National Center on Domestic and Sexual Violences-Day-Report_2011.pdf · Created Date: 5/6/2011 2:33:26 PM

THE AFFORDABLE CARE ACT: THE AMERICAN VERSION OF

HEALTH CARE FOR ALL

MOTHER’S DAY REPORT2011

2011 OWL MOTHER’S DAY REPORT

Table of Contents

Acknowledgements A Message from OWL’s PresidentExecutive SummaryIntroductionHealth Insurance Reforms Near Universal Coverage and Shared Responsibility for Financing Changes in Health Care Effective in 2010 and 2011! "##$%&'()!*$()&+!,$%$-&#!.(/0(1$ Health Insurance Exchanges: States have Primary Responsibility Protection of Coverage for Early Retirees 2014: A Key Date for Health ReformThe Affordable Care Act Implementation TimelineMedicare Related Provisions Prescription Drugs Preventive Services Doctor and Hospital Care Cost Savings Extend Solvency of Medicare for 12 years Changes to Medicare Advantage Plans Increasing the Medicare Tax on HighIncome People Coordinated Care LongTerm Care (LTC) Community Living Assistance Services and Supports (CLASS) Act Home and CommunityBased Services (HCBS) Nursing Home CareElder Justice Act ProvisionsHealth Care Workforce, Health Centers, Quality Improvement Strategy Health Care Workforce Community Health Centers Quality Improvement StrategyOther Provisions Medicare Payment Reform Revenue Savings and Resources Research Demonstration Programs for Improved Patient Care ModelsConclusionOWL’s Recommendations for Improving the Affordable Care ActGlossary of Key TermsAppendix A: Myths and FactsAppendix B: Questions and AnswersEndnotes

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2011 OWL MOTHER’S DAY REPORT 2011 OWL MOTHER’S DAY REPORT2 3

May 2011

OWL – the Voice of Midlife and Older Women – launches a Mother’s Day campaign each year, highlighting an issue of special concern to midlife and older women. This year we again focus on health, particularly the Patient Protection and Affordable Care Act of 2010 provisions that affect the lives of 74 million women over the age of 40.

Most of us realize that “mothering” – i.e., willingly assuming responsibility for the unpaid care of family members – results in women having less economic security than men. The social system needs to support them and make sure their own health does not suffer

by providing universal, affordable, and highquality health care. This has been a top priority of OWL since our formation in 1980, and has been addressed in many prior Mother’s Day reports, including The Picture of Health for Midlife and Older Women (1987), Failing America’s Caregivers: A Status Report on Women Who Care (1989), Critical Conditions: Midlife and Older Women in America’s Health Care System (1992), Faces of Caregiving (2001), A Poor Prognosis: Healthcare Costs and Aging Women (2004), Women and LongTerm Care: Where Will I Live and Who Will Take Care of Me? (2006), MedicareforAll (2007), Elder Abuse: A Women’s Issue (2009) and EndofLife Choices: Who Decides? (2010).

The recently passed legislation is important because it makes it more likely that everyone will have some form of health insurance and realistic options for arranging longterm care insurance in advance. Each state’s aging network of home and communitybased services will be monitored to assure they meet the needs of a growing population of seniors, with special attention paid to care coordination and preventing insurers from denying coverage for “preexisting” conditions. This report informs us about these and other provisions in the Act, with a special focus on !"#$%&%#'&()#&*(+,,-.*%'/()%01%,-(+'0(#10-"(2#)-'3((4'(*5-(1#'/("6'7(*5-()#0%8.+*%#'&(should be costeffective and enhance the quality of life of our nation.

The Affordable Care Act is not the ideal we envisioned when we issued our 2007 Mother’s Day report, MedicareforAll, but it includes some very important steps which must be protected as we move toward joining other developed nations that provide universal health care as a right, not a privilege. This report includes an informative set of facts and recommendations that should guide our advocacy and policy stances.

We must protect our mothers and daughters by ensuring that they, and we, have the health care we need. It is time for action! Please join us!

Margaret Hellie Huyck, Ph.D.

OWL Board Members

A Message from OWL’s President

Margaret Hellie HuyckPresidentChicago, IL

Amy ShannonVice PresidentWashington, DC

Rose GarrettDaughetySecretaryRichardson, TX

Lilo HoelzelSeippTreasurerThompsonville, MI

Bettie BacaAnnandale, VA

Joan BernsteinBrewster, MA

Janice FeinbergChicago, IL

Lowell GreenNortheast Regional RepresentativeBronx, NY

Jacqueline JaramilloColorado Springs, CO

Beedie JonesChicago, IL

Linette KinchenMidwest Regional RepresentativeChicago, IL

Daniella LevineCoral Gables, FL

Donna Phillips MasonWashington, DC

Margie MetzlerSacramento, CA

Paul NathansonWashington, DC

Margaret Beth NealNewberg, OR

Catherine PinkasWalnut Creek, CA

Audrey SheppardChevy Chase, MD

Donna WagnerPresident EmeritaLas Cruces, NM

Sue Fryer WardUpper Marlboro, MD

**Sponsors do not necessarily agree with all contents of report but want to get message out on how ACA !"#"$%&'()*"+',(-"#.

/01&'1&'2'34!)152%1(#'(6'789':'/0"';(15"'(6'<1*)16"'2#*'7)*"+'8(-"#.''789'1&'2'=>?@5A@BA'(+C2#1D2%1(#'%02%'6(54&"&'&()")E'(#'1&&4"&'4#1F4"'%(',(-"#'2&'%0"E'2C".'G'789'H2%1(#2)I'<2E'J>??.'K"+-1&&1(#'%('reproduce all of part of this report is given with the following credit line: Reprinted (or excerpted) with 3"+-1&&1(#'(6'789':'/0"';(15"'(6'<1*)16"'2#*'7)*"+'8(-"#.

Research, Writing, InformationDianna Porter, M.A., J.D.Gladys Considine, B.S., M.S. Laura Frazier, B.A.Shirley Harlan, B.A.Kay RandolphBack, M.A., J.D.Amy Shannon, J.D.Donna Wagner, Ph.D.

EditingDianna Porter

Copy EditingDeborah Akel

ReviewPaul N. Van de Water, PH.D., Senior Fellow, Center on Budget and Policy Priorities

Layout and DesignGen GuracarDianna PorterMark Ibrahim

Illustrations*Bulbul

Sponsors**Amplify Public Affairs, LLC

AcknowledgmentsHappy Mother’s Day!

*Cartoons by Bulbul. Her web site www.bulbul.com features cartoons from current events. A collection of her cartoons appear in the paper back titled, Drawing My Times, A Thirty Year Retrospective.

Bobbie BrinegarExecutive DirectorWashington, DC


Health care for all is a women’s issue, and now that the Affordable Care Act (ACA) is enacted, OWL will devote its health advocacy work to educating women +9#6*(25+*(%*(%&(+'0(5#2(%*(9-'-8*&(*5-)7(+0$#.+*%'/(,#"(%)!"#$-)-'*&(*#(9-'-8*(women and their families, and working against forces that wish to roll it back or refuse to fund it. OWL’s 2011 Mother’s Day report outlines the Affordable Care Act provisions that will affect the lives of 74 million women over the age of 40 – 24% of the U.S. population – and proposes recommendations on ways that the ACA can be strengthened.

When fully up and running, the ACA will expand health care insurance coverage to 95% of the population, offering coverage to 32 million Americans who were previously uninsured. In order to achieve this, Medicaid eligibility will be expanded to 16 million; most employers will have a responsibility to provide health care coverage for their employees; and individuals will be required to obtain insurance independently if it is not provided by their employer. States will establish health insurance exchanges, or electronic insurance marketplaces, for individuals and small businesses to purchase health care insurance.

The elimination of costsharing for preventive services is of critical importance to midlife and older women. Nearly onethird of uninsured Americans have unmet health needs due to cost. Health conditions can become worse with delays in obtaining care, and the costs for eventual treatment greater. Prior to the ACA, most of the preventive services in Medicare required a copayment of 20% or were considered part of the deductible. Approximately half of Medicare 9-'-8.%+"%-&(0%0('#*(*+:-(+0$+'*+/-(of the preventive services available to them. Utilization of these services,

combined with intervention, could prevent or postpone the onset of more serious illnesses, manage early complications and ultimately control costs.

The services contained in the Essential ;-+1*5(<-'-8*&(!+.:+/-(*5+*(*5-(Department of Health and Human Services is required to design are important because the package will become the standard for coverage in the state insurance exchanges, Medicaid and eventually, employerprovided health coverage. Everyone affected by health reform has a stake in what is in the =&&-'*%+1(;-+1*5(<-'-8*&(!+.:+/-3((>5-(challenge is to produce a package that is comprehensive and affordable so that the goal of covering all those who are uninsured with a highquality level of 9-'-8*&(.+'(9-()-*3((

Unfortunately, the ACA does not address the source of many of the outofpocket expenditures of older people – vision, hearing, podiatry, and dental care. Without early treatment, these conditions can quickly lead to further health complications needing much more expensive medical care. OWL urges that a way be found to expand the inadequate Medicare coverage of services and treatments for these potentially debilitating conditions.

>5-()#&*(&%/'%8.+'*("-,#")&(6'0-"(*5-(ACA will begin in 2014. Nearly everyone will be expected to secure coverage for themselves and their families through one of the following:

?( An employer;?( A public program (such as Medicare and Medicaid);

?( Insurance plans offered in new statebased exchanges;

?( The individual insurance market.

The requirement for everyone to obtain coverage in the insurance exchanges – if not obtained elsewhere – is essential if the expansion is to succeed. Without everyone being in the “pool,” the insurance plans and exchanges would be made up primarily of older and sicker individuals which would in turn drive up premiums.

Insurers will no longer be able to deny coverage for “preexisting” conditions, cancel insurance retroactively because of accident or sickness, or impose caps on annual and lifetime limits of coverage. However, insurers may still base premiums on age at a 3to1 ratio above the average. “Age rating” means that older people pay more than younger people for the same dollar insurance coverage. Age rating is a major discriminatory provision applied to older persons and the ACA must be changed to prohibit agebased premiums.

The ACA will phase out the coverage gap in Medicare Part D prescription drug plans known as the “donut hole” and completely close the gap by 2020. Yet, the cost of prescription drugs remains high. An improvement that would produce more cost savings for the Medicare program +'0(%'0%$%06+1(9-'-8.%+"%-&(2#610(9-(*#(allow the Secretary of Health and Human Services to negotiate lower drug prices from pharmaceutical companies.

The Affordable Care Act contains &%/'%8.+'*(1#'/@*-")(.+"-(!"#$%&%#'&A

?( The Community Living Assistance Services and Supports (CLASS) Act which creates a new, voluntary longterm care insurance program available to working adults of participating employers;

?( A mandatory evaluation of each state’s aging network of home and

communitybased services as well as a plan for improvements in the network to meet the needs of a growing population of seniors;

?( Improved federal coordination #,(9-'-8*&(,#"(B06+1(-1%/%91-&C(D(9-'-8.%+"%-&(25#(E6+1%,F(,#"7(#"(+"-(enrolled in, both the Medicare and Medicaid programs; and

?( A number of provisions to enhance *"+'&!+"-'.F(#,(!"#.-06"-&7(&*+,8'/(and care in nursing homes.

With the inclusion of the Elder Justice Act in the ACA, older Americans will now have federal protection against abuse (emotional, physical and sexual), '-/1-.*7(+9+'0#')-'*(+'0(8'+'.%+1(exploitation. Now, funding must follow the authorizations.

The ACA addresses the delivery of health care by expanding funding for the health care workforce and community health centers, and by quality improvement initiatives.

While the Affordable Care Act is not the singlepayer health care system OWL believes is the best approach to achieving universal and affordable health care, the GHG(0#-&()+:-(&%/'%8.+'*(&*-!&(*#2+"0(covering the majority of Americans. OWL will continue to work toward achieving improvements in the Act while maintaining our commitment to a singlepayer system.

