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Open Classroom Series Fall 2013: Policy for a Healthy America

Open Classroom Series Fall 2013: Policy for a Healthy America. Every Wednesday, 6pm – 8pm September 4 through December 4 West Village F, Room 20. Northeastern University School of Public Policy and Urban Affairs. This Week (September 11, 2013). “Promises and Pitfalls of ‘ Obamacare ’”.

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Open Classroom Series Fall 2013: Policy for a Healthy America

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  1. Open Classroom Series Fall 2013: Policy for a Healthy America • Every Wednesday, 6pm – 8pm • September 4 through December 4 • West Village F, Room 20 • Northeastern University • School of Public Policy and Urban Affairs

  2. This Week (September 11, 2013) “Promises and Pitfalls of ‘Obamacare’” John Auerbach Distinguished Professor of Practice and Director of the Institute on Urban Health Research, Northeastern University; former Commissioner of Public Health for the Commonwealth of Massachusetts John McDonough Professor of the Practice of Public Health and Director of the Center for Public Health Leadership, Harvard School of Public Health; former Senior Advisor for National Health Reform to the US Senate Committee on Health, Education, Labor, and Pensions School of Public Policy & Urban Affairs | Northeastern University

  3. Programs in Leadership Development The Affordable Care Act (ACA): EssentialStructure and Implementation Progress John E McDonough, DPH, MPA Harvard School of Public Health September, 2013

  4. Ten Titles: the ACA’s Architecture • Affordable and Available Coverage– private insurance • Medicaid and CHIP – lower-income public coverage • Delivery System Reform and Medicare • Prevention, Wellness, and Public Health • Workforce Initiatives • Fraud, Abuse, Transparency and more • Pathway for Biological Similars • CLASS – Community Living Assistance Services & Supports • Revenue Measures • Manager’s Amendments • Plus Health Care & Education Reconciliation Act (HCERA)

  5. Title I (Private Health Insurance) • I: Affordable and Available Coverage • Immediate Reforms in 2010 and 2011 – • Coverage for young adults <26; Lifetime/annual limits banned; Medical Loss Ratios; Medicare Part D donut hole closing • By themselves, the most substantive private health insurance reforms ever in the U.S. • Coming on 1/1/2014 – the Three-Legged Stool • Insurance Market Reform – Guaranteed Issue/No pre-ex • Individual Mandate/Responsibility • Premium & Cost Sharing Subsidies • State Insurance Exchanges • Employer Responsibility • As of 1/1/2014, fundamental reform

  6. State Exchanges/Marketplaces Federal: 26; Partnership: 7; State Run: 18

  7. Title II: Medicaid • II: Medicaid & CHIP • New national eligibility floor of 138% FPL for all citizens with no access to other coverage • Because of 2012 US Supreme Court decision on the ACA, expansion is optional for states • Federal Financing at 100% for 2014-16 • Trends down no lower than 90% by 2019 • Average state match in traditional Medicaid is 56% • Uniform eligibility and enrollment standards • Immigrants: • All legal immigrants eligible for Exchange coverage/subsidies • No eligibility for undocumented immigrants

  8. Coverage under Titles I and II: Effective January 1, 2014 • 400%+ FPL – Eligible for Exchange without subsidies ($89K, family of 4) • 139-400% FPL – Eligible for Exchange with subsidies ($31K, family of 4) • 0-138% FPL – Eligible for Medicaid (less than $31K, family of 4) – in states that choose to participate • In non-participating states, individuals 100-138% fpl can join Exchanges

  9. State Medicaid Expansion Decisions

  10. Titles III (Medicare) and IV (Prevention) • III: Medicare and Delivery System Reform • Delivery System Reforms • National Quality Strategy, Medical Homes, Accountable Care Organizations, Readmissions & Hospital Infections Penalties, Value Based Insurance, Independent Payment Advisory Board and more • Changes to Lower Medicare Spending • IV: Prevention and Wellness • Prevention and Wellness Commission and Strategy • Prevention & Wellness $15B Trust • Coverage of A & B Clinical Preventive Services without cost sharing • Calorie Labeling in Chain Restaurants

  11. Delivery System Reform: ACOs and more Medical Homes: 50 ACOs: 27 (252) Bundled/Episode Payments: 23 Comprehensive Or Global Payments: 5

