SOME ASSEMBLY REQUIRED HEALTH REFORM AND COLORADO Colorado Consumer Health Initiative Barrier-free access to quality, affordable, health care ©

Making sense of Health Reform ©

What really is health care reform? The Patient Protection and Affordable Care Act and a reconciliation bill passed by Congress and signed by President Obama make up federal health care reform ©

3 Pillars of Health Reform Contain CostsExpand CoverageEnsure Quality ©

Colorado Context  Average premium for employee coverage in Colorado doubled during the decade between 1996 and 2006  Colorado families spend 19% of their income on health insurance in 2007  Between 2000 and 2007 health insurance premiums rose 4 times faster than wages (78% verus 19%) ©

Where we get our insurance (57% CO) (17% CO) (7% CO) (17% CO) 69.5% of uninsured are from working families 155,000 (out of 785,000) are uninsured children “Young invincibles” (18- 34) make up 40% of uninsured (Lewin Group) ©

Building blocks of the Affordable Care Act Insurance market reform – lower profit and less overhead allowed Creation of the Health Insurance Exchange (states do it or the feds will) Shared employer and individual responsibility Improving safety net programs Increased primary care health workforce More support of long-term health services Lets individuals keep their current coverage Risk Pooling – the more purchasers of insurance results in more funding to cover everyone ©

Insurance Market Reforms  Medical loss ratios – 80%/85%  Requirement for basic level of insurance - “essential health benefits” including preventative care, hospitalizations, maternity care, mental health, prescription drugs, rehab, etc.  Insurers must provide coverage to individuals with pre-existing conditions (kids 2010, adults 2014)  Lifetime limits on insurers payouts prohibited (2010)  Young people under 26 can remain on parents insurance (even if not students, or living at home)  New consumer protections must be part of plans: appeals of denials, transparency, rate review, etc. ©

Change to Insurance under PPACA: Individual and Employer Responsibility In 2014, everyone will be required to have health insurance that meets a minimum standard of quality and coverage (certain exemptions) All adults and children below 133% of FPL will be eligible for Medicaid People earning less than 400% of the federal poverty will get subsidies or tax credits to buy insurance within health care exchanges (see next slide) People who go without insurance for more than 3 months will pay a penalty (around the same cost they would pay for insurance) Employer Penalties: Large employers (200+) must provide coverage; mid-sized employers (50+) must either offer coverage or pay a penalty. Small employers (< 50 employees) have no mandate. ©

Health Insurance Exchanges By 2014, each state will have a new “marketplace” (with tiered certified plans – Bronze, silver, gold). If a states fails to create its own exchange the Federal government will provide it. The exchanges will include “navigators” to help small businesses and individuals purchase insurance that is right for them There will be subsidies for individuals and tax credits available through the Exchange (up to 400% FPL) Exchanges must include a non-profit insurer Members of Congress get their coverage in their state Exchange too! ©

Helps small businesses and the economy in Colorado Up to a 35% tax credit to offset the cost of insurance to low and middle income employees ( ) Up to 50% tax credit for 2 years through the Health Insurance Exchange (2014) Up to a 25% tax credit for non-profit organizations (2010) Grants for small businesses to establish wellness programs (2011) Tax credit calculator: ©

What does reform me for me?  Individuals  Young adults  Early retirees  Women  Seniors  Kids  Immigrants  Employers ©

For young adults  If you are under 26, you can stay on your parent’s insurance if your parent’s insurance offers dependent coverage (started 2010)  BUT you must not have a another offer of affordable coverage  You do not have to be in college or living in the same state – and you can be married!  If you are under 30 you can also purchase a low-cost “catastrophic” health plan (includes 3 primary care visits each year with no deductible) ©

For Baby Boomers Current Challenges for Boomers  Have higher uninsured rates (because of high costs for employers, recession)  Have much harder time getting insurance on the private market  PPACA –  Federal assistance for employers who provide insurance to early retirees (2010 – 2014)  Exchanges will provide access after 2014 (currently high-risk pools are available)  Prohibits discrimination by insurance companies based on pre-existing conditions or gender  Limits on insurance premiums based on age-ratings ©

