The Affordable Care Act (ACA)

1. The Affordable Care Act (ACA) Accomplishments to Date: Laying the Foundation for Earlier, More Effective Treatment Bonnie Preston MSPH National Alliance for Mental Illness – California Newport Beach, California August 1, 2014

2. Goals for Today: Review the basics of the Affordable Care Act, its accomplishments and next steps Learn about Federal Priorities & Resources in Mental Health Services Be Inspired about your role to get people enrolled & to reform health care towards improving health To improve people’s health Help save a family/business from financial ruin Help improve country’s economic future

3. Health & Human Services (HHS) has Ten regions

4. Office of the HHS Regional Director • Our office serves as the public interface with federal health programs • Represents Regional Issues to Influence Operation of Federal Programs • Shares Best Practices Across Region

5. Behavioral Health: A National Priority 5 SAMHSA’s Mission: Reduce the impact of substance abuse and mental illness on communities by helping people with mental and substance use disorders, supporting their families and promoting better health for all Americans. Behavioral health is essential to health Prevention works Treatment is effective People recover

6. Pre-ACA Health Care System • 49 Million Americans lacked coverage • Uncoordinated – Fragmented delivery systems with variable quality • Unsupportive – of patients and healthcare providers • Unsustainable – Costs rising at twice the inflation rate

7. Pre-ACA Health Care System • 17.6% of economic output tied up in health care system • Without reform • by 2040, 1/3 of economic output tied up in health care • 15% of GDP devoted to Medicare and Medicaid • Number of uninsured would grow to 58 million in 2020* *Source: Urban Institute: “The Cost of Failure to Enact Health Reform: 2010-2020” March 15, 2010

8. Health Disparities • 1 in 5 Children affected by mental illness are not getting treatment • 61% of Adults with mental illness do not receive any mental health services • 39% of Adults with serious mental illness are not receiving any mental health treatment • Disproportionate number of people with mental illness are in the custody of the correctional system • People with M/SUDs are nearly 2x as likely as general population to die prematurely, often of preventable or treatable causes

9. Health Disparities Factors Shaping Health Outcomes: • Stigma of Mental Illness and Substance Abuse • Lack of access to timely treatment • Lack of health insurance

10. March 23, 2010: A New Day For Health Care After a year of striving, after a year of debate, after a historic vote, Health Care Reform is no longer an unmet promise. It is the law of the land.” - President Barack Obama

11. Three Aims Of the Affordable Care Act

12. Individual Requirement • January 1, 2014 • Exemptions include: • Financial hardship; • Religious objections; • Native Americans • Without coverage for less than 3 months; • Incarcerated individuals; and • Cost exceeds 8% of individual’s income.

13. Employer Requirement (Shared Responsibility) • No Employer Requirement until 2015 • Less than 50 full-time equivalents – exempt from any requirement

14. New Coverage Options for Millions of Americans 0%FPL 133%FPL 400%FPL

15. Medicaid Expansion

16. Medi-Cal Expansion & Improvements • California Expanded Medi-Cal eligibility to adults ages 19 – 64 with incomes up to $16,000 per year for an individual.   • 100% federal funding for newly Medicaid eligible • No longer only disabled or pregnant young • Simplified income calculation • Promotes More Primary Care Provider Participation in Medi-Cal • Opportunity for Supported Employment

17. State Health Insurance Marketplace Decisions, 2014 VT WA ME ND MT NH MN OR MA NY WI SD ID RI MI CT PA WY NJ IA DE OH NE NV IN IL MD CO UT* WV VA CA DC KS MO KY NC TN OK SC AZ AR NM GA AL MS AK TX LA FL HI State-based Marketplace (16 states and DC) Partnership Marketplace (7 states) Federally-facilitated Marketplace (27 states) * In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or SHOP, marketplace. SOURCE: State Decisions For Creating Health Insurance Marketplaces, 2014, KFF State Health Facts: http://kff.org/health-reform/state-indicator/health-insurance-exchanges/.