Executive Summary


For thirty years, OWL, the Voice of Midlife and Older Women, has worked toward the goal of comprehensive, accessible and affordable health care that is publicly +0)%'%&*-"-0(+'0(8'+'.-03((4'(#*5-"(words: a singlepayer system. Although the President and Congress chose not to enact a truly universal health care &F&*-)(%'(IJKJ7(2-(5+$-7(,#"(*5-(8"&*(time in our nation’s history, a law that will nearly close the coverage gap once its implementation is complete.

OWL has championed affordable, universal and sound health care as a centerpiece of its policy efforts because of its importance to the quality of life for women. While the life expectancy of women continues to exceed that of men, these extra years are often spent managing chronic illness with limited options for affordable care and services.

Better access to affordable health care coverage is important because of the role women play in managing care for their family members. Most health care decisions are made by women on behalf of their children and their husbands. The United States has a tradition of the informal caregiving by family members and friends, and women are at the frontlines of providing needed care. An estimated 85% of all longterm care services are provided by family and friends, and women constitute 60% of informal caregivers.1 These informal caregivers not only provide a full range of needed services to aging parents, siblings, spouses, children and friends, but they often do so at the expense of their own health and wellbeing.

In addition to the costs to their personal health, employed women who are also .+"-/%$-"&(#,*-'(8'0(%*('-.-&&+"F(*#()+:-(major work adjustments to carry out their

caregiving duties. More than 60% have employed tactics such as working fewer hours, arriving at work late or leaving early, turning down promotions, losing 9-'-8*&7(*+:%'/(1-+$-&(#,(+9&-'.-(#"(retiring early in order to provide care for their loved ones.2

The economic effects of caregiving can be detrimental and longlasting for women – they are twice as likely as noncaregivers *#(1%$-(%'(!#$-"*F(+'0(8$-(*%)-&()#"-(likely to receive Supplemental Security Income. In 2005, the probability of living in poverty for nonwhite caregivers was 29%.3 A health care system that is accessible can make a dramatic difference in the quality and economic security of caregivers’ lives.

Universal access to affordable health care is also important to midlife and older career women separately from caregiving concerns. Almost 70.6% of women 4554 are in the workforce and over 56% of women ages 5564 are employed.4 Yet, health coverage lags. In the period from 1980 to 2005, the percentage of uninsured women rose, and the percentage of those with health insurance through employment, either their own or a spouse’s, fell.5 Even when they do have health care coverage, women face obstacles to effective use of that coverage because of the high costs. Onethird of continuously covered women ages 1964 did not see a doctor for a medical !"#91-)7(+'0(,+%1-0(*#(811(+(!"-&."%!*%#'7(see a specialist when needed, or follow up with recommended medical tests and treatment.6 Employment is no guarantee of access to health insurance and when working women are covered, they can 8'0(%*(0%,8.61*(*#()+'+/-(*5-%"(5-+1*5(needs. Affordable, universal health care with a

longterm care component is important for women who reach old age. Women who reach age 65 can expect to live 20 more years, and more than twothirds of Americans age 85 and older are women. Along with advanced age often comes the need for greater longterm care services. Among people age 75 or older, women are 60% more likely than men to need help with one or more of their activities of daily living – such as eating, bathing, dressing, or getting around inside the home. In fact, one in nine women age LM(#"(#10-"(D(+'0(#'-(%'(8$-(+/-(NM(or older – needs assistance with daily activities. After a lifetime of caring for others, women often need affordable care 96*(8'0(*5+*(*5-(.#&*&(+"-(5%/5(+'0(*5-%"(options are severely limited. In 2006, the average annual cost of a private room in a nursing home was $75,000; for a shared room, almost $67,000. Costs for home care averaged nearly $20 per hour.7 There are few choices for older women who wish to remain in their homes or in their communities. In the United States,

the ability to obtain services that would help women maintain their autonomy and independence throughout their old age is lacking.

Health care for all is a women’s issue, and now that we have the Affordable Care Act (ACA),* OWL will devote its health advocacy work to educating women +9#6*(25+*(%*(%&(+'0(5#2(%*(9-'-8*&(them, advocating for improvements to 9-'-8*(2#)-'(+'0(*5-%"(,+)%1%-&7(+'0(working against forces that wish to roll it back or refuse to fund it. This 2011 Mother’s Day report outlines the ACA provisions that will affect the lives of 74 million women over the age of 40 – 24% of the U.S. population – and proposes recommendations on ways that the ACA can be strengthened. Although passage of *5-(GHG()+":&(+(&%/'%8.+'*(&*-!(,#"2+"0(in a nearly 100year effort to attain universal health care coverage in this country, there are a number of ways it can be improved and further built upon.

Introduction

*The historic Patient Protection and Affordable Care Act, now called the Affordable Care Act @LMLAI',2&'&1C#"*'1#%(')2,'(#'<2+50'JBI'J>?>'@K.9.'???:?NOA.''/0"'P"2)%0'M2+"'2#*'Q*452%1(#'R"5(#51)12%1(#'L5%'(6'J>?>I'2**1#C'2**1%1(#2)'3+(%"5%1(#&'%('LMLI'!"52-"')2,'<2+50'B>I'J>?>'@K.9.'???:?=JA.''/(C"%0"+'%0"E'-2S"'1-3(+%2#%'502#C"&'%('%0"'#2%1(#T&'0"2)%0'52+"'&E&%"-.


When fully up and running, the ACA will expand health care insurance coverage to 95% of the population, offering coverage to 32 million Americans who were previously uninsured. In order to achieve this, most employers will have a responsibility to provide health care coverage for their employees or pay a penalty, and individuals will be required to obtain insurance independently if it is not provided by their employer. Medicaid will be expanded to cover 16 million persons, almost half the total increase in coverage.

States will establish health insurance exchanges, or insurance marketplaces, for individuals and small businesses to purchase health care insurance.

Prior to the ACA, premiums for businesses and their employees increased 41% across states from 2003 to 2009, while perperson deductibles jumped 77% in 1+"/-(+&(2-11(+&(&)+11(8")&3((O%*5#6*(health care reform, the average premium for family coverage would rise 79% by 2020 to more than $23,000.8

Health Insurance Reforms

Changes in Health Care Effective in 2010 and 2011

?( Extend coverage for adult children under parents’ plans to age 26;

?( Begin lifting caps on annual and lifetime limits of coverage;

?( Prohibit exclusions of preexisting conditions for children;

?( Prohibit retroactive canceling of insurance because of an accident or sickness (in the absence of fraud);

?( Ban copayments and other outof pocket expenses for certain preventive care and immunizations under P-0%.+"-7()+'F(#,(25%.5(9-'-8*(midlife and older women;

?( Offer tax credits of up to 35% of premiums to small employers who

offer coverage (to rise to 50% in 2014);

?( Prohibit new group health plans from !"#$%0%'/(9-'-8*&(*5+*(0%&."%)%'+*#"%1F(favor higher wage employees;

?( Establish a temporary, national, highrisk pool plan for uninsured individuals denied coverage because of medical conditions unless states establish their own plans. Over half of states have done so. This will operate until 2014 when the health insurance exchanges begin operating; and,

?( Establish a temporary reinsurance program for employers with retirees that will operate until 2014.

>5-(G,,#"0+91-(H+"-(G.*()+:-&(&%/'%8.+'*(.5+'/-&(*#(*5-(!"%$+*-(%'&6"+'.-(&F&*-)(+'0(the Medicare and Medicaid programs. Several changes started going into effect shortly after enactment in 2010, including:

Preventive Services. Recommended preventive services under the ACA that receive a grade A or B rating from the U.S. Preventive Services Task Force and *5+*(!+"*%.61+"1F(9-'-8*(2#)-'(%'.160-A9

?( Breast cancer screening every one to two years for women age 40 and older;

?( Cervical cancer screening; ?( Sexually transmitted infection screening;

?( Genetic counseling for the breast cancer gene;

?( Osteoporosis screening for all women 65 and older, and age 60 and older for those at high risk;

?( Colorectal cancer screening for adults over age 50;

?( Blood pressure and cholesterol screening;

?( Aspirin to prevent cardiovascular disease in women ages 55 to 79;

?( Depression screening for adults and adolescents;

?( Screening and counseling for obesity, and

?( Immunizations recommended by the Centers for Disease Control and Prevention.

The elimination of costsharing for preventive services is of critical importance to midlife and older women. Nearly onethird of uninsured Americans have unmet health needs due to cost. Health conditions can worsen with delays in obtaining care, and the costs for

eventual treatment can grow. Figure 1 shows that, prior to the ACA, many insured as well as uninsured women aged 55 and older went without basic preventive screenings.10

The National Cancer Institute recommends that women above the age of 40 have a mammogram at least every one to two years.11 However, one %'(8$-(2#)-'(+/-0(MJ(+'0(#10-"(5+&(not received a mammogram in the past two years. If 90% of women 40 and older received breast cancer screening, 3,700 lives would be saved annually.12 Additionally, if 90% of all adults aged 50 and over received recommended screening for colorectal cancer, an estimated 14,000 additional lives would be saved each year.13

Medicalloss ratio. Beginning in 2011, insurance companies must devote at least 85% of the premium dollars they receive in the large group market or 8085% in the small group and individual markets *#()-0%.+1(9-'-8*&(+'0(E6+1%*F(%)!"#$-ment. This means that at least 8085 cents of every dollar these plans receive is spent on health care, rather than administrative costs and insurance company !"#8*&3((>5%&(%&("-,-""-0(*#(+&(+(B)-0%.+1@loss ratio.” If the medical spending falls below these percentages, insurers must provide consumer rebates. Insurance companies will also be required to submit Q6&*%8.+*%#'(,#"(-R.-&&%$-("+*-(5%:-&(%'(2011 and post them on their websites.

Procedure Insured UninsuredPap Smear 5% 16%Mammogram 14% 35%Cholesterol Test 11% 23%Colon Cancer Screening 35% 54%Source: Strengthening the Health Insurance System: How Health Insurance Reform Will P")3'L-"+152T&'7)*"+'2#*'U"#1(+'8(-"#.'',,,.0"2)%0+"6(+-.C(V.

Figure 1: Percentage of women age 55+ who went without basic procedural screenings prior to the passage of the ACA.

Near Universal Coverage and Shared Responsibility for Financing


!""#$%&'()*#'(%+),#$#-%").'/0'1#))

As part of health reform, the Department of Health and Human Services (HHS) is required to design an “Essential Health <-'-8*&C(!+.:+/-3(>5-(&-"$%.-&(.#'*+%'-0(in this package are important because the package will become the standard for coverage in the state insurance exchanges, Medicaid, and eventually, employerprovided health coverage. Everyone affected by health reform has a stake in what is in the essential 5-+1*5(9-'-8*&(!+.:+/-3((>5-(.5+11-'/-(is to come up with a package that is comprehensive and affordable so that the goal of covering all those who are uninsured with a highquality level of 9-'-8*&(.+'(9-()-*3(( The ACA sets out broad categories of services that must be included, and HHS has discretion on how inclusive or limited the services would be under each category. The broad categories are: 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; and pediatric services, including oral and vision care. HHS has asked the Institute of Medicine (IOM),14 an advisory organization that provides technical assistance to the government, policymakers and the public, to come up

with preliminary guidelines on essential 9-'-8*&3(>5-(4SP(%&(-R!-.*-0(*#("-1-+&-(its report in late 2011, and HHS will likely complete a proposed outline of essential 9-'-8*&(9-,#"-(*5-(-'0(#,(IJKK315 Insurers who want to participate in the exchanges and Medicaid must offer the -&&-'*%+1(9-'-8*&(9F(IJKT3((

SOU(&6!!#"*&(*5-(+0#!*%#'(#,(+(9-'-8*&(package that is comprehensive and affordable without arbitrarily set limits. <-'-8*&()6&*(%'.160-(+(9"#+0("+'/-(#,(home care services, supportive social services, and community and institutional services, including rehabilitative services for maximum independent functioning. 4'(+00%*%#'7(SOU(6"/-&(*5+*(*5-(8'+1(-&&-'*%+1(5-+1*5(9-'-8*&(!+.:+/-(9-(&69Q-.*(*#(!-"%#0%.("-$%-2&(*#("-V-.*(changing health needs, medical research, and medical practices.

