q3 learning session: presentation slides
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q3 2012 learning sessionTRANSCRIPT
Patient-Centered Primary Care Collaborative of Central Ohio
Q3 Learning Session – July 24, 2012
Objective: to improve our collective knowledge on local, state and national implications of Supreme Court rulings on Patient Protection and Affordable Care Act (PPACA or ACA)
Please save Friday, December 7 for our next learning session from 8:00-10:30AM
Access HealthColumbus is a non-profit, public-private partnership working to improve the delivery of local health care by coordinating
collaborative projects focused on improving patient-centered primary care. Please visit our website to learn more: www.accesshealthcolumbus.org
Patient-Centered Primary Care Collaborative of Central Ohio
WHY are we coordinating the Collaborative? To improve access to patient-centered primary care as the foundation of
accountable health care delivery to achieve better care, better health, and better value in our community
WHAT are the objectives? Improve the health of the people in our community Improve the patient experience of care Improve value of health care expenditures
Participating Primary Care Providers: Over 200 primary care providers practicing in private practice, hospital-affiliated,
and federally qualified health centers serving over 350,000 patients with Commercial insurance, Medicaid, Medicare, and the uninsured
Participating Health Plans & Purchasers: 7 health plans & 7 self-funded employers from the private and public sector
Lead Supporter
Major Supporters
Individual & Corporate Donations
100% Access HealthColumbus
Board & Staff
Additional Supporters
Funding from the following public-private partners supports our collaborative work in the community!
why?
To objectively improve our collective knowledge on local, state and national implications of the
Supreme Court rulings on Patient Protection and Affordable Care Act (PPACA or ACA)
what?
Welcome & framing
Legal briefing
Panel discussion
Q&A
Affordable Care Act
Near Universal Insurance Coverage
Guaranteed Issue &
Insurance Mandate
Improvement Programs
(and grants)
Health Benefit
Exchanges
Expansion of Medicaid
Subsidized commercial
insurance for middle-income
families (market based)
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Health coverage sources for Ohioans in 2014
Health coverage sources for Ohioans in 2014
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Affordable Care Act
Near Universal Insurance Coverage
Guaranteed Issue &
Insurance Mandate
Improvement Programs
(and grants)
Health Benefit
Exchanges
Affordable Care Act
Near Universal Insurance Coverage
Guaranteed Issue &
Insurance Mandate
Improvement Programs
(and grants)
Health Benefit
Exchanges
Current Exchange Status
• 15 Established State Exchange
• 1 Planning for Partnership Exchange
• 18 Studying Options
• 11 No Significant Activity
• 6 Decision Not to Create State Exchange
Affordable Care Act
Near Universal Insurance Coverage
Guaranteed Issue &
Insurance Mandate
ImprovementPrograms
(and grants)
Health Benefit
Exchanges
Federal departments proceeding with
improvement programs and grants
Congressional funding approval required for many
programs and grants
National/State Primary Care Activity Monitor
July
A. Medicare and Medicaid: Comprehensive Primary Care Initiative Demonstration
B. Medicare: Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
C. Medicare: Multi-payer Advanced Primary Care Practice Demonstration
D. Medicare: Independence at Home
E. Medicare Physician Payment Formula – 27.4% pay cut delayed through 1/1/2013
F. Commercial Health Plans Shifting Resources to Primary Care
G. Ohio Medicaid Health Homes - Oct. 1 in Butler, Adams, Scioto, Lawrence and Lucas counties - remaining counties phased in by next July
Douglas L. Anderson Of Counsel Bailey Cavalieri LLC | 10 W. Broad Street, Ste. 2100
Columbus, Ohio 43215-3422 d: 614.229.3301| c: 614.264.2773| f: 614.221.0479 [email protected] |
www.baileycavalieri.com
Taft /
Kevin M. Hilvert / Partner
Taft Stettinius & Hollister LLP
65 E. State Street, Suite 1000
Columbus, Ohio 43215
Tel: 614.221.2838 • Fax: 614.221.2007
Direct: 614.220.0238 • www.taftlaw.com /
Legal briefing and reflections
Supreme Court’s Ruling
• Anti-Injunction Act – Is the Supreme Court barred from deciding the constitutionality
of the Affordable Care Act by the Anti-Injunction Act?
