Status of Health ReformSpring 2013

Mt. Sinai HospitalJohn BoumanPresidentShriver CenterChicago, ILApril 26, 2013

Remember: Current system a big problem• Cost ever-increasing, but access to care

decreasing

• Little choice or control or guarantee of quality

• No peace of mind: what if you lose coverage

and never get it back?

• 50 million uninsured – decreasing employer-

based coverage, cost-shift to everyone else

• Billions of uncompensated care

Illinois – layers of change• Affordable Care Act (ACA) (2010)

Market ReformsSubsidized ins. individuals and small business Fill the Medicaid gapSystem reforms

• Medicaid Reform Act (2011)Care coordination (50% by 2015)Long term care re-balancingLots of health IT

• SMART Act (2012)Cuts

Illinois Status -- general• Quinn Administration committed, supportive,

competent specialists but stretched very thin • DHFS leads; DOI, human services agencies• Democrats – strong champions; others timid • Republicans – opposed, but…• Insurance industry strong with both parties• Strong politics around children• Dramatic changes everywhere, and so …

Lots of denialLots of opportunity

ACA Status – market reforms• Pre-existing condition discrimination banned• Lifetime and annual limits• Discriminatory pricing for pre-ex, women• Young adult coverage• “Medical Loss Ratio”• Tax credits for small business• “individual mandate” – penalty if uninsured• “shared responsibility” tax – larger

businesses that don’t insure employees

ACA Status: Healthcare Marketplace• Web portal for policies, common language• All plans good insurance• Plans being filed and evaluated now• “Co-op” option – Land of Lincoln• Subsidies for premiums: 100-400% FPL• Subsidies for out of pocket costs• IL will do hybrid federal-state in 2014• Enrollment October, live January

-- DOI will regulate policies sold-- Feds manage subsidies and website

ACA Status – Marketplace Issues Plan: Illinois Marketplace 2015, but…• Wait and see re: hybrid• SB 34 is pending bill -- maybe• Board composition: how much industry?• Powers – how much actual regulation of

insurance prices (Mass-Colorado-Utah)• Financing – fees and assessments, not GRF

ACA status: Medicaid Completion• Medicaid gap: 19-64, not disabled or parent• 350,000 at least: young adults, empty

nesters, unofficially disabled, veterans• NFIB S.Ct. decision hands it to state politics• SB26: passed Senate, pending House• IHA, Chamber, strong coalition• Republicans? Speaker?• October enrollment; January 2014 “on” date• BIG deal

ACA Status – Cook County Waiver• One year early Medicaid eligibility• Up to 114,000• Live in Cook County• Age 19-64, not eligible for current Medicaid• Income below 133% FPL ($14,856)• Citizen or 5-year LPR• Have SSN or applied for one• Phone: (855) 671-8883, (312) 864-8200• But paper application (with assistance)• 2014 folds into statewide expanded Medicaid

Illinois Status – Care Coordination• Medicaid Reform Act of 2011: 50% by 2015• Lots: 90% in 2014. ITS HERE• Integrated Care Pilot: 40,000 senior and

people with disabilities in suburbs• Innovations RFP: Six projects selected, all

aimed at “high user” populations-- Medical homes plus network of specialists-- Some include housing and social services

• Medical Home Network (parents and kids)• Managed Care contracts to handle “duals”

Illinois Status – Innovations RFP winners• Be Well Partners in Health (organized around

long term care)• Healthcare Consortium of IL (community

based networks, south suburbs)• Macon County Care Coordination (downstate,

features mental health providers)• Precedence Care Coordination (downstate)• Together4Health (Heartland, hard to reach

populations, housing and social determinants)

Illinois Status – Long-term Care • Medicaid Reform Act of 2011 emphasis• More community based options• Transition from nursing and institutional care• Three court orders• Capital budget includes funds• Need to build sites• Need to build workforce

Illinois status – Budget cuts• FY 13 budget (now), SMART Act• FamilyCare to 133% from 185% (26,000)• Illinois Cares RX eliminated• DON score and other limits to in-home care• Adult dental eliminated• Some provider rate cuts• Maximus contract – redetermination project• 4 prescription limit (not kids for now)

Illinois Status – food for thought• Make managed care work• Re-define relationships and networks

Social services, Case managementHousingLegal and advocacy

• Prevention: medical home=prevention and wellness and smart use of IT=cost savings

• Health IT• Immigration reform

InformationFederal: www.healthcare.govNational: www.kff.org, www.familiesusa.org Kids: www.ccf.georgetown.eduLegal: www.healthlaw.orgSeniors: www.nsclc.orgState: http://insurance.illinois.gov/hiric/http://www2.illinois.gov/gov/healthcarereform/Pages/default.aspxState NGOs: www.illinoishealthmatters.orgShriver Brief: www.theshriverbrief.org

John BoumanShriver Center

50 E. Washington, Suite 500Chicago, IL 60602

(312) 368-2671johnbouman@povertylaw.org

www.povertylaw.org