OutofPocket Expenditures of Older People. The ACA does not address the source of many of the outofpocket expenditures of older people—vision, hearing, podiatry, and dental care. Figure 2 indicates by age the high percentages of older people who are affected.

Vision trouble affects 18% of the older population – 19% of women and 15% of men. Among people age 85 and over, 28% report they have trouble seeing. Fortytwo percent of men over age 65 and 30% of older women report trouble with hearing. The percentage with hearing

problems was higher for people age 85 and over (60%) than for people ages 6574 (28%). Twenty percent of those ages 6574 do not have natural teeth, while 34% of people age 85 and over do not.16 Access to foot care and podiatry services is of particular importance to older adults. According to the National Diabetes Education Program at the National Institutes of Health, 11.3% of Americans age 20 and older have diabetes, compared to 26.9% of Americans age 65 and older. High blood glucose can cause serious conditions such as poor blood circulation and diabetic neuropathy (nerve damage). Both conditions can lead to serious infections and sores in the feet.17

In many locations, there are limited services for these conditions, and the outofpocket expenses keep many people from getting healthenhancing treatment.

With copays and Part B deductibles, it is possible to get eyeglasses after cataract surgery; hearing and balance tests to see if medical treatment is needed or if a doctor orders them; and foot exams and treatment if there is diabetesrelated nerve damage. But all of these Medicare covered treatments come after the patient has had considerable outofpocket expenses for the initial diagnosis.18 Without early treatment, these conditions can quickly lead to further health complications needing much more expensive medical care. A way must be found to expand and improve the presently inadequate Medicare coverage of services and treatments for these potentially debilitating conditions.

A way must be found to expand the inadequate Medicare coverage of services and treatments for these potentially

*"!1)1%2%1#C'5(#*1%1(#&.

70

60

50

40

30

20

10

0

Vision Problems Hearing Trouble No Natural Teeth

Percentage of Population 85+

Percentage of Population 65+

Figure 2: Percentage of individuals 65+ and 85+ who suffer from vision problems, hearing trouble, and do not have natural teeth.

U(4+5"W''X"*"+2)'Y#%"+2C"#5E'X(+4-'(#'LC1#C:R")2%"*'U%2%1&%15&.''7)*"+'L-"+152#&'J>?>W'Z"E'Y#*152%(+&'(6'8")):["1#C.

““


Health Insurance Exchanges: States Have Primary Responsibility 2014: A Key Date for Health Reform

Protection of Coverage for Early Retirees

States are charged with establishing a “health insurance exchange,” essentially an insurance marketplace run by a state /#$-"')-'*(#"(+('#'@!"#8*(#"/+'%W+*%#'7(for small businesses and individuals who do not have health coverage. This is a new entity designed to create a more organized, competitive, lowercost and consumerfriendly system for providing health insurance. Federal funding will be provided until January 1, 2015, to states that establish exchanges. If any state does not set up an exchange by 2012, the federal government will step in to do it.

States will receive funding to establish exchanges, to improve oversight of proposed private health premium increases and to take action if they are unreasonable.

New, independent appeals processes are underway and in 2011, states may apply for and receive grants to provide .#'&6)-"(+&&%&*+'.-(2%*5(81%'/(5-+1*5(insurance complaints and appeals.

Effective in 2017, states may receive “innovation waivers” from certain components of the health reform law. These are alternative methods that states can develop and adopt to make health insurance affordable and accessible. The guidelines the federal government would use to grant waivers include coverage that is at least as comprehensive and affordable and covers at least as many state residents as the ACA. It must '#*(%'."-+&-(*5-(,-0-"+1(0-8.%*3((G(&*+*-(that wants to create a different delivery approach, such as a singlepayer system, )6&*(8"&*(#!-"+*-(+'(-R.5+'/-(,"#)(2014 to 2017 before it can do so. A number of policymakers would like to /%$-(&*+*-&()#"-(V-R%9%1%*F(+'0()#$-(up the availability date of waivers to 2014 so that state exchanges would not be established only to be dismantled later. President Obama supports the acceleration of state waivers provided they meet the above requirements.19

X%R*F@8$-(!-".-'*(#,(2#)-'(+/-(MM@YK(and 42% of women age 6264 are in the labor force.20 Women in the early retiree age range are particularly at risk for lack of health care insurance. Fifteen percent of women age 6064, more than 1 in 7, do not have health insurance. Women who retire before Medicare coverage begins (age 65) are less likely than men to receive retirement coverage through their employer (8% for women versus 14% for men).21 Fortyeight percent of all Americans between ages 5564 have a preexisting condition requiring ongoing, regular medical care.22

For early retirees (ages 5564), the ACA provides for a temporary reinsurance pro

gram (until 2014) to help offset expensive premiums for employers who continue to !"#$%0-(.#$-"+/-(#,(5-+1*5(9-'-8*&(,#"(retirees, spouses and dependents. This is particularly important for women in this age group as they are more likely to have dependent coverage and may lose that coverage due to the death of, or divorce from, a spouse. The program covers 80% of claims between $15,000 and $90,000 – the claim thresholds will be adQ6&*-0(,#"(%'V+*%#'(+''6+11F(D(+'0(%&(+$+%1able until either the insurance exchanges begin or the allocated funds ($5 billion) are spent. The program is so popular with employers that applications will likely be cut off after April 2011.23(((G'(%'V6R(#,(additional funding is urgently needed.

>5-()#&*(&%/'%8.+'*("-,#")&(2%11(9-/%'(%'(2014. Nearly everyone will be expected to secure coverage for themselves and their families through either:

?( An employer;?( A public program (such as Medicare and Medicaid);

?( Insurance plans offered in new statebased exchanges;

?( The individual insurance market.

>5-(G,,#"0+91-(H+"-(G.*()+:-&(&%/'%8.+'*(changes to current practices of insurance companies. There will be four different levels of coverage offered: bronze, silver, gold and platinum plans. Individual insurers who qualify to market coverage through an exchange to small groups and individuals must offer at least the silver and gold levels of coverage to everyone and must renew all policies. All of these plans must provide an Essential ;-+1*5(<-'-8*&(!+.:+/-(Z+&(0-&."%9-0(in an earlier section), meet costsharing standards, and provide a certain level of coverage depending on the share of actual costs that an insurer covers. Socalled “grandfathered” health plans – plans in which an individual was already enrolled when the ACA was enacted and subsequently renewed – are exempt.

A bronze plan must have an actuarial value – the share of costs that an insurer covers on average for a standard population – of 60%; a silver plan, 70%; a gold plan, 80%; and a platinum plan, 90%. For all plans, outofpocket costs are limited to $5,950 for single policies and $11,900 for family policies.

The requirement that everyone obtain coverage in the insurance exchanges – if not obtained elsewhere – is essential if the expansion is to succeed. Without everyone in the “pool,” the insurance

plans and exchanges would be made up primarily of older and sicker individuals that would in turn drive up premiums. If younger and healthier persons also participate, then premiums will be lowered by 710 % for everyone, according to the Congressional Budget S,8.-324

Beginning in 2014, the ACA expands Medicaid eligibility for all legal residents up to 133% of the federal poverty level regardless of whether they have children. This expansion alone accounts for new coverage for approximately 16 million, half of the 32 million who will receive new health care coverage in 2014. Premium and costsharing tax credits will be available through the exchanges for this population if they are not eligible for, or offered, other acceptable coverage.

Insurers will no longer be able to deny coverage for “preexisting” conditions, and that will apply to everyone. Insurance companies will also be prohibited from basing their premiums on health status, gender and other factors such as medical history and genetic information.


However, insurers may still base premiums on age, but the oldest age group may be charged no more than three times what the youngest is charged. Other factors for which higher premiums may be levied are whether the plan covers an individual or family; geography (referred to as state rating areas); and tobacco use. The agebased premiums have a disproportionate effect on women whose incomes and savings are lower than that of men of the same age.

“Age rating” means that older people pay more than younger people for the same dollar insurance coverage. “Gender rating” means that women pay more than men for the same dollar insurance. OWL took a strong leadership position on both gender and age ratings of health insurance premiums and moved the dialogue forward on this topic despite

strong opposition. In the struggle to base the ACA on community rating, OWL joined a strong feminist coalition on the gender rating and as a result, the ACA essentially eliminated gender rating. OWL was a leader in addressing age rating and as a result, insurers are restricted to a 3to1 age ratio.

While age rating in insurance premiums 2+&(&%/'%8.+'*1F("-06.-0(%'(*5-(8'+1(health reform law, more can and should be done to end age rating altogether. A recent AARP report analyzed the effect of +/-("+*%'/(#'(*5-(8'+'.%+1(96"0-'(,+.%'/(younger and older adults. The greatest impact occurred for adults whose incomes were 400% of the poverty line and who would not be eligible for a subsidy of their costs. Under a 3:1 rating, the average insurance costs for adults aged 1824 whose incomes are at 400% of poverty would be $3,138. Under a 2:1 age rating, those same young adults would pay about $3,664. This is a difference of $526, or 14% lower. The older adults would spend an average of $7,251 under a 2:1 age rating, and $8,487 under a 3:1 age rating – a difference of $1,236, or 17% higher.25 Age rating is a major discriminatory provision applied to older persons and needs to be changed to prohibit agebased premiums.

The Affordable Care Act Implementation TimelineThe following timeline highlights when provisions of importance to midlife and older ,(-"#'%2S"'"66"5%.'L'#4-!"+'(6'3+(V1&1(#&'!"52-"'"66"5%1V"'1#'J>?>.''U4!&"F4"#%'3+(V1&1(#&'%2S"'"66"5%'(#'\2#42+E'?'(6'"250'E"2+'4#)"&&'(%0"+,1&"'#(%"*.']"%21)"*'*"&5+13%1(#&'(6'%0"'3+(V1&1(#&'-2E'!"'6(4#*'1#'%0"'%"^%'(6'%01&'+"3(+%.

2010?( Provides grants to states to establish consumer assistance/ombudsman programs to receive and respond to inquiries/complaints regarding health insurance coverage.

?( Provides Small Business Tax Credit First Phase. Tax credits up to 35% of premiums %))-0%+*-1F(+$+%1+91-(*#(8")&(#,,-"%'/(5-+1*5(%'&6"+'.-(,#"(-)!1#F--&3((

?( [-9+*-&(\IMJ(*#(P-0%.+"-(9-'-8.%+"%-&(25#(,+11(%'(*5-(]+"*(^(!"-&."%!*%#'(0"6/(“donut hole.”

?( Extends Medicare payment protections for small rural hospitals.?( Enhances screening of health care providers to eliminate fraud and waste.?( Assures Medicaid expansion to parents and childless adults up to 133% of federal poverty level to begin if states choose.

?( Reduces employer cost of covering early retirees through a temporary reinsurance program ending in 2014 when coverage is available through exchanges.

?( Provides immediate access to insurance for uninsured with a preexisting condition.?( Eliminates preexisting condition exclusions for children. This will apply to adults in 2014.

?( Prohibits rescission of health care coverage by insurance companies when a person gets sick, absent fraud.

?( ]"#5%9%*&(%'&6"-"&(,"#)(%)!#&%'/(1%,-*%)-(1%)%*&(#'(9-'-8*&3?( Regulates insurance plans use of annual limits in group plans and new individual plans.

?( Covers preventive health services without costsharing for new plans.?( Extends dependent coverage for young adults up to age 26.?( Funds the building of new and expansion of existing community health centers. ?( Strengthens the Health Care Workforce through expanded and improved lowinterest student loan programs, scholarships and loan repayments.

2011?( Limits health plans’ amount of premiums spent on administrative costs (1520%) or they must provide rebates.

?( Provides a 50% discount on all brandname drugs and biologics purchased when P-0%.+"-(9-'-8.%+"%-&(,+11(%'*#(*5-(0#'6*(5#1-7(+'0(+(L_(/#$-"')-'*(&69&%0F(#'(generic drugs.

