The%20Affordable%20Care%20Act:%20Opportunities%20for%20Care%20and%20for%20Single%20Payer

1
The Affordable Care ActOpportunities for Care
and for Single Payer

• Ellen R. Shaffer PhD MPH
• EQUAL Health Network
• www.equalhealth.info
• 415-922-6204 ershaffer_at_gmail.com
• February 7, 2010

2
The Affordable Care Act

• The Affordable Care Act is a major victory
• Single payer would go farther
• Both are under attack
• Reproductive Rights is an Older Womens issue

3
Crisis Access, Cost, Quality

• 50 million uninsured
• Deaths
• Bankruptcy even with insurance
• 2.5 Trillion a year 8,000/person
• Most expensive in the world
• 37th in outcomes
• Shortage of primary care
• Fragmented

4
Health Reform A Start

• ACA delivered what Obama campaign promised
• Significant though limited reforms
• Takes important steps to expand coverage and
  improve quality, and begins to control costs
• Claim the victory of half a loaf and use policy
  space to proceed deliberately to win the rest.
• Will Administration advance, retreat, hold the
  line?

5
Patient Protection and Affordable Care Act (ACA)
The Gains

• Expanded Coverage and Access
• Improving Quality
• Consumer Protections
• ALL Lower Costs
• How Will We Benefit?

5
6
ACA Benefits Phased In 2010-2020

• Public health grant programs
• 2010-2013
• Consumer protections
• Affordability and quality improvements
• 2014 Major coverage expansions
• Health Insurance Exchanges
• For individuals, small business employees
• Individual Mandate, Employer contributions
• Medicaid Expanded
• Everyone up to 133 of poverty level
• 2020 Medicare drug price doughnut hole gon

6
7
2014 Major coverage expansions

• Medicaid Expanded
• Everyone up to 133 of poverty level
• 14,404 for individuals
• 29,326 for a family of four
• Health Insurance Exchanges
• For individuals, small business employees
• Individual Mandate, Employer contributions
• Premium subsidies up to 400 of poverty level
  (88,000 for 4)
• Limits ib premiums, out of pocket spending
• Undocumented immigrants generally not covered

7
8
Estimated Health Insurance Coverage in 2019
Figure 6
Total Nonelderly Population 282 Million
SOURCE Congressional Budget Office, March 20,
2010
Return to KaiserEDU Tutorials
9
Coverage Now

• New High Risk Pool Pre-Existing Condition
  Insurance Plans (for uninsured with pre-existing
  conditions)
• Covers Young Adults through Age 26 on parents
  coverage

9
10
ACA Benefits Phased In 2010-2020

• 2010-2013
• Consumer protections
• Affordability and quality improvements
• 2014 Major coverage expansions
• Health Insurance Exchanges
• For individuals, small business employees
• Individual Mandate, Employer contributions
• Medicaid Expanded
• Everyone up to 133 of poverty level
• 2020 Medicare drug price doughnut hole gone

10
11
Immediate Improvementsin 2010

• Coverage
• New High Risk Pool (for uninsured with
  pre-existing conditions)
• Covers Young Adults through Age 26 on parents
  coverage
• Quality
• Increased funding for Community Clinics

11
12
Immediate Improvements2010

• Stops Insurance Abuses
• Discrimination against children with pre-existing
  conditions prohibited
• Rescissions Illegal (withdrawal of care)
• Bans lifetime limits on coverage
• Affordability
• Small business tax credits of up to 35
• Rebates begin to close the Medicare Part D
  Doughnut Hole
• Reduces cost of early retiree coverage

12
13
Insurance Exchanges Who
State-based Exchanges begin in 2014 Uninsured
individuals, self-employed and small businesses
can buy standardized, affordable coverage
Safety net for insured who lose a job Est. 2.4
million eligible in CA NOT MOST UNION
MEMBERS. NOT FOR MEDICARE!! Applies to Members
of Congress
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Family of Four

• Joes family income

Joe pays max. premium of

• 25,000/yr
• 50,000/yr
• 80,000/yr

• Eligible for MediCal
• 302/month 3,624/yr
• 663/month 7,956/yr

Actual cost may be less depending on age of the
worker
15
Insurance Reform Limits on Insurance Premiums
Cannot charge more if You are sick You are
female (Gender-rating) Age-rating limited,
31 No more annual or lifetime
limits Administrative costs limited No
underwriting Easier to compare plans
,
15
EQUAL Health Network
16
Other Key Features

• Investments in public health
• Quality Improvements
• Free preventive care
• More to primary care docs nurses
• Consumer Protections
• Medicare
• Trust Fund Preserved to 2029
• Prescription Drug Donut Hole closed - 2020

