health care reform 201

Health Care Reform 201The Affordable Care Act and School-Based Health Care

November 18, 2010

Introduction: How We Got Here

Health Reform 101: NASBHC’s Agenda

Health Reform 102: SBHC GrantsHealth Reform 202: Implementation

Health Care Reform 201: November 2010

Health Reform 101NASBHC’s Federal Policy Agenda Create a federal grant program for SBHCs Support reimbursement opportunities for

SBHCs Position SBHCs to receive support in federal

legislation and in governmental agencies


Health Reform 101, cont.Affordable Care Act Includes a federal grant program for SBHCs Supports reimbursement opportunities for

SBHCs Positions SBHCs to receive support in federal

legislation and in governmental agencies


SBHC GrantsSection 4101(a):Short-Term Appropriations Grants for the Establishment

of School-based Health Centers– $200 million over 4 years,

starting in FY2010– Limitations: only for

expenditures acquiring or improving land, facilities and equipment

No funds for personnel or to provide health services.

Section 4101(b): Authorized Federal Program Grants for Operation of

School-based Health Centers– Equipment; training;

management and operation; and salaries for physicians, nurses, and other personnel

Authorizes spending but doesn’t allocate it.


SBHCC HighlightsCan be used for alteration/renovation,

new construction, equipmentCan cover past equipment purchases

or construction (to March 23, 2010)Preference for programs that serve a

large population of children and adolescents eligible for Medicaid and CHIP


Health Reform 201We will always be reforming our health care system. In that broader sense,

implementation is forever.

-- Drew Altman, President and CEOKaiser Family Foundation


Affordable Care ActOverview

I. Regulates private health insuranceII. Investments in prevention, wellness,

primary careIII. Expands access to coverage through:

a. Subsidiesb. Expansion of public insurancec. Creation of health insurance exchanges

IV. Cost containment strategies– Improving quality/cost effectiveness


I. Regulating private insurance (1 of 2)

Extends dependent coverage up to age 26As of September 2010, insurers can’t

– Deny coverage to kids with pre-existing conditions

– Put lifetime limits on benefits– Cancel a policy without proving fraud– Deny claims without a chance for appeal

New protections, particularly for CYSHCN


I. Private insurance (2 of 2)2011: Health plans must report medical

loss ratios– 80-85% of premiums must spent on clinical

services2014: Preexisting conditions must be

covered for all2018: Excise tax on high-cost insurance

plans


II. Investments in prevention Prevention and Public Health Fund

– $5B for 2010 through 2014; then $2B/year New Prevention Council/National Prevention

Strategy Coverage of Preventative Benefits

– Rated A or B by USPSTF, recommended by AAP’s Bright Futures guidelines

– Copayments eliminated for new plans now– Eliminates Medicaid cost-sharing in 2011

Extends EPSDT to all children covered by Medicaid


II. Investments in primary care Workforce investments

– $1.5 billion mandatory funding for the National Health Service Corps– Support 15,000 primary care providers in shortage areas

– $250 million from Prevention Trust Fund– Other appropriations:

$168 million for 500 new primary care physicians by 2015 $32 million for more than 600 new physician assistants $30 million to train 600 nurse practitioners $15 million for 10 nurse-managed health clinics $5 million for states to plan and implement innovative strategies to

expand their primary care workforce


III. Access to coverage (1 of 3)32M more Americans will be insured

– Including 9 million kids by 2014– 2009’s CHIP reauthorization covered 6.5M

kids (4.1M uninsured)Young adults can stay on parents’ plansSubsidies for private insuranceExpanded eligibility for public insurance


III. Access to coverage (2 of 3)Expands Medicaid coverage to all

under 133% of FPLStates will receive 23% increase in

CHIP match rate (by 2015)Community Transformation Grants

– Planning grants to address disparities– Not appropriated


III. Access to coverage (3 of 3)Creation of state-level health insurance

exchanges; funding to states starts in 2011, must be established by 2014– Available those over 400% FPL– List of essential health benefits is in ACA– NASBHC has submitted comments to

HHS to urge SBHCs be eligible as an as “essential community provider”


IV. Cost Containment (1 of 2)

– Use of EMR – Federal review of premium increases– Tax on high-cost plans– Comparative effectiveness research– National quality improvement strategy– Data collection on disparities– Medical home (discussed earlier today)


IV. Cost Containment (2 of 2)Accountable Care Organizations

– Movement away from fee-for-service– Toward prevention and wellness, and

away from episodic care– $25M in planning grants from CMS to

states for demonstration models allow state to recognize pediatric ACOs (starting in Jan. 2012)


Accountable Care OrganizationsLocal health care organization plus a

set of providers– Health care org.: often a hospital?

Providers accountable for– Cost of care– Quality of care (comparative results)

Providers would get cost savings under private or public insurance


Accountable Care OrganizationsAssumes providers, not insurers, know

what’s bestHospitals thought to part of most

ACOs:– Requires managers, not just providers– Requires a continuum of care, needs to

plan budget and resource needs, and be able to comprehensively measure performance,


IV. Accountable Care Organizations

New concept. Many issues evolving– Design: Physician led? Hospital led?– Will provider participation be mandatory?– How will patients be brought in?– Payment methods?– How to measure quality


Key opportunities and other provisions (1 of 2)

$200M for SBHC equipment and construction

$375M for teen pregnancy prevention $125M for [Teen] Pregnancy

Assistance Fund $11B for Community Health Centers

– Plus $1.5B for CHC construction and renovation


$25M for childhood obesity demonstration programs through 2014

$40M for CHIP outreach & enrollment Authorizes oral healthcare prevention and

education


Key opportunities and other provisions (2 of 2)

Challenges we are facing

Implementation in the hands of the states Many funds are authorized but not

appropriated What SBHCs will be eligible for with

“Meaningful Use” Where SBHCs might fit in the Exchanges,

Medical home, ACOs


Main SourcesKaiser Family FoundationAMCHPNew England Journal of MedicineHealth Affairs/RWJFCRS Reports

(www.crsdocuments.com)


health care reform 201

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