?( Provides under Medicare a free annual wellness visit and personalized prevention plan services, and eliminates costsharing for preventive services recommended by the U.S. Preventive Services Task Force and rated A or B.

?( Waives the Medicare deductible for colorectal cancer screening tests.?( Provides a 10% Medicare bonus payment for primary care physicians and general surgeons who practice in health professional shortage areas.

?( Begins the transition to a revised payment system in Medicare Advantage plans

Ms. Craig, a mother of two adult children, was working for an employee that did not offer health care when she felt a lump in 0"+'!+"2&%.' 'U0"'&3"#%'&1^'-(#%0&' )((S1#C' 6(+'2'#",'"-3)(E"+',0(' 3+(V1*"*' 0"2)%0' 1#&4+2#5".' M(#5"+#"*' %02%' 2' 3+":"^1&%1#C'condition might make her uninsurable, she did not seek diagnostic &"+V15"&'*4+1#C'0"+'&"2+50.'''[E'%0"'%1-"'%02%'&0"',2&'2!)"'%('C"%'*12C#(&"*I'0"+'52#5"+'02*'2*V2#5"*'2#*'-"%2&%2&1D"*'%('(%0"+'32+%&'(6'0"+'!(*E.''U0"'*1"*'(6'!+"2&%'52#5"+'2'E"2+'26%"+'$#*1#C'2'_(!'%02%'3+(V1*"*'0"2)%0'1#&4+2#5".

Age rating is a major discriminatory provision

applied to older persons and needs to be changed to prohibit agebased 3+"-14-&.

““


to bring them more in line with traditional Medicare, that is, reduces payments to these plans.

?( Establishes an annual, nondeductible fee on drug manufacturers with sales over $5 million according to market share. Effective in the tax years after 2010.

?( Through a new Community First Choice Option, allows states to offer increased home and communitybased services (HCBS) under Medicaid (effective 10/1/11).

?( Establishes a Medicare Independent Payment Advisory Board to develop proposals to extend the solvency of Medicare (effective 10/1/11).

2012?( Encourages physicians to join together in “accountable care organizations” for -,8.%-'.F(+'0(%)!"#$-0(E6+1%*F(#,(.+"-3((

?( Begins tracking of hospital readmission rates for highcost conditions.?( Establishes the Community Living Assistance Service and Supports (CLASS) Act 9-'-8*(!1+'(,#"(1#'/@*-")(.+"-(8'+'.-0(9F($#16'*+"F(!+F"#11(0-06.*%#'&3((=,,-.*%$-(10/1/12

2013?( Provides incentives for state Medicaid programs to cover preventive services with no costsharing.

?( Requires states to pay Medicaid primary care physicians the same rate Medicare pays; any additional state costs are paid by the federal government.

?( Eliminates the deduction for the subsidy employers receive who maintain prescription drug plans for their Part D eligible retirees.

?( Increases the Medicare Part A hospital contribution or tax rate on earned income over $200,000 for individuals and $250,000 for married couples, and adds an unearned income Medicare contribution for them.

?( Establishes a 2.3% excise tax on medical devices. Exceptions: eye glasses, contact lenses, hearing aids.

?( Limits executive compensation for insurance CEOs.

2014?( Limits ability of insurers to charge higher rates due to health status, gender, or other factors. Premiums can be higher, however, for age, geography, family size and tobacco use.

?( Prohibits insurers from imposing annual limits on coverage.?( Establishes health insurance exchanges?( Provides premium tax credits to ensure individuals can obtain affordable coverage.?( Requires most individuals to obtain health insurance coverage or pay a penalty.?( Requires employers who do not offer coverage to pay an annual amount for fulltime employees if one or more employees receive a subsidy through the exchange.

?( P-0%.+%0(-1%/%9%1%*F(2%11(%'."-+&-(*#(K``_(#,(,-0-"+1(!#$-"*F(1-$-13((a#"(*5-(8"&*(*5"--(years, states will receive 100% federal funding for the extra costs of coverage expansion.

?( Implements second phase of small business tax credit.

?( Prevents spousal impoverishment for spouses of Medicaid Home and CommunityBased Services recipients. The spouse’s income is not counted when her spouse’s eligibility for HCBS is determined. This ends after 5 years.

2015?( Creates a physician valuebased payment program to promote increased quality of .+"-(,#"(P-0%.+"-(9-'-8.%+"%-&3

?( Reduces Medicare payment for hospitals with a higherthanaverage rate of hospitalacquired conditions (HACs).

2017?( States may allow employers with over 100 employees to purchase coverage through an exchange.

2018?( >5-(8"&*(9-'-8*&(6'0-"(*5-(H#))6'%*F(U%$%'/(G&&%&*+'.-(X-"$%.-(+'0(X6!!#"*&(G.*(can be paid.

2020?( Medicare prescription drug “donut hole” is closed.


Medicare Related ProvisionsMedicare, the nation’s health insurance program for older Americans, is not typically thought of as a woman’s program, but it is. There are 23 million women over age 65. Almost six in ten individuals utilizing Medicare at age 65 are women, and by the age of 85, women outnumber men in the program by more than two to one.26 Older women spend on average 17% of their income on health care.27 Women live longer than men, have lower incomes, are more likely to suffer from chronic health conditions, require more medical care, and are more likely to need assistance with activities of daily living than men of the same age.28 The numbers and proportion of women on Medicare are expected to increase over time.

The Affordable Care Act has a number of provisions that strengthen Medicare and protect older women.

4,(+(P-0%.+"-(9-'-8.%+"F(5+&(!"-&."%!*%#'(drug coverage – Medicare Part D – and has high prescription drug costs, she )+F(8'0(5-"&-1,(%'(*5-('#*#"%#6&(B0#'6*(hole.” This means that, while continuing to pay a premium for the plan as well as +(0-06.*%91-7(+(9-'-8.%+"F(25#("-+.5-&($2,840 in costs for prescription drugs in 2011 has to pay all the expenses of the drugs until she has spent $4,550 outofpocket for prescription medicine. At that point, the plan kicks in again and covers most of the remaining costs. Women account for twothirds of individuals who 8'0(*5-)&-1$-&(%'(*5%&(0#'6*(5#1-329 The ACA will phase out this coverage gap. In IJKJ7(P-0%.+"-(9-'-8.%+"%-&(25#(B,-11(%'C(the donut hole received a onetime $250 rebate.

X*+"*%'/(%'(IJKK7(9-'-8.%+"%-&(2%*5(5%/5(prescription drug costs who reach the donut hole will get a 50% discount on covered brandname drugs and biologics

(medicines developed from a variety of natural sources, such as blood, tissues, cells and microorganisms) while in the donut hole. For each subsequent year, 9-'-8.%+"%-&(2%11(!+F(-$-'(1-&&(,#"(9"+'0@name and generic prescriptions while in the donut hole until there is complete coverage. The donut hole will close in the year 2020. A caveat, however, is that premiums may increase.

The cost of prescription drugs remains high. An improvement that would produce more cost savings for the Medicare !"#/"+)(+'0(%'0%$%06+1(9-'-8.%+"%-&(%&(*#(allow the Secretary of Health and Human Services to negotiate lower drug prices from pharmaceutical companies. The Medicaid program has pharmaceutical company rebates and the Veteran’s Administration program obtains reduced prices through competitive bids from drug manufacturers, but the Medicare program has neither of these options.

Prescription Drugs

Elsie N.' 1&' 2#' OO:' E"2+:()*' ,1*(,' ,0(' )1V"&' 2)(#"I' 1&'diabetic, and has a mild version of Parkinson’s Disease, 01C0'!)((*'3+"&&4+"'2#*'V1&1(#'3+(!)"-&.' 'M(#&"F4"#%)E'&0"'%2S"&'?J'-"*152%1(#&'*21)E.''U0"'02&'02*'2'<"*152+"'K2+%']'LLRK'3)2#'&1#5"'%0"''3+(C+2-'!"C2#.''U0"'6"))'1#%('the donut hole in 2009 and paid $10,000 outofpocket 6(+'0"+'*+4C&.''Y#'J>?>I'0"+'*+4C'(4%:(6:3(5S"%'5(&%&'6"))'%('`BIa>>')2+C")E'*4"'%('-(+"'C"#"+15&'5(-1#C'2V21)2!)".''Yet, this is still a huge amount of money for her and often prompts her to think: “Which medicine can I eliminate?” Unfortunately, she cannot eliminate any of them because %0"E'2+"'2))(,1#C'0"+'%('02V"'2'&(-",02%'#(+-2)')16".'

Anne M.'02&'62))"#'1#%('%0"'*(#4%''0()"'&"V"+2)'%1-"&.''L%'2C"'bNI' &0"' %2S"&' $V"' -"*152%1(#&' 6(+' *12!"%"&I' !)((*' 3+"&&4+"I'50()"&%"+()'2#*'(&%"(3(+(&1&.''K+1(+'%('5+"2%1(#'(6'%0"'K2+%']'3)2#&I'she could not pay for many of her medications and relied on her *(5%(+''6(+'&2-3)"&c2!(4%' JId>>',(+%0'"V"+E'E"2+.''X(+'%0"'$+&%'two years that she was in an AARPapproved Part D plan, she fell into the donut hole late in the year, which she thought was not a 32+%154)2+'02+*&013'2%'%0"'%1-"'c'233+(^1-2%")E'`B>>'2**1%1(#2)'(4%:(6:3(5S"%'5(&%&.''U0"'*1*'#(%'02V"'%('32E'2'3+"-14-'6(+'0"+'3)2#'2%'%02%'%1-".''Y#'\4)E'J>>aI'&0"'6"))'1#%('%0"'*(#4%'0()".''eY%'was a shock to me to have to pay the full amount so much earlier 1#' %0"' E"2+If' &0"' &2E&.' '80"#' &0"' 2&S"*' %0"'302+-251&%',0E'this occurred, she learned that it was because the prices of her -"*152%1(#&'02*'1#5+"2&"*'&1C#1$52#%)E.''U0"'02*'%('%2S"'-(#"E'(4%'(6'0"+'&2V1#C&'%('32E'%0"'2**1%1(#2)'`JId>B',01)"'1#'%0"'0()"'6(+'#"2+)E'&1^'-(#%0&.''


Preventive Services Cost Savings Extend Solvency of Medicare for 12 Years

Doctor and Hospital Care

Starting in 2011, Medicare coverage for wellness and preventive care for older 2#)-'(2%11($+&*1F(%)!"#$-3((<-'-8.%+"%-&(may get an annual physical exam (called a “wellness” exam) so they and their doctors can develop and update a personalized prevention plan. Flu and pneumonia shots as well as other routine vaccinations will be free or at very low cost. New enrollees can get a complete “Welcome to Medicare” physical examination within 12 months of becoming eligible for Medicare.

The ACA provides that any Medicarecovered service given a grade A or B by the U.S. Preventive Services Task Force (see Health Insurance Reforms section above) must be fully covered by P-0%.+"-7(+*('#(.#&*(*#(*5-(9-'-8.%+"Fb!+*%-'*3(>5-(9-'-8.%+"F(2%11('#*(5+$-(*#(meet the annual Part B deductible before Medicare pays for the service and the 9-'-8.%+"F(2%11('#*(5+$-(*#(!+F(+'F(.#@insurance.

Prior to the ACA, most of the preventive services in Medicare required a copayment of 20% or were considered part of the deductible. Approximately half #,(P-0%.+"-(9-'-8.%+"%-&(0%0('#*(*+:-(advantage of the preventive services available to them.30 Studies have shown that even minimal copayments can deter women from getting preventive screenings such as mammograms.31 Utilization of these services, combined with intervention, could prevent or postpone the onset of more serious illnesses, manage early complications and ultimately control costs.

