Patient Protection and Affordable Care Act (PPACA)

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Patient Protection and Affordable Care Act (PPACA)

• CHARU SAWHNEY, DO, MPH
• HOPE Clinic A Community Health Center

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Overview

• Sources of coverage in US
• 6 Key features of PPACA
• Implementation of key features
• US
• Texas
• Challenges ahead

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Sources of Coverage in the US (2010)
Non-elderly Population
Total Population
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Characteristics of the Nonelderly Uninsured, 2010
Family Status
Family Income
Family Work Status
400 FPL and Above
251-399 FPL
No Workers
Children
Adults without Dependent Children
lt100 FPL
1 or More Full-Time Workers
Parents
100-250 FPL
Part-Time Workers
Total 49.1 million uninsured

• The federal poverty level was 22,050 for a
  family of four in 2010.
• Data may not total 100 due to rounding. SOURCE
  KCMU/Urban Institute analysis of 2011 ASEC
  Supplement to the CPS.

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PPACA - Key Features

• Rights and Protections
• Insurance Choices
• Insurance Costs
• 65 or Older
• Employers
• Access to affordable care

6
Rights and Protections from High Out of Pocket
Costs

• Protects your choice of doctors
• Ends annual and lifetime limits on coverage by
  2014
• Ends arbitrary withdrawals (rescissions) of
  insurance coverage 9/2010
• Covers preventive care at no cost to you 9/2010
• No pre-existing condition exclusions
• 2010 for children
• 2014 for all consumers

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PPACA - Key Features

• Rights and Protections
• Insurance Choices
• Insurance Costs
• 65 or Older
• Employers
• Access to affordable care

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Insurance Choices - Immediate

• Pre-existing condition insurance plan - 7/2010
• If you have been rejected for insurance due to a
  health condition or disability
• Young adult coverage 9/2010
• Coverage through your parents insurance plan up
  to age 26
• Even if they are married, not living with you,
  attending school, not financially dependent on
  you or eligible to enroll in their employers plan

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Pre-existing Condition Insurance Plan Texas

• Must be a US citizen or reside here legally
• Must be without health coverage for at least 6
  months
• Must have a pre-existing condition or have been
  denied health coverage because of your health
  condition

Age Standard Option Extended Option HSA Option
0-18 133 179 138
19-34 199 268 207
35-44 239 323 248
45-54 306 412 318
55 426 572 442
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Insurance Choices - Future

• Affordable insurance exchanges - 2014
• Shop for insurance and compare health plans in a
  new state-based Affordable Insurance Exchanges
• CO-OP insurance plans - 2014
• Small businesses or individuals buy insurance
  from a new type of non-profit, consumer-run
  health insurer called Consumer Operated and
  Oriented Plan (CO-OP)

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Linking Americans to Coverage (2014)
FPL 400 300 200 100
Unsubsidized
Exchange
Subsidized
185
Basic Health
133
133
133
2014
75
27
0
0
Children
Undocumented Immigrants
Adults w/o Children
Seniors People with Disabilities
Parents
Pregnant Women and Infants
Medicaid (based on average of state eligibility
levels in 2009) Private Market Coverage,
State-funded Program, or uninsured
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What is a Health Insurance Exchange?
2014
Individuals
Small Businesses
Qualified Health Plans
SHOP Exchange
IRS SSA
SHOP Qualified Health Plans
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Setting up an Exchange Options for States
Regional (Multi-state) Exchange
State-administered Exchange
Federally facilitated Exchange
Federal-State Partnership
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Exchange Implementation Relevant Deadlines
HHS Exchange Planning Grants available
Final deadline for grant applications
Close of most state legislative sessions
Launch of Exchange
HHS certification of state exchange
Fall
July
June
January 1
January 1
2010
2011
2012
2013
2014
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(No Transcript)
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PPACA - Key Features

• Rights and Protections
• Insurance Choices
• Insurance Costs
• 65 or Older
• Employers
• Access to affordable care

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Insurance Costs Value for Your Premium Dollar

• Pre-ACA Post-ACA

Actual Medical Expenses
Actual Medical Expenses
Admin overhead profits
Admin overhead profits
Large Group Market (85) Small Group Market (80)
Can be as low as 65
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Insurance Costs Rate Review

• Starting 9/1/2011, health insurers must justify
  any rate increase of 10 or more to state
  legislators/HHS before the increase takes effect
• 250 million given to states for rate review

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PPACA - Key Features

• Rights and Protections
• Insurance Choices
• Insurance Costs
• 65 or Older
• Employers
• Access to affordable care

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65 or Older

• Medicare Preventive Services
• Eligible for a number of cost-free preventive
  services
• Medicare Drug Discounts
• Eligible seniors who are in the coverage gap
  known as the donut hole automatically receive a
  discount on prescription drugs
• Start at 50 for brand names and 86 for generics
  in 2012
• End in 25 for brand names and 25 for generics
  in 2020

