1. The Affordable Care Act and Integrative Medicine Michael R. Cousineau Professor, Departments of Family Medicine and Preventive Medicine

2. Patient Protection and Affordable Care Act Became Public Law No: 111-148, March 23, 2010 H.R.3590 H.R.3590 Related Bills: Related Bills: H.CON.RES.254 H.RES.1203 H.R.3780 H.R.4872 S.1728 http://www.thomas.gov/cgi- bin/bdquery/z?d111:HR03590:@@ @D&summ2=3& PM 508 Health Services in the U.S.

3. How does PPACA Expand Coverage? Beginning January 1, 2014 Expands Medicaid to all up to 138% of the federal poverty thresholdExpands Medicaid to all up to 138% of the federal poverty threshold Health Insurance Exchange with Approved Health Benefit plan and subsidies for those between 139% and 400% of FPL Estimated 35 million AmericansEstimated 35 million Americans Up to 4 million in CaliforniaUp to 4 million in California PM 508 Health Services in the U.S.

4. Eligibility for Health Coverage under PPACA in California, 2011 Source: UC Berkeley Labor Center and UCLA Center for Health Policy Research PM 508 Health Services in the U.S.

5. Medicaid Expansion Eliminates many of the categorical eligibility criteria and replaces it with a Modified Adjusted Gross IncomeEliminates many of the categorical eligibility criteria and replaces it with a Modified Adjusted Gross Income All up to 138%* of the federal poverty threshold will be eligibleAll up to 138%* of the federal poverty threshold will be eligible Federal government pays 100% of the cost until 2021 when state cost-sharingFederal government pays 100% of the cost until 2021 when state cost-sharing State option to expand Medicaid (Supreme Court)State option to expand Medicaid (Supreme Court) PM 508 Health Services in the U.S.

6. Health Benefit Exchange A new market for those in the individual marketA new market for those in the individual market Approved plans with an essential benefit package but different tiers based on what percentage of the actuarial costs will be coveredApproved plans with an essential benefit package but different tiers based on what percentage of the actuarial costs will be covered Co payments and deductibles but maximum out of pocket costsCo payments and deductibles but maximum out of pocket costs Provides subsidies in the form of tax credits for those from 138-400% FPLProvides subsidies in the form of tax credits for those from 138-400% FPL Family premium limits ranging from 2.0% to 9.5% of incomeFamily premium limits ranging from 2.0% to 9.5% of income Provision for small businessesProvision for small businesses PM 508 Health Services in the U.S.

7. Essential Benefit Package These benefits fit into the following 10 categories: –Ambulatory patient services –Emergency services –Hospitalization –Maternity and newborn care –Mental health and substance use disorder services, including behavioral health treatment –Prescription drugs –Rehabilitative services and devices –Laboratory services –Preventive and wellness services and chronic disease management –Pediatric services, including dental and vision care PM 508 Health Services in the U.S.

8. Benefits for Individuals http://www.coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdfhttp://www.coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdfhttp://www.coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdf PM 508 Health Services in the U.S.

9. Cost to The Individual or Family Varies depending on incomeVaries depending on income Paid through a tax creditPaid through a tax credit Premium subsidies and for co paymentsPremium subsidies and for co payments http://www.coveredca.com/fieldcalc/#calculatorhttp://www.coveredca.com/fieldcalc/#calculatorhttp://www.coveredca.com/fieldcalc/#calculator PM 508 Health Services in the U.S.

10. Who is excluded? Does not include undocumented immigrantsDoes not include undocumented immigrants Non citizens - 5 year waiting period for subsidiesNon citizens - 5 year waiting period for subsidies PM 508 Health Services in the U.S.

11. How Does it Affect Private Insurance? Guaranteed Issue No Pre-existing conditions, children now, adults 2014 (limits underwriting) Rate Restructuring,Rate Restructuring, –age (3:1); – tobacco use (at a rate of 1.5:1); –family composition; and –geography High-risk pool established (temporary) Young adults can remain on their parents’ health plan until age 26, now PM 508 Health Services in the U.S.

12. Young adults can remain on their parents’ health plan until age 26. Young and invincible? PM 508 Health Services in the U.S. adults ages 19 to 29 when offered health insurance benefits through an employer, two-thirds took the coverage. For those who did not they were covered by a parent, spouse, or partner or they couldn’t afford the premiums. Commonwealth Fund, 2013

13. Insurance Changes No lifetime caps or restrictive annual limits on coverage, now Medical Loss Ratio Limited to 80/20,Medical Loss Ratio Limited to 80/20, –No more than 20% spent on administration, or no medical care expenses –Rebates already occurred PM 508 Health Services in the U.S.

14. How Does it Affect Coverage: Individual Mandate Penalties for being uninsured: $695 per adult$2,085 per family 2.5% of household income Maximum Amount - Whichever is greater Exceptions: No prosecutions 2014-2016 Financial hardship Religious objections American Indian ethnicity Uninsured for <3 months Income below tax filing threshold Cost of least expensive plans >8% income Incarcerated Undocumented PM 508 Health Services in the U.S.

15. Health Care Delivery Reform and Practice Redesign Accountable Care Organizations Payment for Quality Outcomes PM 508 Health Services in the U.S. Medical Homes, Team Management, Integrated Care

16. Problems and Limitations People not covered Undocumented immigrants Those unable or unwilling to purchase coverage Was the penalties/taxes high enough Longer term State Medicaid Payments States’ involvement Funding for safety net facilities PM 508 Health Services in the U.S.

17. Challenges Moving Forward Workforce Political Challenges Legal Challenges Financial The on going state budget crisis and the federal deficit General economy Logistical Challenge Getting people enrolled PM 508 Health Services in the U.S.