  12. Titles V (Workforce) and VI (Grab-bag) • V. Health Care Workforce • National Workforce Commission and National Plan • Primary Care Expansions • $$$ for Federally-Qualified Community Health Centers (FQHCs) & National Health Service Corps • VI. Transparency and Program Integrity • Physician Payment Sunshine Act • Medicare & Medicaid Fraud & Abuse • Elder Justice Act • Nursing Home Transparency • Patient Centered Outcomes Research Institute (PCORI)

  13. The ACA’s Financial Impacts (2010-19)

  14. What Has Changed in ACA Since 2010? • Title I, subsidy recipients more at risk for repayment when income increases • Title I, $6B funding for co-ops cut to $2B • Title I, employee “free choice” vouchers eliminated • Title II, Medicaid expansion, made state option • Title IV, $5B (of $15) cut from Prevention Trust Fund • Title V, Community Health Centers $3B (of $11) cut • Title VIII, CLASS Act, repealed • Title IX, corporate tax reporting section repealed ($22B revenue loss)

  15. Summary Judgments & Looks Ahead • ACA has survived its three “near death experiences” – the worst threats are over • January 1 2014 is key date when the major insurance expansions take hold – then no turning back • By 2020, most/all states will be part of the Medicaid expansion (remember 1965) • Reform of the delivery system will only get stronger and deeper – global phenomenon • By 2015, Congress will begin the normal work of oversight and reform of the ACA

  16. Key ACA Spending-Scorable Innovations

  17. Other Non-Score ACA Quality Innovations • National Pilot on Payment Bundling (3023) • Hospital Value-Based Purchasing (3001) • National Quality Improvement Strategy (3011) • Interagency Working Group on Quality (3012) • Reduce Drug Waste in LTC facilities (3310) • Medicaid adult quality measures (2701) • Medicaid “health homes” for chronically ill (2703) • CMS Coordinated Health Care Office (2602)

  18. Understanding CBO Scoring • CBO’s health care numbers often don’t add up • Three major health reform laws since 1975 • 1983 – creation of PPS/DRG system • 1997 – passage of Balanced Budget Act • 2003 – Medicare Modernization Act and Part D • In each case, CBO off by a lot • In each case, in the same direction: • Underestimating savings/revenues, overestimating costs • CBO relies heavily on published RCT research • Better than the alternative – may be good news

  19. Title IV: National Prevention Strategy • National Prevention Strategy/Council: Strategic Directions • Healthy and Safe Community Environments:Create, sustain, and recognize communities that promote health and wellness through prevention. • Clinical and Community Preventive Services: Ensure that prevention-focused health care and community prevention efforts are available, integrated, and mutually reinforcing. • Empowered People: Support people in making healthy choices. • Elimination of Health Disparities: Eliminate disparities, improve quality of life for all Americans.

  20. Some Essential Resources • Bill Text and Section-by-Section Summary • Healthcare.gov • Congressional Budget Office: cbo.gov • Obama Administration Site: healthcare.gov • Commonwealth Fund: cmwf.org • Kaiser Family Foundation: kff.org • Health Reform GPS: healthreformgps.org • Politico’s PULSE: www.politico.com/politicopulse/

  21. Open Classroom Series Fall 2013: Policy for a Healthy America • Every Wednesday, 6pm – 8pm • September 4 through December 4 • West Village F, Room 20 • Northeastern University • School of Public Policy and Urban Affairs

  22. Health Care Reform The Massachusetts Experience John Auerbach Institute for Urban Health Research and Practice

  23. Thanks to MDPH Division of Health Care Finance and Policy/CHIA Blue Cross/Blue Shield Foundation Urban Institute

  24. Why here? - PRE-REFORM FACTORS FACILITATED MASS. HEALTH REFORM • Low rate of un-insured (6% vs. 15%) • Employer-offered health insurance • Medicaid eligibility • Need for reform - fed waiver expiring • Right combination of factors • Less political polarization • History of attempts to address (thank you, Gov. Dukakis) • Support from key insurers & providers • Strong consumer movement

  25. Key Elements of Reform Plan – Shared responsibility • INSURERS: Reformed non-group/small-group markets to lower price & offer choices for individual purchasers. • INDIVIDUALS: Required adults who can obtain affordable health insurance to do so. • EMPLOYERS: Required employers of 11+ employees to contribute to coverage for employees or pay assessment. • GOVERNMENT: • Subsidized insurance to low income adults and children (free for adults to 150%/kids to 300%)

  26. Exchange Created: The Connectorwith Insurance Exchanges functions • Commonwealth Care is an Exclusive Distribution Channel for subsidy-eligible adults (< 300% fpl) • Commonwealth Choice is an Alternative Distribution Channel for unsubsidized non-group & small-group insurance* *(non-subsidized insurance must meet certain coverage and cost standards. Eight insurers offered plans within the state’s approved benefit designs (bronze, silver, and gold).