17
Immediate Benefits for California

• Benefit
• Small business tax credit
• 250 relief from donut hole
• Early Retiree Reinsurance Program benefits
• Ending lifetime coverage limits
• Youth up to age 26 covered

• Increased Coverage for
• 503,000 small businesses
• 382,000 Medicare beneficiaries
• 430,000 early retirees
• 19 million residents
• 196,000 individuals

761 million federal dollars are available to
California to provide coverage for uninsured
residents with pre-existing medical conditions
18
Affordability Now

• Rebates begin to close the
• Medicare Part D Donut Hole
• 250 in 2010 50 brand name drugs 2011
• Small business tax credits of up to 35
• States and feds can reject unreasonable
  premiums
• Reduces cost of early retiree coverage

19
AffordabilityMedical Loss Ratio

• 80-85 of premium must be spent on health care
  (vs. admin., profit)
• Rebates
• Current policy debate
• Wellness programs run by insurance co.s
  Medical care?
• or
• Marketing?

20
Quality Now

• Free preventive care
• Decision point Will HRSA cover contraception
  thru prevention?
• Exception for Grandfathered plans
• Increased funding for Community Clinics
• More money for primary care and public health

21
Consumer Protections Now

• Discrimination against children with pre-existing
  conditions prohibited
• Rescissions Illegal (withdrawal of care)
• Bans lifetime limits on amount of coverage
• Annual limits phased out

21
22
State Insurance Exchanges, 2014 Who
Uninsured individuals, self-employed and small
businesses can buy coverage NOT FOR
MEDICARE!! Safety net for insured who lose a
job Applies to Members of Congress No Public
Option
22
23
Insurance Reform Limits on Insurance Premiums
Cannot charge more if You are sick You are
female (Gender-rating) Age-rating limited,
31 No more annual or lifetime
limits Administrative costs limited No
underwriting Easier to compare plans
,
23
EQUAL Health Network
24
Costs of coverage for subsidy eligible
individuals in exchange compared to existing
non-group market (premium and out-of-pocket)
25
Financing Health Reform, 2010-2019
Figure 15
Federal savings
New revenues
Total Cost 938 Billion
Savings to Federal Deficit 124 Billion
Source Congressional Budget Office, 2010
Return to KaiserEDU Tutorials
26
Premiums on the Exchange

• Premium contributions limited based on income as
  a percent of Federal Poverty Level (FPL)
• 150 FPL (16,245/yr) 68/month
• 200 FPL (21,660/yr) 113
• 250 FPL (27,075/yr) 191
• 300 FPL (32,490/yr) 257
• Hardship exemption Available if lowest cost plan
  exceeds 8 of an individuals income
• Comparison Single payer bills c. 10 payroll
  tax

27
Elements of Single Payer

• Single payment source government
• Vast reduction in administrative costs
• Effective levers for cost control
• Universal coverage
• Can improve administration, information, quality
  of care

28
Universal Coverage Undocumented Immigrants

• Important human right
• Preventive care improves health, reduces ER use
• Undocumented in CA pay 80,000 more in fees than
  receive in lifetime govt. benefits

29
Cost Control

• Budgets control costs on the supply side
• Growth in health spending linked to
• State GDP, population growth
• Technological change
• Demographics (employment, etc.)
• Administration 5 limit
• Negotiate prescription drug prices
• Increase primary care No co-pays or deductibles

30
Delivery System

• Current mix public and private providers
• Choice of primary care MD
• Referral needed to specialist
• Payment methods, risk adjusted
• Fee for service
• Facility budget
• Capitation
• Financial incentives to practice in underserved
  areas for primary care

31
Comprehensive Benefits

• Medical and surgical
• Mental health, substance abuse
• Dental
• Prescription drugs
• Hospice, SNF after hospital
• Health education
• Translation, transportation

32
Accountable Governance

• Elected Health Commissioner
• Health Policy Board
• Office of Medical Practice Standards
• Office of Consumer Advocacy
• Health Care Fund
• Inspector General

33
Quality

• Access to primary care
• Monitor health outcomes
• Program decrease medical errors
• Planning for health providers, facilities

34
Single Payer Bills

• Congress
• HR 676 Conyers
• S 703 Sanders
• HR 3000 B Lee
• State
• CA SB 810
• Vermont Hsiao Report

35
How Is Single Payer Financed

• HR 676 Federal bill Rep. Conyers MI
• Existing federal revenues for health care
• Increase income tax on top 5 income earners
• Excise tax on payroll and self-employment income
  (SSI)
• Tax on stock and bond transactions

36
HR 676 System Savings

• Reduced paperwork
• Bulk procurement of medicines
• Improved access to preventive care

37
Vermont Proposal

• Payroll tax (SSI)
• Exempts workers who are paid and employers who
  pay wages below 180 of the FPL
• exemption is phased out at 220 of FPL.
• payroll contribution capped at 120,000.