18. Covered California • It’s an easier way for individuals and small businesses to shop for health insurance • Most people are able to get a break on costs • Provides clearer options with more straight forward comparisons

19. Enrolling in SHOP:Who, When & How? Who’s eligible? • 2014 /2015 – Covered California set the upper limit at 50 • 2016 – Marketplaces must accommodate 100 FTE and below • 2017 and Beyond – States can decide their upper limit When can businesses enroll? • Throughout the year How can businesses enroll? • Directly through Covered California SHOP • Through a broker registered with Covered California SHOP

20. Removing the Obstacles:Tax Credits The Small Business Health Care Tax Credit Is available to those employers : • With fewer than 25 “full‐time equivalent” employees • Whose employees’ wages average less than $50,000 per year • Who contribute at least 50% of employees’ premium costs • Who buy health insurance through the SHOP Discounts are worth: • Up to 50% of employer’s premium contribution (up to 35% for tax exempt employers)

21. All Qualified Health Plans Will Cover These Essential Health Benefits Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services, including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive and wellness services and chronic disease management Pediatric services, including oral and vision care

22. Consumer Protections w/ Parity • Ends Spending Limits • No more artificial treatment cut offs • Move to support outcome based plans • Ends Pre-existing Conditions Exclusions • Allows Young Adults to be Covered till 26 • 19-25 yr olds at risk of first episode of mental illness • Financial Protections for Families and Providers

23. Strengthens Other Public Programs • Medicare – Improves Care and Lowers Costs • Preventive care with no copays, • Improves drug coverage, • Strict anti-fraud measures and • Better care coordination • Duals Project • Medical Homes • Accountable Care Organizations

24. Affordable Care Act Accomplishments – Expanding Coverage • Nationally, more than 8 million people have enrolled in private insurance through the Marketplace • An additional 6 million additional people enrolled Medicaid • 3 million young adults were able to stay on their parents’ plans

25. Affordable Care Act – Expanding Coverage in California • 1.2 million Californians have enrolled for health insurance and selected plans through the Marketplace through the end of March and over 1.9 million have been found likely eligible and enrolled for expanded Medi- Cal coverage through March • 435,000 young adults have gained insurance through their parents’ plans

26. Affordable Care Act Accomplishments– Improving Coverage • 71 million privately insured people gained improved coverage for preventive services • 105 million Americans have had lifetime limits removed from their insurance • 7.1 million people with Medicare saved over $8.3 billion on drugs since law’s enactment • 37.2 million people with Medicare received a free preventive service

27. ACA Accomplishments in CaliforniaCost, Quality & Consumer Protections • 358,862 people with Medicare through 2013 received $333 million in prescription drug discounts • 3.6 million people with Medicare received a free preventive service • 8 million privately insured people gained improved coverage for preventive services • 12 million California residents have had lifetime limits removed from their insurance

28. Affordable Care Act Accomplishments– Quality and Cost • Slowest sustained national health spending growth in 50 years • Low growth continued in 2013 for Medicare and Medicaid • Resulting in No Increase in 2014 Medicare Premiums Covering Physician Charges • $500 million returned to consumers in 2012 • Plans must spend 80% of premium on healthcare • Over $19.2 billion recovered from anti-fraud efforts – a record level which added years to Medicare Trust Fund

29. Affordable Care Act Accomplishments– Quality, Cost and Access • Medicare Payment reform led to 8% decrease in readmit rate between 1/2012 and 12/2013 • 360 Medicare ACOs developed • Strengthening Primary Care Workforce • Primary Care providers in NHSC doubled since 2008 • 1,200 Community Health Centers are providing primary care to >21 million annually • Small business tax credit provided >$1billion to small employers

30. What’s Next?SAMHSA ENROLLMENT STRATEGY Partner w/national organizations to create and implement enrollment campaigns • Provide marketing materials • Provide T/TA • Provide training to design and implement enrollment assistance • Channel feedback • Evaluate success

