The%20Architecture%20of%20Health%20Reform:

1
The Architecture of Health Reform Building
Access to Reproductive Health Susan Berke Fogel
JD LA County Coalition for Women and Health Care
Reform September 1, 2011
Securing Health Rights for Those in Need
2
NHeLP

• National public interest law firm working to
  advance access to quality health care and protect
  the legal rights of low-income and underserved
  people
• Offices in Washington D.C., Los Angeles, and
  North Carolina
• Comprehensive analysis of health care reform law
  ongoing updates
• Visit our website at www.healthlaw.org

3
Two Roads at Once

• State Exchanges
• ACA Implementation
• Family Planning Expansions

• State and Federal Cutbacks
• Anti-Reform Litigation
• De-funding the ACA

4
Goals and Ideals

• everyone excludes undocumented immigrants
  coverage excludes abortion

5
The current system
6
The current system
7
What Will we Build?
8
Uninsured in California

• 7 million uninsured (2009)
• 4.7 million non-elderly will be eligible for
  exchange
• 3.1 million remain uninsured
• Undocumented
• Exempt from individual mandate
• Wont/cant participate
• Source Unsure the Uninsured Project

9
Insurance Status of Non-elderly Women in
California
Uninsured by Income
Total 2.6 M
Women ages 18-64 Kaiser Family Foundation Insuranc
e Data 2008-2009 Income Data 2007
10
Insurance and income LA County

• Insurance status
• 21.3 of women (18-64) in LAC are uninsured
• 20.4 are enrolled in Medicaid
• 57.1 have private insurance
• Economic status
• 39.7 of uninsured women lt100 FPL
• 30 of uninsured women 100-199 FPL

11
Health disparities and reproductive health

• Women of color of child bearing age are
  disproportionately poor
• 10.7 non-Hispanic white
• 11.1 Asian Pacific Islander
• 25.5 African American
• 22.4 Latina
• 24.2 Native American/Alaska Natives
• People of color are the majority of individuals
  enrolled in Medicaid

12
Health Disparities and Pregnancy
Unintended pregnancy Abortion of all abortions Prenatal care in 1st trimester
African American 69 of pregnancies 30 73
Latina 54 of pregnancies 25 74
White 40 of pregnancies 36 85
13
How Will We Get Insurance?
14
Medicaid Eligibility Overview
15
What does this mean for women?

• 20 of women are uninsured
• 28 of women of color are uninsured
• 37 Latinas
• 23 African Americans
• 18 API
• 54 of uninsured women eligible for Medicaid
• Newly eligible include childless lesbians,
  young adults, older women under age 65, women
  with disabilities, women with HIV
• Source Kaiser Family Foundation

16
Who is left out?

• Undocumented immigrants
• Do not qualify for Medicaid
• Can access emergency care, pregnancy, family
  planning
• Cannot buy insurance in the exchange with their
  own money
• People above 133 FPL who cant afford premiums
• People exempt from mandate
• People who cant navigate the system
• Homeless, mental disabilities, cant prove
  citizenship, LEP, disaster victims, DV survivors

17
Whats Covered?
Exchange Tiers Tier 5 Platinum Tier 4
Gold Tier 3 Silver Tier 2 Bronze (basic) Tier
1 Catastrophic
18
Delivery Systems
19
Preventive Screening Services
U.S. Preventive Taskforce A and B Level Recommendations U.S. Preventive Taskforce A and B Level Recommendations U.S. Preventive Taskforce A and B Level Recommendations U.S. Preventive Taskforce A and B Level Recommendations U.S. Preventive Taskforce A and B Level Recommendations
Lifestyle/Healthy Behaviors Cancer STI/STDs Chronic Conditions Pregnancy
Alcohol Screening Colorectal HIV Hypertension Tobacco
Depression Screening Breast Screening Gonorrhea Diabetes Rh Incompatibility Screening
Healthy Diet Counseling Breast Chemoprevention Chlamydia Obesity Screening Hepatitis B Screening
Tobacco Breast/Ovarian High Risk/BRCA Syphilis Osteoporosis Iron Deficiency Anemia Screening
Immunizations Cervical Cancer Lipid Disorders Bacteriurea Screening
20
Publicly-funded family planning
21
Pregnancy care