38
Vermont

• Firms employing between 1 and 10 employees will
  spend in total 173 million more than they would
  have under PPACA reforms in 2019, or 1,702 per
  employee. However, larger firms will experience
  lower spending than they would have under PPACA.
• Spending for firms with between 101 and 500
  employees will be 20 million less, or 332 less
  per household, while firms with more than 500
  employees will spend 111 million less, or 1,039
  less per household.
• Firms who currently provide health insurance to
  their employees would see lower costs than they
  would have under PPACA reforms. In total,
  offering firms will spend 211 million less in
  2019, or 947 per household. However, firms not
  currently offering insurance will pay more.
  Non-offering firms will see increase in costs of
  285 million in 2019 under option 1a reforms, or
  1,722 per employee. 97

39
Vermont Households

• Total costs including contributions will be lower
  under option 1A by 339 million in 2019 as
  compared to ACA, or 1,201 per household.
• Total additional benefits will also be lower.
• However, the net financial benefit will be 198
  million, or 704 per household.

40
Senate Bill 921 (Kuehl)The Health Care for All
Californians Act

• Similar to HR 1200 (McDermott/Wellstone)
• Financing State Health Fund
• Earmarked state health care taxes replace
  insurance premiums
• Combine existing federal, state, county health
  funds (50 current health care payments)

41
ACA Steps Towards Single Payer

• Expands coverage
• Required financing by government, individuals and
  employers will create incentives for greater cost
  controls
• New quality measures and delivery system reforms
  will guide cost control while protecting benefits

41
42
Toward Single Payer

• legislative commitment to universal coverage
• national benefits standard
• income-based definition of affordability
• an employer mandate,
• global budget for Medicare
• the recognition that insurance must be much more
  strongly regulated, with new institutions for
  doing that

43
ACA

• Effective 1/1/2011 to 12/31/2016, there will be a
  10 bonus in Medicare payments to PCPs that have
  at least 60 of Medicare billing in the areas of
  office, nursing home and home care visits.
• From 1/1/13 to 12/31/14 will raise Medicare
  rates for primary care physicians for evaluation
  and management services, and services related to
  immunization.
• National Health Service Corps funding is planned
  to rise from 320M/year in 2010 to 1.15B/year in
  2015. These funds are those used to help PCPs in
  high need areas pay back their debt.
• Title VII funds to family medicine residency
  programs and academic departments of family
  medicine have also been reauthorized.
• January 1, 2011, funding for community health
  centers will increase by 11 billion.

44
Why is This Controversial?

• Opponents can not muster votes to repeal
• But will focus on undermining it
• Public divided
• Statist government takeover
• Corporate takeover
• Some support, experiencing benefits
• Unfinished issues continue to be controversial
• Social divisions abortion, immigrants
• Role of government public option

45
SB 840

• The California Health Insurance System will be
  funded by a combination of monies already
  collected and used by government health agencies
  such as Medicare and Medi-Cal, and new revenues.
  Government monies already pay for about half of
  all health expenditures. The use of Medicare and
  Medicaid funds will require waivers negotiated
  with the federal government. (140240)
• The specific new revenues for CUHA have not yet
  been included in the bill. A Premium Commission
  will recommend additional new revenues to pay for
  the remaining cost of the program. These will
  likely include health premiums based on a
  percentage of wages, paid partly by employers and
  partly by employees.
• The Lewin Group (2004) studied a proposal for
  approximately 12 of wages along with some other
  taxes, and found it adequate

46
National Deficit With and Without Health Reform
47
Why Do We Do Worse Than Other Countries?
Problem ACA Remedy
For-profit insurance co.s Regulates
Too many specialists Supports primary care and prevention
Fragmented care Medicare Innovations
Inequalities Expands coverage through the public sector
48
Election 2010

• Republican agenda
• Fight about health care as lead up to 2012
  election
• Focus on abortion
• Moderate Democrats and Republicans
• Deficit Commission Slash Medicare, Social
  Security
• Free trade/expand exports
• Dems beat big money in CA
• VT governor stumping for single payer

49
Contest for the Future

• Corporate domination of campaign spending was
  successful in many races but not all
• Analyze whats working and do more of it
• Traditional advocacy groups limited unions,
  women, seniors, etc.
• Take the initiative to create vehicles for
  advocacy