31. What’s Next? Coverage to Care • Department of Education report showed 1 in 10 Americans have proficient level of “health literacy” • Language and cultural barriers add to confusion • IOM found that low health literacy are more likely to be hospitalized and have more ER visits http://marketplace.cms.gov/c2c • to help those with new health care coverage make the most of their coverage, and raise awareness about the importance of getting routine primary care and regular preventive care

32. QUALIFIED HEALTH PLANS (QHPs) • Providers Sufficient to Deliver Services • “Including mental health & substance use disorders services” • MH Providers More Likely to be Experienced in Billing/Being Part of Networks than SA Providers • Community MH/SA Providers Heavily Dependent on Declining Fund Sources • Non-insurance based federal, state, local, private pay

33. California Summary FY 2013/2014

34. SAMHSA Primary and Behavioral Health Care Integration Grants • Nationally $54.6 million to support 221 health centers • to establish or expand behavioral health services for over 450,000 people. • $7,990,619 will support 32 health centers in California • to establish or expand behavioral health services for 111,127 Californians. • Hire new mental health professionals, add mental health and substance use disorder health services; employing integrated models of primary care. 

35. SAMHSA’s WORK WITH OTHER FEDERAL PROGRAMS • AHRQ Center for Integration Models: Developing models of integrated BH care in primary care settings • CMS/CMMI Innovative Financing Models for Integration: Grants to test models • SAMHSA’S Primary/BH Integration (PBHCI) Grants: Physical health of adults w/ SMI and TA for bi-directional integration • HRSA FQHCs: Integrating BH screening, brief intervention and treatment • Medicare Accountable Care Organizations: Payment for integrated care and outcomes • CMS Health Homes: Whole person care for persons with specific characteristics or health conditions • CMS Partnership for Patients: Reducing hospital readmissions; increasing quality

36. CMS Center for Medicare & Medicaid Innovation • Supports the ongoing development of new models of payment and delivery. • Invests $10 billion in this Center over 10 years to test payment and delivery innovations that can improve the quality of care and/or increase cost efficiency, identifying successes that could be expanded by the Secretary of Health and Human Services (either regionally or nationally). • These funds will produce returns on investment and reduce Medicare and Medicaid spending over the long-term.

37. Community Integrated Healthcare • Healthy Population Centered • Population Health Focused Strategies • Integrated networks linked to community resources capable of addressing psycho social/economic needs • Population based reimbursement • Learning Organization: capable of rapid • deployment of best practices • Community Health Integrated • E-health and telehealthcapable US Health Care Delivery System Evolution Health Delivery System Transformation Critical Path Community Integrated Healthcare System 3.0 Coordinated Seamless Healthcare System 2.0 Acute Care System 1.0 Outcome Accountable Care Episodic Non-Integrated Care • Patient/Person Centered • Transparent Cost and Quality Performance • Accountable Provider Networks Designed Around the patient • Shared Financial Risk • HIT integrated • Focus on care management • and preventive care • Episodic Health Care • Lack integrated care networks • Lack quality & cost performance • transparency • Poorly Coordinate Chronic Care Management Neal Halfon, UCLA Center for Healthier Children, Families & Communities

38. Thank you! Bonnie Preston Regional Outreach & Policy Specialist 415-437-8503 – Direct Number Bonnie.Preston@hhs.gov

39. California Summary FY 2013/2014

40. PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS SA TREATMENT FACILITIES ACCEPTANCE OF INSURANCE PAYMENTS * SOURCE OF FUNDS FOR CMHCS** *Source: NSATSS **Source: 2011 NCCBH BH Salary Survey

41. National Prevention StrategyStrategic Directions and Priorities

42. ACA /Parity Projected Reach NOTE: These estimates include individuals and families who are currently enrolled in grandfathered coverage Source: ASPE Research Brief, February 2013