For women  New anti-discrimination rules (ban on increased premiums for being a woman)  Requires insurance not have co-pays for preventative services and screening like mammograms, and maternity coverage required  Myth-buster: No subsidies for abortion in the Exchange, Hyde restrictions in Medicaid. ©

Strengthening Medicare  No co-pays for annual visits  No cost for vital preventive services to improve seniors health  Reform of Medicare Advantage plans - requires at least 85¢ of every $1 on health care service  Deals with the Donut Hole (gap in coverage): Rebate of $250 in 2010 and closes if by 2020  Creates program to provide 50% off drugs to seniors falling in the Donut Hole ©

For kids  Kids under 19 in families that earn less than 133% FPL ($24,300 for a family of 3) will be eligible for Medicaid  Medicaid reimbursement rates for providers will be increased to the same as Medicare – to increase access to providers  Child Health Plus (CHP+) will continue until All kids up to 400% FPL ($73,240 for a family of 3)  Kids no longer be subject to a pre-existing condition exclusions (2010) ©

For immigrants  If you are an immigrant who currently has insurance, and you like it, may keep it.  If you are a lawfully present immigrant and don’t like your insurance, or do not have insurance, starting in 2014 you may purchase insurance in the Exchange. You may be eligible for subsidies if you meet the standard eligibility requirements.  If you are an undocumented immigrant you cannot buy insurance or get subsidies for yourself in the Exchange. But, you can get it for your family members who may be citizens or lawfully present ©

Quality Provisions  Less overhead costs: Insurers must devote at least 85% of premiums to medical benefits (“Medical Loss Ratio”) for large groups. 80% MLR for small groups and individuals.  Create incentives for better care: Reduces Medicare hospital payments for preventable readmissions & infections (2012)  More data: Requires reporting of quality indicators by physicians (2011)  Less junk: Minimum benefit standards in the exchange to prevent sales of junk insurance (2014) ©

Ensuring there are providers Starting in 2010:  Expanded scholarships and loan repayment through National Health Service Corps for primary care providers in high-need communities  Awards grants to expand primary care residency programs in community and rural health clinics  Awards grants to expand training programs for primary care, dental care, long-term care, behavioral health and public health  10% Medicare bonus to all primary care physicians and for general surgeons in rural areas  Increase in Medicaid payment rates for primary care physicians to equal Medicare rates (2013) ©

Cost of health reform  Net cost of $980 billion over 10 years  Reduces the federal deficit by $1.2 trillion in second ten years  Repeal would cost $230 billion between 2013 and 2021 (according to neutral CBO) ©

Paying for health reform  Medicare Advantage – eliminating subsidies (saving ~$150 billion)  Increase in the Medicare premium for those with high income (2013)  Savings in Medicaid and Medicare prescription drug costs ($80 billion)  Hospital payment reforms – hospitals cannot charge more to uninsured, more transparency (2010)  Fees on certain device manufacturers, insurers, tanning salons, etc.  Reduce waste, fraud & abuse in public programs  Improved health Information technology ©

Colorado Health Institute: How many uninsured adults and children stand to become insured after health reform? 800, , , , ,000 © Source: Colorado Health Institute, “Helping communities prepare for health reform: Coverage estimates of Coloradans after implementation”

Next steps for the ACA?  The Affordable Care Act will be phased in over 4 years and fully implemented beginning January 1, 2014  Federal policymakers and agencies are issuing technical regulations and guidance  State policymakers and advocates have begun working on implementation including Colorado creation of the Colorado Health Benefits Exchange in 2011 ©

Resources  Colorado Consumer Health Initiative:  State of Colorado Health Reform Website:  Federal Health Reform Website:  Kaiser Family Foundation: ©

Phew! What do you think about it all? Questions? Thanks! Ashley Wheeland This presentation is for the use of CCHI. Any use of the presentation without permission from CCHI is prohibited. ©