50
The ACA Educate, Defend, Implement

• Regulations.Gov
• Comment on Medical Loss Ratio, repro rights
• State activities
• Implement exchanges
• Incorporate larger businesses sooner
• Create public insurance

51
Reproductive Rights

• Contraception is a preventive health care service
• Abortion has been stigmatized and marginalized
• 30 of women have had an abortion
• Safe rare and legal not sufficient
• Overturn Hyde amendment limiting federal funding

52
Trust Women/Silver Ribbon Month

• Anniversary of Roe v. Wade Jan. 22
• Broad coalition of health, repro rights, social
  justice groups
• The majority needs a visible, vocal campaign
• Speak out, take action, wear silver ribbon
• Trust Women

53
Immigrants

• Of the 12.3 million immigrants without health
  insurance, more than half (6.3 million) are
  working, and about 900,000 are children.
• Other countries treat US nationals abroad Demand
  reciprocity.

54
State and National Single Payer Campaigns

• Reclaim the important role of effective,
  accountable government in creating affordable
  health care, economic prosperity and a socially
  just society
• Defend Medicare and Social Security

55
Building for the Future

• Join the EQUAL Listserv
• Send a blank message to
• join-equal_at_list.equalhealth.info
• www.equalhealth.info
• Thanks for contributions to this presentation to
  Keely Monroe, Lisa Kernan Social Justice Fellow
  EQUAL partners including Deborah LeVeen, Elinor
  Blake, Karl Keener, Joel Adelson, Lee Lawrence,
  Robert Mason and many organizations

55
56
Optimal use of professionals

• The Patient-Centered Medical Home model
• Non-physician primary care providers
• Extenders of care emanating elsewhere

56
57
Include public health in our thinking and planning

• Integrated with clinical care, part of PCMH
• Independent community-based providers
• Supported in title IV and V of the ACA

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Improving the System

• Quality measure development
• Outcomes and function status
• Management and coordination across episodes and
  care transitions
• Patient-centeredness

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System Change

• Drivers are toward integrated systems of care,
  including quality measures applied to patient
  transfers
• Broadening to include more emphasis on care in
  the home Section 3024 establishes an
  Independence at Home Medical Practice category,
  serving at least 200 applicable beneficiaries and
  using electronic health information systems,
  remote monitoring, and mobile diagnostic
  technology

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System Change continued..

• Community health teams, patient centered-medical
  homes, health teams (Section 3502)
• Regionalized systems for emergency care

60
61
System Change Big Picture

• Secretary develops a national strategy to improve
  the delivery of health care services, patient
  health outcomes and population health
• Secretary develops quality measures assessing
  health outcomes and functional status, management
  and coordination across episodes and care
  transition, and experience, quality, and use of
  information to and used by patients

61
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Big Picture continued

• Center for Medicare and Medicaid Innovation in
  CMS
• National Health Care Workforce Commission
• Patient-centered Outcomes Research Institute and
  trust fund rural-relevant comparative
  effectiveness research?

62
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Using Elements of the Legislation as a Package

• Integrating systems for payment and quality
  improvement
• Patient focus and primary care
• Opportunity for public health overlay

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ACA OpportunitiesTitle IV, Subtitle A

• The new National Prevention, Health Promotion and
  Public Health Council
• The new Advisory Group on Prevention, Health
  Promotion, and Integrative Public Health
• Use of a new Prevention and Public Health Fund
• CDC to convene an independent Community
  Preventive Services Task force

64
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ACA OpportunitiesTitle IV, Subtitle A,
continued

• Planning and implementation of a national
  public-private partnership for a prevention and
  health promotion outreach and education campaign
  to raise public awareness of health improvement
  across the life span
• Establish and implement a national science-based
  media campaign on health promotion and disease
  prevention

65
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ACA OpportunitiesTitle IV, Subtitle B

• School-based health centers
• Medicare coverage of personalized prevention plan
  services

66
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ACA OpportunitiesTitle IV, Subtitle C

• CDC grants for implementation, evaluation, and
  dissemination of evidence-based community
  preventive health activities in order to reduce
  chronic disease rates, prevent the development of
  secondary conditions, address health disparities,
  and develop a stronger evidence base of effective
  prevention programming
• Grants to provide public health community
  interventions, screenings, and clinical referrals
  for persons between ages 55 and 64

67
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ACA OpportunitiesTitle IV, Subtitle D

• Funding for research in the area of public health
  services and systems
• Employer based wellness assisted
• Epidemiology and Laboratory Capacity Grant
  Program
• Funds to carry out childhood obesity
  demonstration projects

