options and finding the best plans; and • Strong insurer oversight http://www.healthcare.gov/marketplace /index.html
- 29. Kaiser Family Foundation;Healthreform.kff.org/en/the-states.aspx The Choice is UpTo the States
- 30. Online Marketplace Current DecisionMaking How insurers will participate What types of plans and how many What types of assistance will be available to help people enroll Navigators (federal) Navigators/Assistors (state) Building IT infrastructure
- 31. Purchasing through theOnline Marketplace Individual pays 2-9.5% of premium, government gives tax credit to cover balance of premium, determined at time of online enrollment Policies will at least meet essential benefit package coverage though other features may vary and OOPS may vary No one can be turned down for insurance, minimal rating system (max 3X for age, group/geographic, single/family, NO MEDICAL HISTORY FORMS)
- 34. Medicaid Expansion isa Key to Health Reform Public Programs (Medicaid/CHIP/Medicare) Employer Coverage Online Marketplace Coverage
- 35. Medicaid 101 Began1966 after Medicare First came elderly, then poor Always a state-federal partnership, federal share varies by state 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 pool of willing providers ACA’s stool depended upon states participating in putting ALL population under 138% of FPL in their Medicaid programs.
- 36. What Happened tothe Medicaid Expansion after SCOTUS Decision ACA does not provide an affordable alternative to Medicaid coverage • The subsidies are not available for this population to help purchase health insurance in the online marketplaces This leaving many likely to still be uninsured (6 million) • The new “donut hole” of health reform Source: Merrill Goozner, The Fiscal Times; July 24, 2012
- 38. Who Benefits fromthe Affordable Care Act Coverage Expansions? Percentage of Nonelderly Population With Income Up to Four Times the Poverty Level Who Were Uninsured or Purchasing Individual Coverage, 2010
- 39. How Else DoesACA Affect Medicaid? Increases primary care provider payments Gradually reduces disproportionate share hospital payments Requires a maintenance of eligibility (MOE) compliance that states maintain their eligibility standards in place as of March 23, 2010 until the Secretary of the Department of Health and Human Services (HHS) certifies state’s online marketplace readiness
- 40. What are StatesDoing for Medicaid? All modernizing and streamlining enrollment systems Almost all participating in “Money follows the person” restructuring of long term care Moving from institutional to community-based care 10 states creating “Health Homes” for those with chronic disease or serious mental illnesses Comprehensive care management Health promotion Transitional care
- 41. ACA and InsuranceReforms Preventive Aspects Free preventive care for those with insurance, including Medicare (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 plans until age 26 Children cannot be denied coverage for having pre-existing condition (Adults Jan 2014)
- 42. ACA and InsuranceReforms Medical loss ratio Insurance companies held to 80-85% standard of premium dollars to direct medical care $1 Billion already returned to policyholders Standardized easy to read summary of benefits and coverage
- 43. Personal and Social Responsibilities Personal responsibility: Making healthy choices for oneself Social responsibility: Responsibility of government, communities, and corporations Considers health of whole population
- 44. Rewarding Responsibility RewardsMedicare and Medicaid enrollees for completing behavior modification programs Requires Medicaid coverage of smoking cessation services for pregnant women Gives free annual wellness visits for those on Medicare Prevention plan services and health risk assessment Free preventive services for all on insurance (July 2012)
- 45. Federal & StateHealth Promotion Efforts Creates a National Council to coordinate federal prevention, wellness, and public health activities Offers new prevention research and health screenings, education and outreach
- 46. Promoting Health AtWork Gives grants to employers for up to 5 years for wellness programs Funds grants for employers to reward employees for entering wellness programs Requires chain restaurants to state nutrition content on all items Employers must provide a break time and also offer a separate location (other than bathroom) for breastfeeding
- 47. Making Communities Healthier Community Transformation Grants Competitive state grants for preventive services to reduce disease and address health disparities Grants for more community health workers Individualized Wellness Plan Project Pilot program giving wellness plans to at-risk populations using health centers
- 48. 48 Joel Diringer, JD,MPH Diringer and Associates 2475 Johnson Avenue San Luis Obispo, CA 93401 805-546-0950 joel@diringerassociates.com www.diringerassociates.com
- 49. 49 Agricultural worker Legal authorization to work Annual income below138% FPL (app $26,600 family of 3) Eligible for Medicaid Employer supplied insurance (ESI) for large employers when working Annual income above 138% FPL (app $26,600 family of 3) Large employer coverage when working Insurance through Exchange if no employer coverage Forgo insurance; individual pays penalty if affordable insurance is available No legal authorization to work Employer supplied insurance Reliant on safety net and emergency Medicaid Private insurance Farmworker Health Coverage under the Affordable Care Act in 2014
- 50. Summary • Farmworkers willcontinue to face difficulties in securing health coverage and 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 who work for a single employer for more than 90 days • The Marketplaces will benefit documented individuals with subsidized premiums, but potentially large out of pocket expenses • Some safety net providers will see increased income, while others may become financially unstable • Critical to health reform is immigration reform. 50
- 51. • Health ReformHits Main Street Henry J. Kaiser Family Foundation Presents http://www.youtube.com/watch?v=3- Ilc5xK2_E&feature=player_embedded • Easy-to-Use Summary Kaiser Family Foundation http://www.kff.org/healthreform/8060.cfm
- 52. 1) Present unbiasedinformation about health reform legislation; 2) Set forth implementation issues; 3) Help people understand legislation 4) Help federal and state legislative and public agency staff, private organizations and interest groups involved in implementation, health policy researchers, and the press. Robert Wood Johnson Foundation http://www.healthreformgps.org/
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- 59. • Roberta Riportella,Ph.D. • Kansas Health Foundation Professor of 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 • rriporte@ksu.edu
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