  27. Commonwealth Choice: 33,000 peopleConnects Mass residents and businesses to insurance Commonwealth Care: 175,000 people Connects low-income residents to subsidized plans Non-Group Vol. Plan Employers Small-Group

  28. WHAT HAPPENED?Access, health, cost, public opinion

  29. Access – B+

  30. Within months - MASSACHUSETTS HAD THE LOWEST RATE OF UNINSURANCE IN THE COUNTRY PERCENT UNINSURED, ALL AGES U.S.AVERAGE MASS. 2000 2002 2004 2006 2007 2008 2009 2010 NOTE:The Massachusetts specific results are from a state-funded survey — the Massachusetts Health Insurance Survey (MHIS). Using a different methodology, researchers at the Urban Institute estimated that 507,000 Massachusetts residents were uninsured in 2005, or approximately 8.1 percent of the total population. Starting in 2008, the MHIS sampling methodology and survey questionnaire were enhanced. These changes may affect comparability of the 2008 and later results to prior years. The national comparison presented here utilizes a different survey methodology, the Current Population Survey, which is known to undercount Medicaid enrollment in some states. SOURCES:Urban Institute, Health Insurance Coverage and the Uninsured in Massachusetts: An Update Based on 2005 Current Population Survey Data In Massachusetts, 2007; Massachusetts Division of Health Care Finance and Policy, Massachusetts Health Insurance Survey 2000, 2002, 2004, 2006, 2007, 2008, 2009, 2010; U.S. Census Bureau, Current Population Survey 2010.

  31. UNMET NEED FOR CARE FOR ANY REASON HAS DECREASED SINCE REFORM PERCENT OF NON-ELDERLY ADULTS REPORTING AN UNMET NEED FOR CARE FOR ANY REASON, BY SELECTED POPULATIONS Fall 2006 Fall2009 Fall 2006 Fall2009 Fall 2006 Fall2009 Fall 2006 Fall2009 Fall 2006 Fall2009 All adults Lower-income adults(<300% FPL) Middle-income adults(300-500% FPL) Adults with a chronic condition Adults of minority race/ethnicity SOURCE:Urban Institute, Massachusetts Health Reform Survey, 2010.

  32. MORE MASSACHUSETTS ADULTS HAVE A USUAL SOURCE OF CARE PERCENT OF NON-ELDERLY ADULTS REPORTING A USUAL SOURCE OF CARE, SELECTED POPULATIONS Fall 2006 Fall2009 Fall 2006 Fall2009 Fall 2006 Fall2009 Fall 2006 Fall2009 Fall 2006 Fall2009 All adults Lower-income adults(<300% FPL) Middle-income adults(300-500% FPL) Adults with a chronic condition Adults of minority race/ethnicity SOURCE:Urban Institute, Massachusetts Health Reform Survey, 2010.

  33. Compared with the insured adults, uninsured non-elderly adults were much less likely to have had a doctor visit in the past 12 months. The 2009 estimates are not significantly different from the estimates for 2008. NON-ELDERLY ADULTS WITH A DOCTOR VISIT IN PAST 12 MONTHS BY INSURANCE STATUS Note: In some cases, what appear to be relatively large differences in estimates between 2008 and 2009 are not statistically significant. This arises because estimates based on small subgroups of the overall population have larger variances, making point estimates less precise. Source: Urban Institute tabulations on the 2008 and 2009 Massachusetts HIS Massachusetts Division of Health Care Finance and Policy

  34. FEWER MASSACHUSETTS ADULTS HAVE SIGNIFICANT OUT-OF-POCKET HEALTH EXPENSES PERCENT OF NON-ELDERLY ADULT POPULATION WITH FAMILY INCOME LESS THAN 500% FPL WHO SPENT 5 OR 10 PERCENT OF INCOME ON OUT-OF-POCKET HEALTH CARE COSTS Fall 2006 Fall 2006 Fall 2010 Fall 2010 Out-of-pocket expenses at 5% or more of family income Out-of-pocket expenses at 10% or more of family income NOTE:“Out-of-pocket” health care costs includes deductibles, co-insurance, co-payments, but excludes the cost of premiums. SOURCE:Urban Institute, Massachusetts Health Reform Survey, 2012.

