Health Care Reform Implementation Through the Cancer Lens

ACS CAN Policy TeamApril 2010

2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

Medicare Savings: MA payment reductions, productivity offset to FFS updates

Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal

Coverage: Small business premium tax credit

Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review

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

Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates

Timeline of Key Health Reform Provisions

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

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 ImplementationExpanding 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 ImplementationEnhancing 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 ImplementationMenu 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 ImplementationAddressing 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 ImplementationImproving 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

ImplementationExpanding 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

ImplementationExpanding 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

ImplementationExpanding 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

ImplementationResponsibility

• 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

ImplementationExpanding 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

ImplementationExpanding Coverage: Medicare

• Closes prescription drug (Part D) “doughnut hole”

• Will change reimbursement to emphasize integration of delivery and better health outcomes

ImplementationEnhancing 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

State experiences

State experiences

HIAS patient stories and

reports

HIAS patient stories and

reports

Consumer experiences

Consumer experiences

Mandatory federal reports

Mandatory federal reports

Legislative and Regulatory

“Fixes”

Legislative and Regulatory

“Fixes”

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 ImplementationACS 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