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

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The Affordable Care Act: Opportunities for Care and for Single Payer Ellen R. Shaffer PhD MPH EQUAL Health Network www.equalhealth.info 415-922-6204 ershaffer_at_gmail.com – PowerPoint PPT presentation

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Title: 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
13
14
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

57
58
Improving the System
  • Quality measure development
  • Outcomes and function status
  • Management and coordination across episodes and
    care transitions
  • Patient-centeredness

58
59
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

59
60
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
62
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
63
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

63
64
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
65
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
66
ACA OpportunitiesTitle IV, Subtitle B
  • School-based health centers
  • Medicare coverage of personalized prevention plan
    services

66
67
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
68
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

68
69
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

69
70
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
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