  35. PERCENTAGE OF ADULTS WITHOUT HEALTH INSURANCE, BY RACE/ETHNICITY2001-2010 (NON-ELDERLY) All percentages are age-adjusted to standard population (U.S. 2000) Chart shows two-year moving averages Data Source: MA Behavioral Risk Factor Surveillance System (BRFSS)

  36. RACIAL/ETHNIC DISPARITIES IN ACCESS TO AND USE OF CARE HAVE DECREASED IN MASSACHUSETTS SINCE REFORM PERCENT OF POPULATION WITHA USUAL SOURCE OF CARE PERCENT OF POPULATION WITH ANY DOCTOR VISIT IN PRIOR YEAR White,non-Hispanic adults Adults of minorityrace/ethnicity White,non-Hispanic adults Adults of minorityrace/ethnicity White,non-Hispanic adults Adults of minorityrace/ethnicity White,non-Hispanic adults Adults of minorityrace/ethnicity Fall 2006 Fall 2009 Fall 2006 Fall 2009 SOURCE:Urban Institute, Massachusetts Health Reform Survey, 2010.

  37. BUT SOME STILL UNINSURED 2%=120,000 Male Hispanic Non-citizen Low-income Not working or working part-time PERCENT UNINSURED, 2010, BY RACE/ETHNICITY

  38. Health – B

  39. Compared with the insured adults, uninsured non-elderly adults were much less likely to have had a preventive care visit in the past 12 months. The 2009 estimates are not significantly different from the estimates for 2008. NON-ELDERLY ADULTS WITH A PREVENTIVE CARE VISIT IN PAST 12 MO. BY INSURANCE STATUS Massachusetts Division of Health Care Finance and Policy

  40. PREVENTIVE CARE AND USE OF OTHER MEDICAL SERVICES HAVE INCREASED AMONG MASSACHUSETTS ADULTS SINCE REFORM PERCENT OF NON-ELDERLY ADULTS REPORTING USE IN PRIOR YEAR, BY TYPE OF SERVICE Fall 2006 Fall 2006 Fall 2006 Fall 2006 Fall2009 Fall2009 Fall2009 Fall2009 Any doctor visit Preventive carevisit Dental carevisit Prescription drug use SOURCE:Urban Institute, Massachusetts Health Reform Survey, 2010.

  41. IMPROVED SCREENING AND VACCINE RATES

  42. DRAMATIC DECREASE IN SMOKING of MassHealth enrollees Smoking prevalence among the uninsured changed very little after July 2006, but the MassHealth population saw a sharp and significant decrease from 38% pre-benefit to 28% just 2.5 years later. This decrease began the month the MassHealth benefit was implemented. 6-Month Annual Rolling Average, Model Estimates Health care reform implemented Massachusetts Department of Public Health Source: MA BRFSS, 1998-2008

  43. BUT WITH HCR: INCREASED PREVENTIVE CARE AMONG PEOPLE WITH DIABETES The number of people with diabetes who received recommended preventative care (eye exam, foot exam, flu shot and twice annual A1c check) has increased by 7.6 percentage points in the period following health care reform implementation. Four measures: Annual Eye Exam, Annual Foot Exam for Numbness, Flu Shot, and Twice yearly A1c check *Statistically significant increase (p<.05) Massachusetts Department of Public Health Source: MA BRFSS, 2005-2009

  44. Focus on quality improvement – reduction of health care infections & injuries Emphasis on primary care medical homes as model Structuring payment incentives to ensure high level quality ELEVATED FOCUS ON QUALITY

  45. Cost – C+ (but with a recent A for effort)

  46. LONG-TIME COST ISSUES Per capita health spending 15% higher than the nat’l average Highest individual market premiums in the country

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