P-0%.+"-(9-'-8.%+"%-&(&!-'0(+'(+$-"+/-(of $15,081 annually on health care costs, both outofpocket and through insurance. Sixty percent of that is spent

on physician and hospital care.32 G(P-0%.+"-(9-'-8.%+"F(.+'(&*%11(/#(*#(5-"(own doctor if that doctor participates in Medicare. Most doctors and hospitals do participate, so there should be a wide choice of, and access to, care. The Affordable Care Act provides bonus payments to doctors who provide primary care services under Medicare.

;#2-$-"7(*5-"-(%&(+('--0(*#(0-8'%*%$-1F(+00"-&&(*5-(&#@.+11-0(B0#.(8R3C((>5%&(%&(an issue that has been hanging over the Medicare program since 1997. At that time, legislation set a formula that limits the growth of physician reimbursement under Medicare. As doctors each year threaten to refuse Medicare patients because of the limits, Congress capitulates and postpones any cuts to physicians. Resolution of this issue was omitted from the ACA.

Hospitalacquired conditions (HACs) are complications patients acquire from care within a hospital. The Centers for Disease Control and Prevention estimate that almost 100,000 Americans die each year and millions suffer from HACs.33 Beginning in 2015, the ACA will include a Medicare payment reduction for hospitals that have HAC rates much higher than average as an incentive to reduce this alarming situation.

c-+"1F(#'-(%'(8$-(P-0%.+"-(9-'-8.%+"%-&(who leave the hospital is readmitted within 30 days of discharge.34 The Medicare Payment Advisory Commission, known as MedPAC, estimates that Medicare spends $12 billion annually on potentially preventable readmissions.35 The ACA attempts to reverse this trend 9F(!"#$%0%'/(8'+'.%+1(%'.-'*%$-&(*#(hospitals to improve their transitional care processes and coordinate with community supports and services. Readmission rates for all patients for each participating

hospital will be publicly available on the website of the Centers for Medicare and Medicaid.Under the ACA, the life of the Medicare Hospital Insurance Trust Fund will be extended for 12 years (to 2029). This will be accomplished through cost savings measures such as changes to Medicare Advantage plans, increasing the Medicare tax on highincome persons, and coordination of care, which slows the growth of health care costs. (See also “Other Provisions” section below). This 2%11(!"#06.-(&+$%'/&(,#"(9-'-8.%+"%-&(in future premiums and outofpocket coinsurance payments.

Changes to Medicare Advantage Plans

Most older women are enrolled in traditional or original Medicare. However, some are enrolled in Medicare Advantage (MA) plans administered by private insurers. These companies are paid $1,000 more per person on average than original Medicare. This additional money comes, in part, from the premiums all P-0%.+"-(9-'-8.%+"%-&(!+F(D(%'.160%'/(the 77% of seniors who are not enrolled in Medicare Advantage. Under the Affordable Care Act, Medicare Advantage plans will not be getting as much in overpayments per enrollee as they did in the past. This should lower Part B premiums for all people with Medicare. It is possible that those enrolled in Medicare Advantage programs might see *5-%"(9-'-8*&(.5+'/-7(0-!-'0%'/(#'(*5-(decisions made by the private insurance company. Medicare Advantage plans must meet at least the same guaranteed level of service (except hospice care) provided by traditional Medicare.

Increasing the Medicare Tax on HighIncome People

The law raises the Medicare tax rate for individuals with incomes over $200,000 and couples with incomes over $250,000. It also extends the tax to those households’ dividend, capital gains, and other unearned income.

Coordinated Care

New Accountable Care Organizations (ACOs) will integrate delivery of care 2%*5#6*(%'*-",-"%'/(2%*5(9-'-8.%+"%-&d(existing relationships with, and the right to choose, providers. Medicare will contract with ACOs to combine higher quality with lower cost by coordinating care across providers and meeting quality and cost targets. Successful ACOs will share in savings, while Medicare’s estimated cut in expenditures from this shared savings program will be nearly \M(9%11%#'(#$-"(8&.+1(F-+"&(IJK`@IJKe3((Other measures in the ACA will streamline operations in the Centers for Medicare and Medicaid Services, providing for coordinated program administration, %''#$+*%#'(+'07(8&.+1("-&!#'&%9%1%*F3

LongTerm Care (LTC)

Generally, longterm care refers to support services for those who have a chronic illness or disability. The services provide assistance with basic activities of daily living (ADLs) such as bathing, dressing, transferring (such as from a bed to a chair), toileting, and eating. They may be provided in a variety of settings – in one’s home and community, in an assisted living facility, or in a nursing home.

The preference of older women, and the majority of Americans, is that they remain


in their homes, neighborhoods and communities for as long as they want. Surveys indicate that 73% of people over age 45 would like to stay in their current residence as long as possible.36 It is ."%*%.+1(*5+*(*5-"-(+"-(&6,8.%-'*(&6!!#"*&(*#(facilitate this.

Longterm care is a woman’s issue. Seventy percent of those over age 65 who need assistance with ADLs are women. Informal caregivers – family and friends – are primarily women and provide 85% of the help needed at home. Over twothirds of assisted living residents and 77% of nursing home residents are women.37 Direct care workers, those who provide most of the handson care whether at home or in a facility, are nearly 90% women, half of whom are women of color.38

Currently, Medicare does not pay for longterm care although it does pay for limited nursing home and home health care following a hospitalization of at least 3 days. Medicaid, a jointly funded federalstate program providing health coverage for lowincome individuals who meet income, asset and categorical eligibility criteria, is the primary source of payment for LTC and that is primarily for nursing home care. Medicaid pays for 39% of the longterm care costs and Medicare pays for 26%. Outofpocket spending covers 21% of the total longterm care expenses in the nation and private insurance only 7.9%.39

The Affordable Care Act contains three longterm care provisions:

Community Living Assistance Services and Supports (CLASS) Act

The Community Living Assistance Service and Supports (CLASS) Act is the brainchild of the late Senator Edward Kennedy of Massachusetts. The CLASS Act creates a new, voluntary longterm care insurance program available to working adults. Employees of participating employers will pay premiums into the program through payroll deductions and will be automatically enrolled unless they opt out. Employees of nonparticipating employers and the selfemployed will be able to enroll directly.

Older retired or disabled persons not in the workforce cannot take advantage of this program because of the work requirement. However, older persons close to retirement can participate and 9-'-8*(,"#)(%*3(((

After meeting eligibility criteria, enrollees who have functional limitations of two or three activities of daily living that are expected to last 90 days or more 2%11("-.-%$-(+'(+$-"+/-(.+&5(9-'-8*(of $50 a day. This will help pay for the services and supports participants need to maintain independence in their homes and communities. Supports may %'.160-(5#)-()#0%8.+*%#'&7(+&&%&*+'.-(technologies, home care aides and !-"&#'+1(+&&%&*+'.-3((<-'-8.%+"%-&(have control of their own care and can choose to hire informal caregivers, including family members. This is important because, as noted earlier in this report, family and friends provide 85% of the help needed at home. An +''6+1(+..#6'*%'/(#,(*5-(9-'-8*&(6&-0(%&("-E6%"-0(,#"(-+.5("-.%!%-'*3((>5-(9-'-8*(may also be used to pay for endoflife counseling or legal fees to create a living will or durable power of attorney for health care decisions.

In order for the program to be selfsustaining and offer participants meaningful levels of support, it is necessary for younger, healthy Americans to enroll. The adverse selection risk can be mitigated by extending the waiting !-"%#0(,#"(9-'-8*&(9-F#'0(*5-(.6""-'*(8$-@F-+"(!-"%#07(9+1+'.%'/(*5-(.#&*&(2%*5(9-'-8*&(+'0(0-&%/'%'/(+'(-,,-.*%$-(marketing strategy to encourage both employers and employees to participate in the CLASS program.40

The program will be available after October 2012. The Department of Health and Human Services and the Administration on Aging are designing the plan in order to assure its solvency over +(LM@F-+"(!-"%#03((>5-(8"&*(!"-)%6)&(2%11(9-(.#11-.*-0(%'(f+'6+"F(IJK`(+'0(*5-(8"&*(9-'-8*&(2%11(9-(!+%0(%'(f+'6+"F(IJKN3(

Home & CommunityBased Services (HCBS)

The “Aging Network,” funded under the Older Americans Act, is a wellestablished, costeffective, and responsive system for providing home and communitybased services within state and local areas. The network assists more than 8 million older adults and more than 660,000 caregivers every year.41 The CLASS Act includes a mandatory evaluation of each state’s aging network by March 2012 as well as a plan to improve it to meet the needs of a growing population of seniors.

O#)-'(.#)!"%&-(LJ_(#,(*5-(9-'-8.%+"%-&(who qualify for, or are enrolled in, both Medicare and Medicaid programs (referred to as “dual eligibles”).42 The “dual eligible” population often falls between the cracks where care coordination is concerned. In order to improve care coordination, the Affordable Care Act

provides for state demonstration projects, and a federal Coordinated Health Care #,8.-(2%*5%'(*5-(H-'*-"&(,#"(P-0%.+"-(+'0(Medicaid Services (CMS) to integrate and %)!"#$-(.##"0%'+*%#'(#,(9-'-8*&(9-*2--'(the federal and state governments. The Secretary will submit an annual report to Congress with recommendations to %)!"#$-(.+"-(.##"0%'+*%#'(+'0(9-'-8*&3

The ACA also provides new protection from “spousal impoverishment” under Medicaid Home and CommunityBased Services (HCBS). A spouse’s income is not counted when eligibility for HCBS is determined for the other spouse. ;#2-$-"7(*5%&(2%11(-'0(+,*-"(8$-(F-+"&3((OWL believes this protection should be -R*-'0-0(%'0-8'%*-1F3

Nursing Home Care

The ACA includes a number of provisions to enhance transparency of procedures, &*+,8'/(+'0(.+"-(%'('6"&%'/(5#)-&3

The federal and state governments will be required to implement a system for collecting and reporting information about how well nursing homes are staffed, accurate information about the number of hours of nursing care residents receive, the turnover rates of staff, and how much facilities spend on wages and 9-'-8*&3((S*5-"(0+*+(*#(9-(.#11-.*-0(,#"(CMS’s Nursing Home Care website include information on ownership, number of substantive complaints, criminal violations and civil monetary penalties.

The Elder Justice Act (see next section) authorizes funding to improve longterm .+"-(&*+,8'/(+'0(&*+*-(1#'/@*-")(.+"-(ombudsman programs. There are also new authorizations for hospice care, assisted living, longterm care, and home and communitybased services for disabled elderly.

Currently, Medicare does not pay for longterm

care although it does pay for limited nursing home and home health care following a 0(&31%2)1D2%1(#'(6'2%')"2&%'B'*2E&.'

““


The Elder Justice Act was pending in both the House and Senate while health care reform was being debated and was +00-0(*#(*5-(8'+1($-"&%#'(#,(*5-(GHG3(The inclusion of the Elder Justice Act in the health reform law represents a 56/-(1-+!(,#"2+"0(%'(*5-(8/5*(*#(%0-'*%,F7(prevent, and end elder abuse. Advocates, including OWL, and policymakers have been working to pass elder justice legislation since 2002. Older Americans will now have federal protection against abuse (emotional, physical and sexual), '-/1-.*7(+9+'0#')-'*(+'0(8'+'.%+1(exploitation. The elder justice provisions commit the most federal resources yet to 8/5*(-10-"(+96&-344

As the numbers of aging Americans grow, so does the population of potential victims. The U.S. Census Bureau projects that more than 72 million Americans will be age 65 or older in 2030, 20% of the total U.S. population. In 2008, there were an estimated 39 million age 65 and over, 13% of the population. The population age 85 and over could quadruple from 5.7 million in 2008 to 19 million in 2050.45

Women constitute the greatest percentage of victims of elder abuse. They comprise 66% of elder abuse victims in the United States, and 89% of the cases of abuse occur in a domestic setting. In a 2006 telephone survey of 800 women 60 years of age and older, almost half reported they had experienced abuse and many had multiple exposures to abuse since turning 55.46

Federal CoordinationThe Elder Justice Act will create two councils: the Elder Justice Coordinating Council and the Advisory Board on Elder Abuse, Neglect and Exploitation. Together they will work to bring together the federal agencies with responsibility for

elder abuse to make recommendations #'(5#2(*#(.##"0%'+*-(*5-(8/5*(+/+%'&*(abuse as well as to create strategies for 0-$-1#!%'/(*5-(8-10(#,(-10-"(Q6&*%.-3(

Adult Protective Services a#"(*5-(8"&*(*%)-7(H#'/"-&&(5+&(+6*5#"%W-0(+(&!-.%8.(,-0-"+1(,6'0%'/(source for the states’ adult protective services programs rather than through a block grant. Congress authorized appropriations of $100 million per year ,#"(,#6"(F-+"&(&*+"*%'/(2%*5(8&.+1(F-+"(2011. In addition, the Elder Justice Act provisions authorize $25 million for each #,(8&.+1(F-+"&(IJKK(*5"#6/5(IJKT(,#"(training programs to help state and local governments detect or prevent elder +96&-(+'0(8'+'.%+1(-R!1#%*+*%#'3(

LongTerm Care Ombudsman Program This program will receive $32.5 million over 4 years for training grants and pilot programs to improve the capacity of states to investigate abuse in nursing homes and in the community. An additional $10 million per year for four years will provide for training of national organizations and state longterm care ombudsman programs.