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Significant Limits

• Reproductive Health Retreat from current law
• Contraception (Preventive?)
• Abortion care (Hi-risk pools, Exchanges)
• Immigrants inclusion Undocumented cannot
  purchase thru Exchange
• Affordability
• State options for innovative approaches
• Single payer

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Always a Tough Road


July, 2010
70
EQUAL/Center for Policy Analysis
71
Structural Adjustment for the U.S.1980 - present

• Deregulation
• Privatization
• Constraints on public interest organizations
  (civil society)

72
Effect Income Inequality Explodes1979-2005

• 1947 and 1973 income growth was distributed
  roughly equally income growth at least as fast
  for the poorest 20 of families as the richest
  20
• 1979-2005 Bottom fifth of households average,
  inflation-adjusted income growth of just 200
  over the entire 26-year period.
• By contrast, a small number of households at the
  top 0.1 of the income scale saw average income
  growth of almost 6 million over the same time.
  
• Economic Policy Institute

73
Health Care Policy Corporations

• Maintain control of health care
  benefitsworkplace discipline
• Oppose government role, favor private insurance
  industry
• Public relations
• Liberty
• Freedom of choice

74
Health Care Industry 2.5 T

• Insurance co.s
• Lack clout to negotiate rates with concentrated
  providers (hospital chains
• Individual market adverse selection
• Price gouging
• Providers Hospitals, docs, drugs, medical supply
• some Government payments, yes
• Negotiated prices, no

75
Corporate media
July, 2010
75
EQUAL/Center for Policy Analysis
76
Who Owns Your TV?

• General Electric NBC, AE, History Channel
• Walt Disney ABC, ESPN
• News Corp Fox
• CBS CBS
• Sold Salt Lake City network to 4 Points Media,
  subsidiary of Cerberus, which owned Chrysler
• Viacom Comedy Central
• Time Warner CNN, HBO, TCM

77
Health Care Considered 1 Drag on Economy- Until
Fall, 2008

• Speculative bubbles burst
• Houses/real estate
• Finance
• Trade imbalance
• Wars
• Tax breaks for wealthy
• Redistribution of income
• Reverse Robin Hood

78
Unemployment by Race, Dec. 2007- Aug. 2010
79
Home Prices Jan. 96 June 2010
80
Election 2010

• Republican agenda
• Fight about health care as lead up to 2012
  election
• Focus on abortion
• Moderate Democrats and Republicans
• Deficit Commission Slash Medicare, Social
  Security
• Free trade/expand exports
• Dems beat big money in CA
• VT governor stumping for single payer

81
Contest for the Future

• Corporate domination of campaign spending was
  successful in many races but not all
• Analyze whats working and do more of it
• Traditional advocacy groups limited unions,
  women, seniors, etc.
• Take the initiative to create vehicles for
  advocacy

82
The ACA Educate, Defend, Implement

• Regulations.Gov
• Comment on Medical Loss Ratio, repro rights
• State activities
• Implement exchanges
• Incorporate larger businesses sooner
• Create public insurance

83
Reproductive Rights

• Contraception is a preventive health care service
• Abortion has been stigmatized and marginalized
• 30 of women have had an abortion
• Safe rare and legal not sufficient
• Overturn Hyde amendment limiting federal funding

84
Trust Women/Silver Ribbon Month

• Anniversary of Roe v. Wade Jan. 22
• Broad coalition of health, repro rights, social
  justice groups
• The majority needs a visible, vocal campaign
• Speak out, take action, wear silver ribbon
• Trust Women

85
Immigrants

• Of the 12.3 million immigrants without health
  insurance, more than half (6.3 million) are
  working, and about 900,000 are children.
• Other countries treat US nationals abroad Demand
  reciprocity.

86
State and National Single Payer Campaigns

• Reclaim the important role of effective,
  accountable government in creating affordable
  health care, economic prosperity and a socially
  just society
• Defend Medicare and Social Security

87
Health Care Policy Is Linked With Broader Agendas

• Demand policies that create a healthy economy
• Public investment to re-stimulate productivity
  and demand
• Jobs to lower-income people create demand
• Health care, education, energy, environment
• Fair financing for public services
• Government role to support baseline survival,
  advance social justice and wellbeing
• Guarantee rule of law financial regulation
• Activate organizations of civil society

87
88
Building for the Future

• Join the EQUAL Listserv
• Send a blank message to
• join-equal_at_list.equalhealth.info
• www.equalhealth.info
• Thanks for contributions to this presentation to
  Keely Monroe, Lisa Kernan Social Justice Fellow
  EQUAL partners including Deborah LeVeen, Elinor
  Blake, Karl Keener, Joel Adelson, Lee Lawrence,
  Robert Mason and many organizations

88