– A tax may only be challenged after it is paid by suing for a refund. Therefore, does the Court have to wait until 2014 when the individual mandate becomes effective and is enforced against an individual before it can challenged?
– Does not apply because Congress used “penalty” not “tax.”
• Individual Mandate – What is the individual mandate?
– The mandate commands individuals to purchase insurance.
• Unconstitutional under the Commerce Clause.
– The mandate is a tax on those without insurance.
• Constitutional under Congress’s taxing powers.
Supreme Court’s Ruling
(cont.)
• Medicaid Expansion
– Does conditioning all Federal Medicaid funding on the States
agreeing to expand Medicaid exceed Congress’ authority under
the Spending Clause of the Constitution?
– Medicaid Expansion violated the Constitution since it threatened
revocation of existing Medicaid funds which was unduly
coercive.
– Additional funding can be conditioned on States’ participation in
the Medicaid expansion.
• Severability
– If any part of the Accountable Care Act is unconstitutional, can
the rest of the Act stand?
Supreme Court Ruling
The insurance market reforms and subsidies
were upheld and will go into effect.
Insurance market reforms
The 2010 insurance reforms will remain in
effect
– No lifetime limits and restricted annual limits
– Coverage of dependents up to age 26
– No rescissions except for fraud
– No pre-existing condition exclusions for children
– Preventive care at no co-pays or cost sharing
Insurance market reforms
The 2011 insurance reforms will remain in
effect
– Medical Loss Ratio Limits
Medical loss ratios must be at least 85% for large group
coverage and 80% for small group and individual
coverage.
– Premium Rates Review standards (2011).
Premium rates in excess of 10% must undergo
heightened review.
Permanent Market Reforms
• The 2014 permanent market reforms were
upheld.
– Guaranteed issuance of coverage
– Modified community rating of coverage
• Rates can only vary by age (3 to 1) and smoking status
(1 ½ to 1).
• No pre-existing condition exclusions
• Individual mandate
• Employer mandate
Low Income Subsidies
The 2014 low income subsidies were upheld.
– Sliding scale subsidies are available at incomes
between 100% to 400% FPL
– At 100% FPL, the cost of coverage will be:
$223 per year or $18.50 per month for
individuals; or
$461 per year or $38.40 per month for a family
of 4.
Health Insurance Exchanges
Exchanges were upheld.
– Each state shall establish a qualified Exchange by
January 1, 2014.
– If a state chooses not to operate an exchange,
the federal government will do so.
Exchange Options
1. An Ohio Exchange
2. A Federal Exchange
3. A Hybrid Exchange
– States control plan management including
certification of qualified plans
– States operate the consumer assistance function
– HHS retains authority and approve state partners
– States may control reinsurance and Medicaid
eligibility determinations
Timeline
Reforms already in effect: – 2010 Insurance Benefit Reforms
– Medical Loss Ratios
– Premium Rate Review
November 6, 2012 - The Election – Change in direction as to implementation
– Can’t change requirements on insurance companies
Timeline
November 16, 2012 – States must submit an Exchange Blueprint to
HHS, including (1) a Declaration of Intent signed by the Governor and (2) an Application indicating the state’s intentions.
– A state may submit a “Blueprint” for an exchange which will become operational after 2014, but November 16th is the deadline.
Timeline
January 1, 2013 – HHS must certify state exchanges that become
operational on January 1, 2014. The state must demonstrate “the ability to satisfactorily
perform all required Exchange activities.”
