The Affordable Care Act and Integrative Medicine

Michael R. CousineauProfessor, Departments of Family Medicine and Preventive Medicine

Patient Protection and Affordable Care Act

• Became Public Law No: 111-148,

• March 23, 2010

• H.R.3590 

• 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&

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How does PPACA Expand Coverage?

Beginning January 1, 2014

• Expands 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 Americans

• Up to 4 million in California

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Eligibility for Health Coverage under PPACA in California, 2011

Ineligible due to immigration;

1,070,000

Newly eligible for Medi-Cal;

1,180,000Previously eligible for

Medi-Cal; 880,000

Eligible for exchange with

subsidies; 780,000

Eligible for exchange no

subsidies; 970,000

Source: UC Berkeley Labor Center and UCLA Center for Health Policy Research

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Medicaid Expansion• Eliminates 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 eligible

• Federal government pays 100% of the cost until 2021 when state cost-sharing

• State option to expand Medicaid (Supreme Court)

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Health Benefit Exchange

• A 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 covered

• Co payments and deductibles but maximum out of pocket costs

• Provides subsidies in the form of tax credits for those from 138-400% FPL

• Family premium limits ranging from 2.0% to 9.5% of income

• Provision for small businesses

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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

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Benefits for Individuals

• http://www.coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdf

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Cost to The Individual or Family

• Varies depending on income

• Paid through a tax credit

• Premium subsidies and for co payments

• http://www.coveredca.com/fieldcalc/#calculator

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Who is excluded?

• Does not include undocumented immigrants

• Non citizens - 5 year waiting period for subsidies

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How Does it Affect Private Insurance?

• Guaranteed Issue No Pre-existing conditions, children now, adults 2014

• (limits underwriting)

• 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

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Young adults can remain on their parents’ health plan until age 26. Young and invincible?

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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

Insurance Changes

• No lifetime caps or restrictive annual limits on coverage, now

• Medical Loss Ratio Limited to 80/20,

– No more than 20% spent on administration, or no medical care expenses

– Rebates already occurredPM 508 Health Services in the U.S.

How Does it Affect Coverage: Individual MandatePenalties for being uninsured:

$695 per adult $2,085 per family2.5% of household income

Maximum Amount - Whichever is greaterExceptions:• 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

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Health Care Delivery Reform and Practice Redesign

Accountable Care Organizations Payment for Quality Outcomes

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Medical Homes, Team Management, Integrated Care

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

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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

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Clinicians

• Section 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 force

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.”

• 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.

• 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.

• Source: http://www.functionalmedicine.org/home/Affordable_Care_Act/

Resources

•  

• http://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.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-medicine

Additional Resources

• Kaiser Family Foundation http://healthreform.kff.org/

• Commonwealth Fund http://www.commonwealthfund.org/

• California Health Care Foundation http://www.chcf.org/

• 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.pdf

• http://www.urban.org/health/

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