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Strengthening Medicare

• Cracks down on waste, fraud and abuse while
  providing new protections for seniors
• New rules and sentences for criminals
• Enhanced screening and other enrollment
  requirements
• Increased coordination of fraud prevention
  efforts
• Sharing data to fight fraud (Medicare, Medicaid,
  CHIP, VA, DOD, HIS, Social Security Disability
  Insurance program)
• New focus on compliance and prevention
• Expanded overpayment recovery efforts
• New Durable Medical Equipment Requirements
• New resources to fight fraud
• Greater oversight of private insurance abuses

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PPACA - Key Features

• Rights and Protections
• Insurance Choices
• Insurance Costs
• 65 or Older
• Employers
• Access to affordable care

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Employers Small Businesses

• Small Employer Tax Credits 1/1/2010
• Tax credits for small businesses and non-profits
  to help you bring down the cost of providing
  insurance
• If you have fewer than 25 employees and provide
  health insurance, you may qualify for a tax
  credit of up to 35 (up to 25 for non-profits)
  to offset the cost of your insurance.
• This credit will increase in 2014 to 50 (35 for
  non-profits). This will make the cost of
  providing insurance much lower.

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PPACA - Key Features

• Rights and Protections
• Insurance Choices
• Insurance Costs
• 65 or Older
• Employers
• Access to affordable care

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Preventing Disease and Illness

• 15 billion invests in proven prevention and
  public health programs that can help keep
  Americans healthy
• Reduce health care costs
• Improve quality of care

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Rebuilding the Primary Care Workforce

• The Prevention and Public Health Fund
• Creating additional primary care residency slots
• Supporting PA training in primary care
• Increasing the number of NPs trained
• Establishing new NP-led clinics
• Encouraging states to plan for and address health
  professional workforce needs
• Focus on Education and Worker Training
• Increasing access to providers in underserved
  areas
• National Health Service Corps
• Focusing on career training
• Expanding tax benefits to health professionals
  working in underserved areas
• Building primary care capacity through Medicare
  and Medicaid
• Providing financial assistance for students
• Making health care education more accessible

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Investing in Prevention

• Community Prevention (298 million)
• Community and state prevention
• Tobacco prevention
• Obesity prevention and fitness
• Clinical Prevention (182 million)
• Access to critical wellness and preventive health
  services
• Behavioral health screening and integration with
  primary health
• Public Health Infrastructure and Training (137
  million)
• Public health infrastructure
• Public health workforce
• Public health capacity
• Research and Tracking (133 million)
• Health care surveillance and planning
• Prevention research
• Building on Other Initiatives that Promote
  Prevention
• Presidents Childhood Obesity Task Force
• First Ladys Lets Move! Initiative
• National Prevention, Health Promotion and Public
  Health Council

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Strengthening Community Health Centers

• New funding to support the construction of and
  expansion of services at CHCs (11 billion)
• Serve 20 million new patients across the country
• Builds on the funding provided to CHCs in 2009
  through the American Recovery and Reinvestment
  Act (2 billion)

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Other key features

• Payments for rural health care providers
• Improving health care quality and efficiency
• Center for Medicare and Medicaid Innovation
• Improving health care for seniors after they
  leave the hospital
• Community Care Transitions Program
• Coordinating care to avoid unnecessary
  readmissions
• New Innovations to bring down costs
• Independent Payment Advisory Board submit
  proposals to Congress and the President aimed at
  extending the life of the Medicare Trust Fund
• Community First Choice Option
• Allows states to offer home and community based
  services to disabled people through Medicaid
  rather than institutional care in nursing homes
• Encouraging Integrated Health Systems
• Accountable Care Organizations

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Improving Quality

• Linking Payment to Quality Outcomes 10/2012
• Establishes a hospital Value-Based Purchasing
  program
• Increasing Medicaid Payments for PCPs 2013
• Requires states to pay PCPs no less than 100 of
  Medicare payment rates for primary care services
• Expanded Authority of Bundle Payments
• National pilot program to encourage hospitals,
  doctors and other providers to work together to
  improve the coordination and quality of patient
  are
• Pay flat rate for an episode of care rather than
  the current fragmented system where each service
  is billed separately to Medicare
• Paying Physicians Based on Value Not Volume - 2015

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Promoting Individual Responsibility

• Most individuals who can afford it will be
  required to obtain basic health insurance
  coverage or pay a fee to help offset the costs
  for uninsured Americans
• If affordable coverage not available, he/she will
  be eligible for exemption

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Challenges ahead for Texas

• Political gridlock on ACA
• Lack of consumer engagement and involvement
• Tight implementation timeline
• TX population of newly covered largest scale in
  US

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Resources

• Kaiser Family Foundation
• www.kff.org
• The Health Care Law and You
• www.healthcare.gov
• Center for Public Policy Priorities Working for
  a Better Texas
• http//www.cppp.org/files 2011_11_TexasHealthCare.
  pdf
• Dave Chandra, Senior Policy Analyst, Center on
  Budget and Policy Priorities