Transcript Disparities Breakout Session - American Cancer Society

Health Care Reform Implementation
Through the Cancer Lens
ACS CAN Policy Team
April 2010
Timeline of Key Health Reform Provisions
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
Coverage: Medicaid expansion, major insurance reforms (eg, guaranteed
issue, rating rules, no pre-ex for adults) insurance exchanges, premium /
cost sharing subsidies, individual / employer responsibility requirements
Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review
Coverage: Small business premium tax credit
Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates
Medicare Savings: MA payment reductions, productivity offset to FFS updates
Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal
Delivery System Reform: Center for Medicare and Medicaid Innovation
Delivery System Reform: ACOs, hospital value-based purchasing
Delivery System Reform: Hospital readmissions, payment bundling
Delivery System Reform: Physician quality reporting penalties
New Revenue: Tax on prescription drug manufacturers
New Revenue: Excise tax on medical device makers, Medicare tax on high earners
New Revenue: Tax on health insurers
New Revenue: Tax on
high-cost health plans
What Is In the Patient Protection and
Affordable Care Act?
The Basic Structure of
Health Care Reform
• Expanding Coverage
• Private insurance
• Medicaid
• Medicare
• Enhancing Prevention
• Improving Quality of Life
Early Implementation: 2010-2013
Early Implementation
Expanding Coverage: Private Insurance
Within 90 days:
• Creates a temporary high-risk pool for those
uninsured because of a pre-existing condition
New “plan year” beginning 6 months after
enactment:
• Dependent coverage extended until age 26
• No pre-ex for children
• Eliminates rescissions
• No lifetime limits on coverage
• Regulates annual limits on coverage
• No cost for preventive care in “new plans”
Early Implementation
Expanding Coverage: Medicaid
CY 2010
• New optional category for parents and childless adults
under 133% FPL
• States under Maintenance of Effort (MOE) until 2014
– May not reduce B&C treatment eligibility during this time
CY 2011
• Optional state coverage of preventive services
– Increases FMAP for states that cover prevention (Jan 1,
2013)
•
Mandatory coverage of tobacco cessation services for
pregnant women
– Tobacco cessation coverage for pregnant women (Oct 1,
2010)
CY 2013
• Increases reimbursement to primary care doctors
Early Implementation
Expanding Coverage: Medicare
CY 2010
• $250 rebate for those in the Part D
“doughnut hole”
CY 2011
• Eliminates co-payments for preventive
services
• Free wellness visit and personalized
prevention plan
• 50% discount on brand-name drugs while
in the doughnut hole
Early Implementation
Enhancing Prevention
CY 2010
• New Interagency Prevention Council at HHS to expand
and coordinate prevention and public health programs and
strategies.
•
Establishes a National Strategy on Prevention and
Wellness
– First report July 1, 2010
•
Creates a Prevention and Public Health fund
– $500 million for fiscal years 2010 and increased to $2 billion in
2015 and subsequent years
•
Temporary credit to small businesses to encourage
investment in new therapies for the prevention of chronic
diseases.
Early Implementation
Menu Labeling
• Requires regulations on menu labeling for
restaurant chains by 2011
• States and localities are preempted on
enactment from having a policy that applies to
restaurants with 20 or more chains that is not
identical to the federal law.
• We are currently working with outside experts to
determine what "identical" means for states and
localities that currently have or are considering a
policy.
Early Implementation
Addressing Disparities
CY 2010
• Increases funding for Community Health Centers
•
Requires enhanced collection and reporting of data on
race, ethnicity, sex, primary language, disability status, and
for underserved rural and frontier populations
•
Expands funding for scholarship and loan repayment for
physicians working in underserved areas
•
Reauthorizes Patient Navigator Act
•
Reauthorizes the Indian Health Care and Improvement Act
Early Implementation
Improving Quality of Life
•
Pain Management
– Institute of Medicine Conference and report on pain
– New Interagency Pain Research Coordinating Committee at
HHS to expand NIH pain research
– Health professional education and training grants
•
Comparative Effectiveness Research
– Establishes a private, non-profit corporation to undertake
comparative effectiveness research and information
dissemination
•
Quality Care Measures Development
– National strategy and action plan to develop quality measures
– New Interagency Working Group on Health Care Quality
Implementation: 2014 and Beyond
Implementation
Expanding Coverage: Private Insurance
• Availability
– Establishes health exchanges in 2014 for those without
employer-sponsored health insurance
– Allows inter-state compacts to sell insurance across
state lines
– Requires the federal Office of Personnel Management
to establish nationwide, non-profit plans
– No pre-existing condition restrictions
– Requires guaranteed issue of health insurance
regardless of health status
– Waiting periods not longer than 90 days
– Allows non-profit coops to be formed to provide
insurance
Implementation
Expanding Coverage: Private Insurance
• Affordability
– Provides premium subsidies for middle income
individuals and families (up to $88,000 for a family of
four)
– Bans annual limits on coverage in 2014 (ceiling on
them before 2014 TBD by Secretary of HHS)
– Limits out of pocket maximums
– Limits deductibles
– Premium rating can only be based on age (3:1), family
status, and geography AND premium surcharge for
tobacco use (1.5:1)
– Allows employer wellness programs to provide
insurance discounts up to 30%. Also demo projects in
individual market in 5 states.
