Health Reform Implementation – Focus on the States February 11, 2011 Marcy Frosh

1. Health Reform Implementation – Focus on the States February 11, 2011 Marcy Frosh Meg Booth & Colin Reusch Children’s Dental Health Project

2. Implementation of oral health provisions Example of a problem the ACA sought to address? Status of challenges to the law? What are the timelines and opportunities around the state exchanges and the pediatric dental benefit? What are some steps states can take to influence the exchange and benefit processes?

3. Example of a problem that requires an innovative solution that: The “upside down” problem: Children with most need have least care

4. As the Children’s Dental Health Project (CDHP) sees it: The challenge is to: • Reduce disease burden • Improved access to quality care The “fix” : Children with most need get most care

5. How federal Health Care Reform can innovate: Systems Framework • Comprehensive systems approach, building on CHIPRA • Health coverage bill – estimated by 2019, 92% non-elderly will have health insurance • Provides dental coverage to nearly all children • Coverage is supported by numerous additional provisions • Unfortunately, many of these provisions still await funding

6. Prevention & Health Promotion

7. Workforce and Training

8. Delivery System

9. Infrastructure, Quality & Surveillance

10. Mandatory ACA Funding

11. Future of Health Care Reform Law • Congress: Attempts to repeal & to modify • U.S. Supreme Court: Does Congress have the power to require people to buy health insurance? Arguments: -- Yes – within power to regulate interstate commerce, to impose taxes and to pass laws that are necessary and proper to carry out its intentions. -- No (and whole law is potentially unconstitutional) - exceeds Commerce Clause power to reform and regulate the market

12. Timeline for Federal Appropriations: September 2010: Congress passed a continuing resolution (CR) for FY11 until December 3. Senate Appropriations Committee and House Labor HHS Appropriations Subcommittee proposals included oral health, but fell short of full funding December 2010: Congress passed 2nd CR for FY11 until December 21. December 2010: Congress passed 3rd CR for FY11 until March 3, 2011. Despite lack of funding, Federal government is moving forward with implementation through regulations & rulemaking, ARRA funding, and shifting money between agencies (e.g. Title VII)

13. MN not a party to the health reform challenge . . . Governor Mark Dayton is on record with: • Support for most of the federal health care reform law, including requirements on allowing individuals with pre-existing conditions to purchase insurance, and is in favor of asking for and accepting most grants and other incentives • A proposal to create a “health care helpline” to advocate for patients regarding insurers, providing a public option, reducing paperwork, e-prescribing, telehealth, and home-based care

14. Current State Action: Insurance Exchanges Key Players: • National Association of Insurance Commissioners (NAIC) • Office of Consumer Information and Insurance Oversight (OCIIO) at HHS • State Insurance Commissioners & Departments of Insurance • Governors’ Offices & State Health Agencies

15. State Insurance Exchanges: Timeline Fall: Initial guidance released Exchange planning grants awarded NAIC Model Legislation released Fall: Exchange rules for public comment 2014 2010 2011 2012 2013 State Exchange Planning Process Winter/Spring: Finals rules on Exchanges issued January: States indicate whether they will operate an exchange January: State and/or Federal Exchanges up and running January: Second round of state planning and establishment grants now available. 2011 & 2012: Stakeholder engagement, exchange governance decisions, plan selection, rates review, etc. January: Exchanges must be certified by HHS

16. State Insurance Exchange Planning Grants:MN is one of 2 states with no award but is reportedly pursuing an expedited application Alabama Arizona Arkansas California Colorado Connecticut Delaware D.C. Florida Georgia Hawaii Idaho • Illinois • Indiana • Iowa • Kansas • Kentucky • Louisiana • Maine • Maryland • Massachusetts • Michigan • Mississippi • Missouri • Montana • Nebraska • Nevada • New Hampshire • New Jersey • New Mexico • New York • North Carolina • North Dakota • Ohio • Oklahoma • Oregon • Pennsylvania • Rhode Island • South Carolina • South Dakota • Tennessee • Texas • Utah • Vermont • Virginia • Washington • West Virginia • Wisconsin • Wyoming Award details available at: www.healthcare.gov/news/factsheets/grantawardslist.html

17. Oral health on the radar screen Approaches to consider: 1) Advocate to include oral health in exchange planning application (indication that the establishment grants should be adequate to accomplish well-developed proposals) 2) Ensure capacity to address oral health in new benefit structure 3) Emphasis state capacity needs to integrate oral health into a plan for seamless interface among Medicaid, CHIP, and the new ACA provisions

18. Connect with State Insurance Authorities Defining stakeholder input with or without a planning grant: • Who are interested stakeholders both within oral health and beyond? How can you partner? 2. What are the opportunities for stakeholder input (e.g., consumer protections, ensuring viable provider networks, plan options, etc?)

19. Benefit Design: Timeline March: DOL report on employer plans released Fall: Determination of Essential Benefits by HHS Fall: DOL begins review of employer benefits 2014 2010 2011 2012 2013 IOM Ongoing Review of Essential Benefits January: State and/or Federal Exchanges up and running with Essential Benefits Packages and Qualified Health Plans January: IOM public meeting on determination of essential benefits study March-Sept: IOM study recommendations on essential benefits published

20. At the national level, CDHP is working on: 1. Ensuring Medicaid & CHIP access and stability 2. Getting the lay of the land (e.g., timelines, champions for individual provisions), etc.) • Stakeholder input: 70 organizations signed on to a May 2010 letter requesting funding for the ACA oral health provisions • Engaging in determination of benefit design (e.g., that the law’s “essential benefit” for oral pediatric services is defined by medical necessity) • Awareness & influence consumer protections

21. Quick Recap! Health Care Reform at the moment: • State insurance Commissioners have power w/ consumer protections, networks, & plan options! • Messages on Medicaid/CHIP dental benefit need to be reinforced! • Federal funding for the ACA oral health provisions is key!

22. Resources • ACA Summary and Talking Points, CDHP Healthcare Reform Center: www.cdhp.org/cdhp_healthcare_reform_center • Sample correspondence concerning ACA rules & regulations: www.cdhp.org/cdhp_healthcare_reform_center • Comment on Rules and Regs, Office of Consumer Information & Insurance Oversight www.hhs.gov/ociio • NAIC Model Exchange Legislation: www.naic.org/documents/committees_b_exchanges_adopted_health_benefit_exchanges.pdf • IOM Essential Health Benefits Survey Results: www.nami.org/Content/ContentGroups/Policy/Issues_Spotlights/Health_Reform/NAMICommentsIOM1210.pdf Visit the CDHP website at: www.cdhp.org

23. Thank You! Visit the Children’s Dental Health Project at: www.cdhp.org