18. Clinicians Section 2706 of the Affordable Care Act prohibits discrimination against licensed health practitioners, including those who practice integrative medicineSection 2706 of the Affordable Care Act prohibits discrimination against licensed health practitioners, including those who practice integrative medicine Section 5101 of the law says that all "doctors of chiropractic," and all "licensed complementary and alternative medicine providers, integrative health practitioners" are included in definition of the national health care work forceSection 5101 of the law says that all "doctors of chiropractic," and all "licensed complementary and alternative medicine providers, integrative health practitioners" are included in definition of the national health care work force

19. Prevention Establishing a National Prevention, Health Promotion and Public Health Council, charged with providing “coordination and leadership at the Federal level, and among all federal departments and agencies, with respect to prevention, wellness and health promotion practices, the public health system, and integrative health care in the United States.”Establishing a National Prevention, Health Promotion and Public Health Council, charged with providing “coordination and leadership at the Federal level, and among all federal departments and agencies, with respect to prevention, wellness and health promotion practices, the public health system, and integrative health care in the United States.” Appointment of an Advisory Group on Prevention, Health Promotion, and Integrative and Public Health that includes “a diverse group of licensed health professions, including integrative health practitioners” to “develop policy and program recommendations and advise the Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion.”Appointment of an Advisory Group on Prevention, Health Promotion, and Integrative and Public Health that includes “a diverse group of licensed health professions, including integrative health practitioners” to “develop policy and program recommendations and advise the Council on lifestyle-based chronic disease prevention and management, integrative health care practices, and health promotion.” Definition of a healthcare workforce that includes preventive medicine physicians, doctors of chiropractic, licensed complementary and alternative medicine providers, and integrative health practitioners.Definition of a healthcare workforce that includes preventive medicine physicians, doctors of chiropractic, licensed complementary and alternative medicine providers, and integrative health practitioners. Funding for patient-centered outcomes research (PCORI) to measure the comparative clinical effectiveness of a variety of treatments and services, including “integrative health practices,” with emphasis on chronic conditions and attention to “the potential for new evidence to improve patient health, well-being, and the quality and cost of care.”Funding for patient-centered outcomes research (PCORI) to measure the comparative clinical effectiveness of a variety of treatments and services, including “integrative health practices,” with emphasis on chronic conditions and attention to “the potential for new evidence to improve patient health, well-being, and the quality and cost of care.” Establishing (through HRSA) a National Coordinating Center for Integrative Medicine (NccIM) that will provide technical assistance to and evaluate integrative medicine residency (IMR) programs.Establishing (through HRSA) a National Coordinating Center for Integrative Medicine (NccIM) that will provide technical assistance to and evaluate integrative medicine residency (IMR) programs. Source: http://www.functionalmedicine.org/home/Affordable_Care_Act/Source: http://www.functionalmedicine.org/home/Affordable_Care_Act/http://www.functionalmedicine.org/home/Affordable_Care_Act/

20. Resources http://holisticprimarycare.net/topics/topics-h-n/news-policy-a-economics/1443- healthcare-reform-no-birthday-for-holistic-medicine.htmlhttp://holisticprimarycare.net/topics/topics-h-n/news-policy-a-economics/1443- healthcare-reform-no-birthday-for-holistic-medicine.htmlhttp://holisticprimarycare.net/topics/topics-h-n/news-policy-a-economics/1443- healthcare-reform-no-birthday-for-holistic-medicine.htmlhttp://holisticprimarycare.net/topics/topics-h-n/news-policy-a-economics/1443- healthcare-reform-no-birthday-for-holistic-medicine.html http://www.functionalmedicine.org/home/Affordable_Care_Act/http://www.functionalmedicine.org/home/Affordable_Care_Act/http://www.functionalmedicine.org/home/Affordable_Care_Act/ http://www.sciencebasedmedicine.org/cam-practitioners-as-pcps-under-the-aca-part-2/http://www.sciencebasedmedicine.org/cam-practitioners-as-pcps-under-the-aca-part-2/http://www.sciencebasedmedicine.org/cam-practitioners-as-pcps-under-the-aca-part-2/ http://www.scnm.edu/news-events/262-affordable-care-act-the-future-of-naturopathic- medicinehttp://www.scnm.edu/news-events/262-affordable-care-act-the-future-of-naturopathic- medicinehttp://www.scnm.edu/news-events/262-affordable-care-act-the-future-of-naturopathic- medicinehttp://www.scnm.edu/news-events/262-affordable-care-act-the-future-of-naturopathic- medicine

21. Additional Resources Kaiser Family Foundation http://healthreform.kff.org/Kaiser Family Foundation http://healthreform.kff.org/http://healthreform.kff.org/ Commonwealth Fund http://www.commonwealthfund.org/Commonwealth Fund http://www.commonwealthfund.org/ California Health Care Foundation http://www.chcf.org/California Health Care Foundation http://www.chcf.org/http://www.chcf.org/ Covered California (California’s Health Exchange) http://www.coveredca.com/Covered California (California’s Health Exchange) http://www.coveredca.com/Covered California (California’s Health Exchange) http://www.coveredca.com/Covered California (California’s Health Exchange) http://www.coveredca.com/ http://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/downloads/Disproportionate_Share_Hospital.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/downloads/Disproportionate_Share_Hospital.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/downloads/Disproportionate_Share_Hospital.pdfhttp://www.cms.gov/Outreach-and-Education/Medicare-Learning- Network- MLN/MLNProducts/downloads/Disproportionate_Share_Hospital.pdf http://www.urban.org/health/http://www.urban.org/health/http://www.urban.org/health/http://www.urban.org/health/ PM 508 Health Services in the U.S.