Implementation
Expanding Coverage: Private Insurance
• Adequacy
– Creates essential health benefits package
– Coverage of preventive health services with no co-pays
or deductibles
Implementation
Expanding Coverage: Private Insurance
• Administrative simplicity
-Exchanges can standardize and simplify forms
-Plans will have ratings to reflect level of
coverage (bronze, silver, gold, platinum)
-Appeals and other administrative processes will
be standardized
-Internet portal will be established to facilitate
comparison and enrollment
Implementation
Responsibility
• Individual mandate
– Fine or income tax for those w/o coverage
– Exceptions for religious or affordability
reasons
• Employer mandate
– Employers w/ more than 50 employees have
to contribute $2000 for each worker
receiving subsidies in exchange
Implementation
Expanding Coverage: Medicaid
• Expands coverage to all persons under 133%
FPL (up to $29,327 for a family of four)
• Simplifies enrollment into Medicaid
• Incentive programs to encourage participation in
chronic disease preventive programs
• Increases access to cessation drugs
Implementation
Expanding Coverage: Medicare
• Closes prescription drug (Part D) “doughnut
hole”
• Will change reimbursement to emphasize
integration of delivery and better health
outcomes
Implementation
Enhancing Prevention
• Incentives to increase number of primary
care providers
– Loan repayment
– Low interest loans
– Graduate Medical Education training slots
• Permits employers to have wellness
premium discounts
Implementation
Addressing Disparities
• Qualified health plans must provide materials in
appropriate languages
• Strategy for increases access to language
translation services
Implementation
Improving Quality of Life
• Clinical Trials Coverage
– All group or individual commercial plans must cover
routine patient care costs for trials participation
– Includes FEHBP plans, but not self-insured plans
(ERISA plans)
– Preemption provision protects existing state laws &
voluntary agreements
Assessment and Improvements
Mandatory
federal reports
State
experiences
Legislative and
Regulatory
“Fixes”
HIAS patient
stories and
reports
Consumer
experiences
Legal Challenges to HCR
• Lawsuits by Attorney Generals
– Claims that imposing the individual mandate is
unconstitutional
– Asserts that the expansion of Medicaid is an
enormous unfunded mandate that the states
cannot bear financially
– Other legal issues
• The law will be defended by U.S. Attorney
General
• Judicial Advocacy Initiative (JAI) will
continue to monitor challenges, but ACS
CAN is not a party to any lawsuit
Health Care Reform Implementation
ACS CAN’s Primary Focus
• New High Risk Pool Plan
--important transitional program for currently uninsured,
high risk people
--will establish tone and precedent for future HCR
implementation issues, and therefore, we want to be very
visible
• Exchanges—critical to making the 4As real for
cancer patients and survivors
• Prevention—an opportunity to truly enhance its
role in our nation’s health system
• Medicaid expansion—issues around state costs,
benefits for new enrollees, and maintenance of
B&C program
YOUR ROLE
Implementation: State activity
•
•
•
•
Contracting of high-risk pools
Creation of the exchanges
Creation of state-based ombudsman programs
Protecting mandates and B&C program until at
least 2014
The Federal Regulatory Process
• The federal regulatory process is highly
structured and formal
– Strict rules about comment periods and external
contacts
– Very reliant on concrete information
• HHS will be primary agency, but Labor and
Treasury have important roles, too
Implementation: To do list
• Learn what’s in the bill
• Identify state publications where call for
regulatory comments will appear
• Develop a relationship with your state
Insurance Commissioner and Medicaid Director
• Refer questions to State and Local Campaigns
team
Implementation: Resources
• ACS CAN HCR Web page
• Refer questions to State and Local Campaigns
team
Thank You!
www.acscan.org