• Insurers must cover maternity care
• Funding for research and treatment of post-partum
  depression
• Pregnancy supports especially educational
  support for pregnant and parenting teens and
  young adults
• Medicaid coverage of birthing centers

22
Abortion restrictions in Exchanges Nelson
Amendment
23
The Exchange
24
Systems Issues

• Qualified Health Plans must include Essential
  Community Providers (ECP) such as
• Community clinics (FQHC and others)
• Title X and other family planning clinics
• Implementation issues
• Contracting
• Recognizing ECPs as medical homes
• Network adequacy access to all covered services
  religiously-controlled health systems

25
Impact of Religiously-controlled Health Systems

• Ethical and Religious Directives for Catholic
  Health Care Services US Conference of Catholic
  Bishops
• Absolute bans on abortion, sterilization, family
  planning
• Limits on treatment miscarriage mgmt, ectopic
  pregnancy care, EC, end of life care
• No health or life exception
• May refuse some services to LGBT communities
• Refusal to provide referrals barrier in managed
  care
• Some California Catholic hospitals allow some
  limited services under limited circumstances

26
Refusal Clauses Exempt Providers from Meeting the
Standard of Care

• Refusal clauses shield individual providers and
  institutions from liability for their failure to
  deliver care that would otherwise be required
• accepted medical standards of care
• legal requirements for care
• Refusal clauses allow institutions to prevent
  providers from meeting the standard of care
• Regardless of health outcome

27
The California Exchange Board

• 5 member board
• Kimberly Belshe, Diana Dooley, Paul Fearer, Susan
  Kennedy, Robert Ross
• Executive Director Peter Lee
• Responsibilities
• Determine structure of Exchange
• Determine criteria for participation in Exchange
  selective contracting
• Stakeholder input
• Accountability

28
Access and affordabilityNo Wrong Door

• Web Portal
• Eligibility and enrollment
• Language access
• Toll-free hotline
• Navigators
• Assist with outreach and enrollment
• New proposed rules open comment period
• Affordability
• Subsidies
• Cost-sharing

29
Low Income Health Program

• ACA allow states to begin Medicaid expansion
• CA waiver county option (LAC is up and running)
• lt133 FPL resident citizen or lawful immigrant
  5 yrs
• Medical home
• No categorical eligibility
• No cost
• Preventive, mental health, specialty care

30
Other options on the horizon

• Basic Health Plan (SB 703)
• State option
• 134 200 FPL
• Enrollees dont get subsidies or tax credits, but
  premiums cannot be higher than in exchange
• State gets 95 of federal share of subsidies and
  tax credits
• Managed care
• Essential health benefits
• Lower cost-sharing

31
A few of the many remaining questions

• Transitions between Medi-Cal and Exchange
• Fluctuations in income
• Pregnant women above 133 FPL
• Family planning expansions post 2014?
• Breast and Cervical Cancer Treatment
• Title X, Ryan White, etc what will happen to
  targeted funding?
• Refusal Clauses?
• Citizenship documentation
• How much flexibility to the states is good for
  consumers?

32
Stakeholder Input

• Comment on federal regulations www.healthcare.gov
• Exchanges
• Medicaid eligibility and enrollment
• Womens health preventive services
• Essential Health Benefits
• Participate in California Exchange Board meetings
  www.healthexchange.ca.gov
• In person meetings in Sacramento
• Web-cast

33
NHeLP

• www.healthlaw.org
• www.healthconsumer.org
• Fogel_at_healthlaw.org
• 310-204-6010 ext 113