Wellness and Prevention in Health Reform Concerns with wellness plans and examples of consumer-friendly prevention provisions Claire McAndrew Families USA February 16, 2010

Wellness Plans Today Individual market wellness plans are not federally regulated; some states have passed relevant laws Group market (workplace) wellness plans are regulated by HIPAA rules Rules divide employer wellness plans into two groups:

Wellness Plans Today: Employer Plan Design Plans based on participation goals: Example: Employees who participate in a nutrition seminar will have a lower deductible for their health insurance Incentive size restriction: none

Wellness Plans Today: Employer Plan Design Plans based on health factors/ outcomes: Example: An employer charges a higher deductible to workers who do not have a BMI under 35 Incentive size restriction: 20% of the value of total health insurance premium (including the employer’s and the worker’s share) Average worker premium for ESI in 2009: $4,824 (Kaiser/HRET 2009 Annual Health Benefits Survey) 20%= $965

Concerns with wellness plans today Access to coverage and care: Surcharges could make health coverage unaffordable altogether Lack of evidence-base Lack of comprehensive supports in programs Inequities: may place a disproportionate burden on individuals with low-incomes, racial and ethnic minorities, and individuals with chronic health problems or disabilities

Concerns with wellness plans today Privacy issues Alternative standards Verifying compliance/ measuring achievement Lack of appeal rights

Wellness Plans and Health Reform: Senate Bill Increases allowable incentive from 20% of premium value to 30%, with the option to go up to 50% This would increase allowable surcharges from $965 to $1,447 for an average worker, with the possibility of a $2,412 surcharge (using 2009 average values as an example)

Wellness Plans and Health Reform: Senate Bill Provides incentives for 10 states to start incentive-based wellness plans in their individual markets/ exchanges Expands to more states in 2017 at the Secretary’s discretion Major concern: Bill language appears to allow wellness surcharges to be tacked-on after people receive premium credits, undermining affordability protections

Wellness Plans and Health Reform: Medicaid Grants for states to do Medicaid wellness programs Protections Evidence-based Take into account unique needs of Medicaid population Incentives cannot affect eligibility or benefits Issue to watch

Wellness Plans and Health Reform: House Bill No change to incentive limit (20% for outcome- based plans still stands) Grant program for small businesses to start wellness plans, but only those that do NOT vary premiums or cost-sharing To receive grants, programs must also be comprehensive and provide an array of supports Note: Final Senate bill adopted some of these provisions— created a small business grant program with some standards, but doesn’t prohibit insurance-linked incentives.

Wellness Plans and Health Reform: Talking About It House provisions reflect broader health reform goals: evidence-based, comprehensive supports for improving health Senate provisions contradict broader goals of health reform, which seek to eliminate: Pre-existing condition and health status discrimination Unaffordable health coverage and care Concerns with today’s plans still stand

Wellness and Prevention that Works for Consumers: Senate Bill Comprehensive coverage for and increased access to preventive and health promotion services Private Market: Essential benefits package Medicare: wellness visit, no preventive cost-sharing Medicaid: smoking cessation for pregnant women Grant program for states to increase adult vaccination rates; Medicare study of beneficiary vaccine access

Wellness and Prevention that Works for Consumers: Senate Bill Targeted prevention and health promotion efforts based on where people spend their time: Grants for school-based health centers Grants to states, local governments, and community organizations to implement evidence-based, community prevention activities Specific grants for community health prevention and health promotion activities targeted to individuals ages 55-64, including screenings and referrals

Wellness and Prevention that Works for Consumers: Senate Bill Support for a preventive and public health infrastructure Creates a preventive medicine and public health training grant program Establishes a Community Health Center fund to increase investments in centers

Wellness and Prevention that Works for Consumers: Senate Bill Public awareness and education New fund for national prevention and health promotion strategies New campaign to make Americans aware of new access to preventive services Oral health prevention campaign Breast cancer awareness campaign targeted at young women New national diabetes prevention campaign and CDC National diabetes “report card”

Wellness and Prevention in Health Reform: Takeaway Wellness and prevention= GOOD! Underwriting and insurance discrimination disguised as wellness= BAD!

Wellness and Prevention in Health Reform: Resources Families USA Talking Points: “Senate Amendment on Wellness Program Surcharges Jeopardizes Access to Affordable Coverage and Care” amendment-in-senate-bill.pdf amendment-in-senate-bill.pdf Families USA Blog Post: “The Wellness Plan Discrimination Loophole” ness_plan_discrimination_loophole/ ness_plan_discrimination_loophole/ HIPAA Rules on Wellness Plans: “Nondiscrimination and Wellness Programs in Health Coverage in the Group Market; Final Rules,’ Federal Register 71, no. 239 (December 13, 2006):