Training Nursing Facility Surveyors The Department of Health and Human Services will establish an institute to help federal and state nursing home surveyors. Surveyors are responsible for inspecting nursing homes for quality of care, services and status of the facility.

Combating Criminal Acts of AbuseThe Elder Justice Act provisions in the ACA include requirements that longterm care facilities which receive at least $10,000 in federal funding report suspected crimes against residents. Nursing home staffs will work under a set of tight deadlines for reporting crimes and they face stiff penalties for failing to do so. The Elder Justice Act also establishes Forensic Centers. Studies indicate that !"##,(#,(+96&-(,"-E6-'*1F(%&(0%,8.61*(*#(establish so grants will be awarded to develop forensic expertise on elder abuse and to set up forensic evidence centers.

Also folded into the ACA is the Patient Safety and Abuse Protection Act (PSAPA). These provisions create a comprehensive national system of criminal background checks rather than the previous piecemeal system. Under PSAPA, states will coordinate their programs so they can check nursing home job applicants against neglect and abuse registries. They will also conduct a police check at the state level. Additionally, job applicants will be screened against the FBI’s national criminal records database.

Health Care Workforce, Health Centers, Quality Improvement Strategy

Reforming health care delivery is necessary to controlling costs and assuring affordability of care, improving

the quality and appropriateness of care, and securing access to care for all. Cost, quality, and access are intertwined. For example, access to early detection and ongoing management of chronic disease can reduce avoidable costs for complications and preventable hospitalizations, as well as improve quality of life. Insurance coverage alone does not achieve these goals. A number of the ACA’s numerous provisions for reforming health care delivery and improving quality are discussed at various points in this report. Here, provisions for health workforce development and federally funded health centers are discussed along with the strategy for improving quality.

*#'(%+)2'3#)4530653/#

According to the Congressional Research Service, transforming the nation’s health care delivery system—from one focused on fragmented specialty care for acute illness to one that places more emphasis on primary care, disease prevention, and the coordination and management of care for chronic illness +."#&&(&-**%'/&g2%11("-E6%"-(&%/'%8.+'*(changes in health workforce education and training.47 The Affordable Care Act continues and expands Public Health Service Act workforce development programs. The aims of the provisions are to increase the supply of professionals in primary health and oral health care, public health, and underserved locations, including rural areas and those with severe shortages of mental health professionals; to better prepare the workforce in geriatrics, primary care, .61*6"+1(.#)!-*-'.-7(+'0(#*5-"(8-10&h(and to improve the underrepresentation of minorities in the health workforce. The federal government’s investment in health workforce development under the PHSA

Elder Justice Act Provisions


has declined, in 2009 dollars, from over $2.5 billion in the early 1970s to about $200 million in recent years.48

Another way the federal government invests in health workforce development is through higher Medicare reimbursement to hospitals that provide graduate medical education (GME). The hospitals educate more young physicians to become specialists, rather than generalists. Medicare’s support for this practice contributes to an imbalance: the nation has 65 specialists for every 35 generalists. The imbalance contributes to the fact that the U.S. has the highest per capita health care costs in the world.

>5-(GHG()#0%8-&(P-0%.+"-(iP=(reimbursement to foster education in primary care in communitybased settings and to reimburse for graduate nursing education, a pioneering step.

Provisions of special importance to midlife and older women include:

?( $1.5 billion supplemental +!!"#!"%+*%#'&(&!"-+0(#$-"(8$-(F-+"&(to the National Health Service Corps for more scholarships and student loan repayments to health professionals who will provide primary care in Health Professional Shortage Areas.

?( In response to Institute of Medicine concerns about skills in geriatrics, new and revised training programs for faculty and practitioners in various disciplines; direct care workers

in longterm care settings; and family caregivers to support frail elders or persons with disabilities. Financial incentives will foster more interest within various disciplines about entering practice in geriatrics, longterm care, and chronic care management. Traineeships will help students toward advanced nursing 0-/"--&(%'(/-"%+*"%.&(#"(#*5-"(8-10&(specializing in elder care.

?( Two demonstration projects under a new Section 2008 of Title XX of the Social Security Act to address health workforce needs by creating educational opportunity for nontraditional groups.

1. Temporary Assistance for Needy Families (TANF) clients and other lowincome persons can receive—without affecting eligibility for means*-&*-0(!"#/"+)&g8'+'.%+1(+%07(.5%10(care, case management, and other supportive services to help prepare for health occupations for which pay is good and demand is high.

2. >"+%'%'/(+'0(.-"*%8.+*%#'(#,(!-"&#'+1(and homecare aides distinguishes between working for an agency versus working for a consumer. Training is &!-.%8.(*#(*5-('--0&(#,(*5-(.#'&6)-"((such as an elder), and evaluation of *5-(0-)#'&*"+*%#'(%'.160-&(9-'-8.%+"F(and family caregiver satisfaction.

?( Expansion of supports for targeted nursing education for undergraduates and graduates, faculty and potential faculty. For example, a demonstration program will help train new nurse practitioners for careers in primary .+"-(%'(a-0-"+11F(j6+1%8-0(;-+1*5(Centers (also called Community Health Centers) and NurseManaged Health Centers.

To address the nation’s 14,000 health professional shortage areas—which leave 65 million Americans without easy access to primary care practitioners—the ACA %'Q-.*&(\KK(9%11%#'(#$-"(8$-(F-+"&(%'*#(*5-(community health centers for operations and construction.49 It also authorizes $34 billion in regular appropriations for 8&.+1(F-+"&(IJKJ(*5"#6/5(IJKM3((>5-(federal health centers serve 19 million patients and the infusion of money will enable them to reach 40 million by 2015. Federally funded health centers offer .+"-(*#(+117(+00"-&&%'/(9#*5(8'+'.%+1(+'0(geographic barriers to access. Women comprise 56% of the 12 million older Americans who lack access to a primary care practitioner,50 so they especially &*+'0(*#(9-'-8*(,"#)(*5%&(-R!+'&%#'3(

When the ACA expands Medicaid eligibility in 2014, demand for primary care practitioners who accept Medicaid will become even more acute than today. Federal community health centers may experience competition for patients with new coverage, but areas without resources will rely on these centers.

The new law also moves forward the NurseManaged Health Center (NMHC), a primary care delivery model pioneered over the last 25 years and now numbering 250. The NMHCs add access points for vulnerable people, provide highquality, lowercost care, and boost patient satisfaction. They also elevate nurses, more than 90% of whom are women and whose median age is 46, to a higher status within the medical arena. The ACA creates a program of grants to NMHCs.

Quality Improvement Strategy

Quality improvement under the ACA will lead to better health care delivery, better

outcomes, better health, and better value for the money spent for care. The ACA uses complementary approaches, such as:?( Developing a national strategy with stakeholders to inform the process, build consensus, and monitor progress;

?( Expanding, strengthening, and 811%'/(/+!&(%'(*5-()-+&6"-)-'*(#,(quality, including development, and implementation of measurements;

?( Remedying shortcomings in the organization and delivery of health care through coordination, research, and implementation of quality improvement methods in care delivery. To support implementation, states will be funded to deploy “health extension agents” to support primary care providers. Quality measures will be used to assess coordination. Medicaid patients with chronic conditions will be able to designate a provider to be the patient’s “health home” where care is coordinated and patientcentered;

?( H"-+*%'/(8'+'.%+1(%'.-'*%$-&(,#"(E6+1%*F(improvement by providers and private insurers such as Medicare’s hospital readmissions reduction program that starts in 2012.

A number of other provisions address delivery and quality of care and the means to achieve cost savings. The following is representative but not intended to be inclusive.

Community Health Centers

Federallyfunded health centers offer care to all,

2**+"&&1#C'!(%0'$#2#512)'and geographic barriers to 255"&&.

““


Other Provisions ConclusionWhile the Affordable Care Act is not the singlepayer system OWL believes is the best approach to achieving universal and affordable health care, the ACA does )+:-(&%/'%8.+'*(&*-!&(*#2+"0(.#$-"%'/(the majority of Americans. Many provisions of the ACA will also make a dramatic difference in the lives of midlife and older women by ensuring that more of them have affordable health insurance at a lower cost with more comprehensive, )-+'%'/,61(9-'-8*&(*5+'(-$-"(9-,#"-3

It is possible for states to institute their own health care system, including a singlepayer approach, as long as it meets the criteria for comprehensiveness #,(9-'-8*&(+'0(*5-(!#!61+*%#'(.#$-"-07(affordability and cost savings. It is also still possible to establish a national public health insurance option such as an enhanced Medicare program for all ages.

In the meantime, there are improvements that can be made to the Act, as OWL has delineated in the recommendations for improvements that follow. OWL will work toward achieving these goals while maintaining our commitment to ultimately attaining a singlepayer system.

Medicare Payment Reform

?( The Independent Payment Advisory Board (IPAB) is charged with making recommendations to Congress on reducing the per capita rate of growth in Medicare spending. They are explicitly prohibited from making recommendations to ration health care, raise taxes, or change Medicare 9-'-8*&7(-1%/%9%1%*F7(#"(.#&*@&5+"%'/3(((The Consumer Advocacy Council will advise IPAB on the impact of payment policies on consumers.

Revenue Savings and Resources

?( Efforts to combat fraud and abuse include increased funding for the Health Care Fraud and Abuse Control Fund by $250 million over the next 0-.+0-3((a6'0&(+"-(%'0-R-0(*#(8/5*(Medicaid fraud based on increases in the consumer price index.

?( Collection of industry fees or excise taxes from pharmaceutical and medical device manufacturers, insurance companies and highcost insurance plans. These fees or excise taxes "-V-.*("-&!#'&%91-(.#'*"%96*%#'&(,"#)(health care stakeholders who will 9-'-8*(,"#)(*5-(-R!+'0-0(.#$-"+/-(#,(as many as 32 million Americans under the ACA. The excise tax on highcost plans encourages streamlining of health plans to make premiums more affordable.

Research

?( The Center for Strategic Planning will consolidate research and policy development.

?( Nearly every federal department responsible for some aspect of health

"-&-+".57(*"+%'%'/7(9-'-8*&7(#"(,6'0%'/(2%11(%'.160-(+(O#)-'d&(S,8.-(#,(;-+1*53(

?( The Medicare Payment Advisory Commission (MedPAC) will study the adequacy of Medicare payments for providers in rural areas.

?( Elevation of the National Center on Minority Health and Health Disparities to full Institute status within the National Institutes of Health will result in increased data collection and research about health disparities in racial and ethnic populations.