– Conditional approval can be granted to states making “significant progress” if they will be ready by October, 2013.
– It is hard to believe a state filing a “Blueprint” after the election could establish a 2014 exchange.
Timeline
2012 - 2013 – IT/Consumer Infrastructure established
– Qualified health plans certified
– Vendor/partner agreements executed Agents/Navigators
– Operations established
– Marketing/outreach to consumers
Fall, 2013 – People begin to enroll in exchanges
Timeline
January, 2014 – Permanent reforms take effect
– Low income subsidies start
– Mandates take effect
– Coverage through exchanges becomes effective
Impact of Court’s Ruling on
Medicaid Expansion
• Original Act
– The “Medicaid Expansion” creates a newly eligible group of
Medicaid beneficiaries
• Individuals age 19-64 who
– Are below 133% of FPL.
– Meet citizenship requirements.
– Are not incarcerated.
– Are not entitled to Medicare.
– Conditions all existing Medicaid funding on a State’s agreement
to expand Medicaid coverage to the new group of Medicaid
eligible individuals.
– For States that participate in the Medicaid expansion, the
Federal government will pay 100% of the expansion for three
years, 95% for the next 3 years, and 90% thereafter.
Impact of Court’s Ruling on
Medicaid Expansion (cont’d)
• Supreme Court held
– Medicaid expansion is unconstitutional under the Spending
Clause because conditioning all Medicaid funds on participation
in the expansion is unduly coercive.
– The Medicaid expansion may nonetheless be implemented
under the ACA, but the Federal government can only condition
access to new Medicaid funding on a State’s participation.
• Implications of the Court’s ruling on Medicaid expansion
– Implementation of the Medicaid expansion is now “optional” by
the States.
– Many low-income people may remain uninsured.
– Who carries burden of cost of uninsured?
Other Issues to Consider after the
Ruling
• State decisions on Medicaid expansion
– “Hell No” states (Texas, Florida, Mississippi, Louisiana, South
Carolina, Nebraska)
– Wait and See approach
– Impact on Hospitals
• State decisions on Insurance Exchanges
– 15 have established state exchanges
– 1 is planning a partnership exchange
– 18 are studying their options
– 12 are not showing any significant activity
– 5 have decided not to create an exchange
http://healthreform.kff.org/en/the-states.aspx
Other Issues to Consider after the
Ruling (cont’d)
• Ohio Issue 3 (amendment to the Constitution of the State
of Ohio) – … “In Ohio, no law or rule shall compel, directly or indirectly, any
person, employer, or health care provider to participate in a health
care system.”
– Supremacy Clause prevents Issue 3 from “overruling” ACA.
– But….other consequences
• Other challenges to the ACA
Sharing of Reflections
Consumer perspective: Isi Ikharebha, Executive Director,
Physicians CareConnection
Payer perspective: Miranda Motter, President and CEO, Ohio Association of Health Plans
Provider perspective: Bill Wulf, M.D., Corporate Medical Director, Central Ohio Primary Care Physicians
Purchaser perspective: Mike Stull, Regional Vice President, Employers Health
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Health coverage sources for Ohioans in 2014
Health coverage sources for Ohioans in 2014
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Current Exchange Status
• 15 Established State Exchange
• 1 Planning for Partnership Exchange
• 18 Studying Options
• 11 No Significant Activity
• 6 Decision Not to Create State Exchange
Q&A
In the interest of our limited time this morning:
please be concise with your question
please no testimonials or advocacy
Want to learn more about the Affordable Care Act?
Health Policy Institute of Ohio - Supreme Court Policy Brief: http://bit.ly/SjDBca
Kaiser Family Foundation - A Guide to the Supreme Court's
Affordable Care Act Decision: http://www.kff.org/healthreform/upload/8332.pdf
Special thanks to Doug, Kevin, Isi, Miranda, Mike, and Dr. Wulf for
donating their time to help us improve our collective knowledge!