1. 22 May 2012
HEALTH CARE REFORM
101

2.  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
WHAT IS THE ACA?

3.  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
REFORMS IN THE ACA ATTEMPT TO:

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. 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)
KEY COMPONENTS

6. 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
INSURANCE REFORM

7. 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
INDIVIDUAL MANDATE

8. 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
MEDICAID EXPANSION

9.  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
HEALTH INSURANCE EXCHANGE

11. 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
ESSENTIAL HEALTH BENEFITS
WHAT IS ESSENTIAL?

12. 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 %
COVERAGE REFORM

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.  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
HEALTH INFORMATION TECHNOLOGY
REFORM

17. §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
HEALTH EQUITY PROVISIONS

18. CONSTITUTIONAL CHALLENGES
Kaiser Family Foundation. Available at: http://www.kaiserhealthnews.org/Supreme-Court-Decides-
Health-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 pre-
existing 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?