Demonstration Programs for Improved Patient Care Models

Demonstration projects are initiated to test possible improvements in coverage, quality of care or payment alternatives. The results of demonstrations have led to )+'F((9-'-8.%+1(.5+'/-&(%'(P-0%.+"-(#$-"(the years. Some of the demonstrations in ACA not previously noted are:

?( The MultiPayer Advanced Primary Care Practice Demonstration (MAPCP) is a publicprivate collaboration. Advanced primary care practices will utilize a team approach to health care, with the patient at the center. Patients may designate one provider as their “medical home” where all records are kept and services are coordinated.

?( The new Payment Innovation Center within the Centers for Medicare and Medicaid Services will study promising innovative payment and service delivery models.

?( The Independence at Home Demonstration is a payment incentive and service delivery model for P-0%.+"-(9-'-8.%+"%-&(6*%1%W%'/(!"%)+"F(care teams.

A number of other provisions address delivery and quality of care and the means to achieve cost savings. The following is representative but not intended to be inclusive.


GlossaryOWL’s Recommendations for Improving the Affordable Care ActAccountable Care Organization (ACO): An organization of health care providers that +/"--&(*#(9-(+..#6'*+91-(,#"(*5-(E6+1%*F7(.#&*7(+'0(#$-"+11(.+"-(#,(P-0%.+"-(9-'-8.%+"%-&(25#(are enrolled in the traditional feeforservice program and who are assigned to it.

Activities of Daily Living (ADLs): Common activities necessary to carry out basic human functions such as bathing, dressing, transferring, toileting and eating.

Affordable Care Act (ACA): The Patient Protection and Affordable Care Act signed into law March 23, 2010, ultimately expanding health care coverage to most Americans.

Age Rating: System by which insurance companies base their premiums on the age of the insured.

Aging Network: Funded under the Older Americans Act, a nationwide system of support for services to the aging population through State and Area Agencies on Aging, or local Councils on Aging.

Biologics: Medicines developed from a variety of natural sources, such as blood, tissues, cells and microorganisms.

Centers for Medicare and Medicaid Services (CMS): The federal agency responsible for administering the Medicare and Medicaid programs.

Chronic Disease: A longterm or frequently recurring condition or illness.

Community Health CentersA((a#")+11F(.+11-0(a-0-"+11F(j6+1%8-0(;-+1*5(H-'*-"&7(H;H&(+"-('#'!"#8*(5-+1*5(.-'*-"&(#"(.1%'%.&(*5+*(&-"$-()-0%.+11F(6'0-"&-"$-0(+"-+&(+'0(!#!61+*%#'&7(operating on a slidingfee basis.

Community Living Assistance Services and Supports (CLASS) Act: Legislation included in the Affordable Care Act which creates a voluntary longterm care insurance program for employees of participating employers.

Community Rating: A rule that prevents health insurers from varying premiums within a geographic area based on certain factors.

Congressional Research Service (CRS): A nonpartisan resource for Congress, providing policy and legal analysis.

CostSharing: Consumers pay a portion or percentage of the cost for a service. Co!+F)-'*&(+"-(+(V+*(0#11+"(+)#6'*(*5+*(+(9-'-8.%+"F(!+F&(,#"(+(.#$-"-0(&-"$%.-(Z-3/37(\KJk3((Coinsurance is a payment of a proportion of the costs of a service (e.g., 20%).

Deductibles: The amount an individual must pay for covered care before the health insurance begins to pay.

Donut Hole: A coverage gap in Medicare Part D prescription drug plans when the individual must pay all costs outofpocket until reaching an annual limit after which the plan resumes coverage.

Dual EligiblesA((<-'-8.%+"%-&(25#(E6+1%,F(,#"(#"(+"-(-'"#11-0(%'(9#*5(*5-(P-0%.+"-(+'0(P-0%.+%0(programs.

1. G0#!*(+'(=&&-'*%+1(;-+1*5(<-'-8*&(]+.:+/-(*5+*(%&(.#)!"-5-'&%$-(Z%'.160%'/(home, community and institutional services) and affordable and which is subject to !-"%#0%.("-$%-2&(*#("-V-.*(.5+'/-&(%'(5-+1*5('--0&7()-0%.+1("-&-+".5(+'0(!"+.*%.-&3

2. Amend the ACA to establish a national public health insurance option such as expanding Medicare.

3. Support state options to implement innovative approaches in health insurance coverage, including a singlepayer approach. Move up the eligible date for State Innovation Waivers from the Secretary of Health and Human Services from 2017 to 2014 so that states will not be faced with creating a state exchange only to dismantle it three years later.

4. Eliminate the age rating in insurance premiums.5. Allow the Secretary of Health and Human Services to negotiate with pharmaceutical companies for lower drug prices under Medicare.

6. Initiate coverage for dental care and expand coverage for vision, hearing, and podiatry services under Medicare.

7. Make permanent the protection from spousal impoverishment under Medicaid for home and communitybased services.

8. G00"-&&(*5-(B0#.(8R7C(H#'/"-&&d(5+9%*6+1(!"+.*%.-(#,(&6&!-'0%'/(+(.#)!1%.+*-0(formula that cuts payments to doctors under Medicare when the spending limit for physician services kicks in. Establish a commonsense formula that provides for "-+1%&*%.(!+F)-'*&(,#"(5%/5(E6+1%*F7(-,8.%-'*(.+"-3((

9. Provide additional funds for the early retiree health coverage program as the allocated $5 billion is expected to be depleted before 2014.

10. Provide additional funding to assist states experiencing budget shortfalls with implementation of the ACA changes, particularly the Medicaid expansions.

11. CLASS Act?( ]"#$%0-(,#"(*+R(#"(#*5-"(%'.-'*%$-&(,#"(-)!1#F-"&(*#(!"#$%0-(9-'-8*&(6'0-"(*5-(CLASS act as well as to those who subsidize the premiums for their employees.

?( Provide for tax or other incentives to employees to participate in the program.12. Elder Justice Act

?( Fully fund Elder Justice Act provisions.?( Fully fund and staff adult protective services agencies which face enormous and growing workloads.

?( Fully fund a national resource center that would:a) Provide information on effective prevention of elder abuse as well as effective interventions;b) Provide education and training to adult protective services personnel, law -',#".-)-'*(#,8.-"&7(:-F(!-"&#'&(%'(*5-(community to recognize, and effectively coordinate and handle response to elder abuse;c) Serve as a data repository on research practices.


care providers, high infant mortality, high poverty and/or high elderly population.

Medicare: The U.S. health insurance program for Americans age 65 and older, some people under age 65 with certain disabilities and those with endstage renal disease. It includes: Medicare part A (hospital insurance); Medicare Part B (medical insurance); and Medicare Part D (prescription drug coverage).

Medicare Advantage (MA): Health plans run by Medicareapproved private insurance .#)!+'%-&3((>5-F()6&*(#,,-"(*5-(&+)-(9-'-8*&(+&(#"%/%'+1(P-0%.+"-(-R.-!*(5#&!%.-(.+"-3((>5-F(6&6+11F(#,,-"(&6!!1-)-'*+"F(9-'-8*&(,#"(+'(+00%*%#'+1(!"-)%6)3

Medicare Payment Advisory Commission (MedPAC): Established in 1997 to analyze access to care, cost and quality of care, and other key issues affecting Medicare, MedPAC advises Congress on payments to health plans participating in the Medicare Advantage program and providers in Medicare’s traditional feeforservice programs.

National Health Service Corps (NHSC): A network of 7,500 primary health care professionals and 10,000 sites in underserved communities which provide services to persons who would otherwise lack access to primary care. NHSC provides physicians, nurse !"+.*%*%#'-"&7(!5F&%.%+'(+&&%&*+'*&7(+'0(#*5-"(5-+1*5(!"#,-&&%#'+1&(2%*5(8'+'.%+1(&6!!#"*(%'(*5-(form of loan repayment and scholarships to support its services.

Nurse Managed Health Centers (NMHCs): Centers managed by advanced practice nurses to improve access to primary health care, disease prevention and health promotion in medically underserved areas. Such centers have an association with a university, department of nursing, ,-0-"+11F(E6+1%8-0(5-+1*5(.-'*-"7(#"(%'0-!-'0-'*('#'!"#8*(5-+1*5(#"(&#.%+1(&-"$%.-&(+/-'.F3(

OutofPocket: Expenses, usually for medical or social services, that an individual pays for themselves; expenses for services that are not paid for by insurance or government sponsored programs. May include copayments, insurance premiums and deductible amounts.

SinglePayer Health Care System: A comprehensive, accessible and affordable health care &F&*-)7(!691%.1F(+0)%'%&*-"-0(+'0(8'+'.-03

Shared Savings Program: Part of the Accountable Care Organization model under Medicare to combine higher quality with lower cost through coordination of care: the ACOs share in the savings.

Temporary Assistance for Needy Families (TANF): Established under welfare reform legislation of 1996, this agency provides assistance and work opportunities to needy families by /"+'*%'/(&*+*-&7(*-""%*#"%-&(+'0(*"%9-&(*5-(,-0-"+1(,6'0&(+'0(V-R%9%1%*F(*#(0-$-1#!(+'0(%)!1-)-'*(their own welfare programs.

U.S. Preventive Services Task Force (USPSTF):. An independent panel of nonfederal -R!-"*&(%'(!"-$-'*%#'(+'0(-$%0-'.-@9+&-0()-0%.%'-(-&*+91%&5-0(*#(.#'06.*(&.%-'*%8.(-$%0-'.-(reviews of a broad range of clinical preventive health care services (such as screening, counseling, and preventive medications) and to develop recommendations for primary care clinicians and health systems.

Waivers: A system whereby states are allowed to waive, or disregard, federal rules or service criteria and install other requirements that allow services to be delivered in alternative settings. This is usually based on funding for nonmandatory services and allows states to provide service to more people.

Elder Justice Act: A comprehensive bill within the Affordable Care Act committing federal "-&#6".-&(*#(8/5*(+/+%'&*(-10-"(+96&-3

Excise Tax (and Fees): A tax on insurance companies with highcost health plans to encourage streamlining in order to make premiums more affordable.

Gender Rating: Rating system by which insurance companies have based premiums on the gender of the insured.

Generic drug: A drug that is chemically identical and bioequivalent to the brandname drug but considerably less expensive.

Health Insurance Exchanges: An electronic insurance marketplace run by the government #"(9F(+('#'@!"#8*(#"/+'%W+*%#'(,#"(&)+11(96&%'-&&-&(+'0(%'0%$%06+1&(*#(!6".5+&-(5-+1*5(insurance coverage. Exchanges will take effect in 2014.

Health Professional Shortage Area (HPSA): Area (geographic, demographic, or institutional) designated by the Health Resources and Services Administration as having a shortage of primary medical care, dental or mental health care providers.

Health Resources and Services Administration (HRSA): An agency of the U.S. Department of Health and Human Services, the primary agency for improving access to health care services for people who are uninsured, isolated, or medically vulnerable.

Home and CommunityBased Services (HCBS): Resources and supports for individuals who need some help with activities of daily living but do not need institutional care. Generally, HCBS encompass personal care and assistance, health related services, specialty services, adaptive services and family and caregiver supports.

Hospital Acquired Conditions (HACs): Complications patients acquire from care within a hospital.

Instrumental Activities of Daily Living (IADLs): Tasks necessary for independent community living such as shopping, meal preparation and light housekeeping.

LongTerm Care (LTC): Refers to a range of health and supportive services for persons who have lost the capacity for selfcare due to illness, disability, or frailty. Services include institutional care such as nursing homes, and communitybased services such as congregate living arrangements, home health, homemaker, adult day care, personal care and respite services for caregivers.

Medicaid: A jointly funded federal/state program providing health coverage for lowincome individuals who meet income, asset and categorical eligibility criteria.

Medical Home: Patients with multiple health care providers may designate one provider to be their “medical home” where all records are kept and services are coordinated.

MedicalLoss Ratio: The percentage of premium dollars that insurance companies must 0-$#*-(*#()-0%.+1(9-'-8*&(+'0(E6+1%*F(%)!"#$-)-'*&3

Medically Underserved Areas/Populations (MUA/MUPs): Areas or populations designated by the Health Resources and Services Administration as having too few primary


Appendix A: Myths and FactsThere have been many misconceptions regarding the Affordable Care Act. OWL has examined those most frequently mentioned and prepared the following responses.

employees, offer health insurance, and they are likely to continue doing so as the provisions of the ACA become effective because they will continue to receive tax 9-'-8*&(,#"(!"#$%0%'/(5-+1*5(%'&6"+'.-(or because they could face penalties for failing to provide insurance.57 The provisions that became effective in 2010 have proven to be very popular. As the public becomes aware of other ACA features, it is likely that they, too, will have widespread acceptance.

While there are attempts in the 112th Congress to repeal the ACA, outright repeal is unlikely. Also, it is costly – the CBO says repeal would increase the ,-0-"+1(0-8.%*(9F(\IKJ(9%11%#'(#$-"(*5-(next 10 years and another $1 trillion over the following decade. It would eliminate $40 billion in tax credits to help small employers purchase health insurance for their employees.58

Myth: The new health reform law will hurt employment.

Fact: The effect of the ACA on employment will be small. The major impact of health reform does not begin until 2014 so employers will have time to adjust. It is more likely that workers would experience smaller increases in their take home pay for several years. The CBO foresees a small net reduction in labor supply because some people who now work mainly to obtain health insurance will choose to retire earlier or work somewhat less, not because employers will eliminate jobs.59 Small employers are encouraged to offer health care coverage for their employees with tax cuts.

Myth: The ACA will increase health care spending, add to the federal !"#$%&'#%()*&+',-#'!".#%-'/"&".%'generations with debt.

Fact:((>5-(H#'/"-&&%#'+1(<60/-*(S,8.-((CBO) estimates that health care reform 2%11("-06.-(*5-(960/-*(0-8.%*3((H<S(estimates that repealing health reform 2#610(%'."-+&-(*5-(0-8.%*(9F(\IKJ(9%11%#'(over the next ten years and by about onehalf of one percent of gross domestic product (equivalent to more than $1 trillion) over the following decade.60

Health reform will increase national 5-+1*5(&!-'0%'/(&1%/5*1F(+*(8"&*(9-.+6&-(it greatly expands health insurance coverage, and insured people use more health services than uninsured ones. But health reform will also slow the growth rate of health care costs, generating savings that will grow over time. National health expenditures are likely to fall below their level in the absence of health reform during the law’s second decade.61

Myth: The longterm care insurance program will balloon entitlement costs.

Fact: The new longterm care insurance created under the Community Living Assistance Services and Support (CLASS) Act is voluntary and will be paid for by payroll contributions from workers who participate. However, it is important for younger, healthy Americans to enroll and continue their participation in order for premiums to be affordable and the program to be selfsustaining.

Myth: The requirement for everyone to obtain health insurance coverage is unconstitutional.

Fact: This is an issue that is before a number of courts. The legal question is whether Congressional power to regulate commerce under Article I, Section 8 of the Constitution extends to mandating that individuals obtain health care coverage. In decisions thus far, two

Myth: The majority of Americans are opposed to the health care reform law.

Fact: The Kaiser Family Foundation has polled Americans monthly since the ACA passed. Americans are split on the overall law with slightly more in favor in some months and slightly more against in others. In February 2011, 43% were in favor versus 48% against and the rest undecided. However, with few exceptions – such as requiring that people have insurance – the law’s major provisions are popular with the public. Among those who favored repeal of the ACA in February 2011, 60% favored closing the Medicare prescription drug “donut hole,” and 58% favored establishment of the voluntary longterm care insurance under the ACA’s CLASS Act provisions.51

The Commonwealth Fund surveyed over K7`JJ(5-+1*5(!#1%.F7(8'+'.-(+'0(.+"-(delivery opinion leaders shortly before passage of the ACA. Nearly 90% of respondents think that health reform will expand access to affordable health insurance for Americans without coverage (a key goal of the ACA). (Nearly 90% are also concerned/ very concerned about the nation’s supply of primary care providers, a shortage addressed in the ACA).52

Some critics want the legislation to do more rather than less. OWL and other advocates of the singlepayer approach to health care (or at least a public option) remain committed to that goal while acknowledging the positive measures in ACA.

Myth: Insurance premiums for employers and individuals will increase because of the ACA.

Fact: Employers: Currently, small employers cannot afford coverage for employees. Small business premiums rose 129% over the last decade. Without health care reform, insurance premiums were projected to increase to nearly $24,000 for an average family by 2020. The H#'/"-&&%#'+1(<60/-*(S,8.-(ZH<Sk(estimates that ACA will reduce average premiums by up to 3% in 2016.53 With the ACA, employers will get a tax credit of up to 35% of premiums and be able to shop for competitive rates when the exchanges begin as there will be more people in the insurance pools. In the meantime, the early retiree reinsurance !"#/"+)(2%11(!"#$%0-(%'*-"%)(8'+'.%+1(relief to employers for the cost of covering early retirees between ages 55 and 65.54 Individuals: The CBO says premiums will be 710% lower for a given amount of insurance coverage.55 According to the Commonwealth Fund, without health care reform, individuals and families would see insurance premiums rise as much as 79% over the next ten years. Health insurance premiums have increased three times more than wage increases over the last decade.56

Myth: The requirement for everyone to get insurance coverage will cause a revolt, noncompliance and even repeal.

Fact: It is important to remember that the ACA allows 32 million Americans to get insurance who don’t have it, extending coverage to 95% of the population. Half of the 32 million will be covered under an expanded Medicaid program. The vast majority of large businesses, those with 50 or more


Appendix B: Questions and Answers

Q: Why does the ACA require everyone to get insurance or face a !"#"$%#&'()"#&*+,

A: The goal of the ACA is to ensure that nearly all Americans have health care coverage protection. Consequently, the ACA imposes requirements on insurance companies (such as prohibitions on preexisting condition coverage, rescission of coverage, annual and lifetime caps) that must be accompanied by requirements on individuals to participate in order to increase the health insurance risk pools. It is important to remember that paying for the uninsured is exorbitant. Currently, those who are insured subsidize care for the uninsured. This is a “hidden” tax on the insured as they pay higher premiums passed on by hospitals and insurance companies. Approximately $1 billion is spent annually on medical costs for the uninsured. And the loss of lives due to lack of health care coverage is great: 45,000 a year die in the U.S. because they don’t have health insurance.63 The ACA changes that by requiring everyone to have basic health care coverage.

Q: How much will the penalty be and -.)"'/0)1'%*'2)3%",''40)1'%*'%"$&5/)'%6(7%10"6)"*'807'"0"9$06(&%#"$),

A: The requirement to obtain insurance begins in 2014. The penalty for most individuals who do not obtain acceptable health insurance is $95 for 2014 (or 1% of income), $325 for 2015 (or 2% of income), $695 for 2016 (or up to 2.5 % of income), up to a cap of the national average bronze plan premium. (A bronze plan must have an actuarial value, i.e., the share of costs that an insurer covers on average for a standard population, of

60%). Families will pay half the amount for children, up to a cap of $2,250 per family. It is unlikely that anyone would go to prison for failing to meet this requirement.

Q: How will the subsidies to help buy .)#&*.'%"157#"$)'-07:,

A: For those who cannot afford coverage, there will be subsidies in the form of premium tax credits and costsharing. They will apply to those people with incomes 133% and 400% of the federal poverty line who are not eligible for or offered other acceptable coverage.

Q: Are there exceptions for individuals to the coverage 7);5%7)6)"*,

A: There are some exemptions: 1) those 2%*5(%'.#)-&(9-1#2(*5-(81%'/(*5"-&5#10h(2) those who cannot access affordable coverage (i.e., if they spend more than 8 to 9.5% of income on coverage); 3) those who experience a short gap (less than 3 months) in coverage; 4) a hardship exemption; 5) members of Native American tribes; 6) members of an exempt religious sect; and 7) members of a “health care sharing ministry” (i.e., those with a common set of religious beliefs who share medical expenses among the members).

Q: Do employers have a penalty if *.)+'/0'"0*'$0<)7'*.)%7')6(&0+))1,

A: Yes. Employers with 50 or more employees who do not offer coverage must pay $2,000 annually for each full*%)-(-)!1#F--(#$-"(*5-(8"&*(`J(+&(1#'/(as one of their employees receives a tax credit.

courts have ruled it is constitutional, one has said it is not, and motions to dismiss have been granted in 12 similar cases. It is widely believed that the issue will ultimately be brought to the U.S. Supreme Court, perhaps in 2012. Similar legal challenges were raised after passage of the Social Security Act and the Civil Rights Act but failed.

Myth: Expansion of Medicaid – to 16 million, half of the 32 million who will become insured – puts a heavy burden of unfunded mandates on states.

Fact: The effect on the individual states 2%11($+"F3((>5-(GHG(8R-&(-1%/%9%1%*F(+*(133% of the federal poverty line so there 2%11(9-(+(&%/'%8.+'*(-R!+'&%#'(#,(*5#&-(eligible for Medicaid coverage. States 5+$-(#!*%#'&(,#"(8'0%'/(.#&*(&+$%'/&(which include obtaining new federal grants, coordinating medical care, or creating new payment systems. Some of these changes may require initial investment of state money but bring savings later on. National estimates of *5-(8'+'.%+1(%)!+.*(#,(P-0%.+%0(-R!+'&%#'(show that aggregate savings related to reductions in uncompensated care generally outweigh national estimates of new state costs under the ACA.62 The ACA provides federal matching payments to states for costs of services to newly eligible individuals (those whose income is up to 133% of the federal poverty level) under Medicaid at 100% for the 8"&*(*5"--(F-+"&(#,(*5-(-R!+'&%#'(ZIJKT@2016); 94% in 2018; 93% in 2019; and 90% in 2020 and beyond. The ACA also maintains current funding levels for the Children’s Health Insurance Program (CHIP) through 2015.

Myth:''0123%'3,&*3(%#'4*&1'&1%*.'current coverage will lose it.

Fact: It is unlikely, as employers who currently provide health care coverage will continue to get tax credits for the insurance they provide. In addition, their employees with coverage will be protected from discriminatory practices of insurance companies of excessive premium increases, rescission of policies when those covered become ill or are in an accident, and annual or life caps. These are protections they did not have prior to passage of the ACA.

Myth: The ACA is a government takeover of health care.

Fact: The ACA does not replace but rather preserves the employerbased private insurance delivery system most Americans know. It will create a system that will resemble the program Congress enjoys—the Federal Employee Health <-'-8*&(]"#/"+)3

Myth: The bill was pushed through without transparency, hearings or debate.

Fact: There were over 15 months of hearings, meetings, debates and town meetings on the health care reform proposals. Congressman Rush Holt estimated that the House had 79 bipartisan hearings on health insurance reform; debated 239 amendments and 5-+"0(,"#)(KNK(2%*'-&&-&(!"%#"(*#(8'+1(passage of the ACA in the House of Representatives.


A: Plans in the exchanges should include pediatric hearing and vision screening, preventive dental care and treatment for cavities. However, in Medicare the services are very limited. With copays and Part B deductibles, it is possible to get eyeglasses after cataract surgery; hearing and balance tests if a doctor orders them; and foot exams and treatment for those with diabetesrelated nerve damage. Although the expansion of preventive services is an important addition to Medicare, dental, podiatry, vision and hearing services require &%/'%8.+'*(#6*@#,@!#.:-*(&!-'0%'/(9F(9-'-8.%+"%-&3((>5%&(%&(#'-(#,(*5-(+"-+&(%'(which the ACA can be improved.

Q: I live in a rural area (or frontier state). What does the ACA do for ()0(&)'&%:)'6),

A: It will expand the health care workforce in underserved areas through programs such as the National Health Service Corps. The National Health Service Corps is a program that repays loans and gives scholarships to primary care providers who work in areas of the country with too few health professionals. This will add more than 17,000 primary care doctors, dentists, nurse practitioners, physician assistants and mental health professionals in medically underserved areas. Also, community health centers, a main provider of primary care for many rural communities, will get substantially more funding ($11 billion over the next 8$-(F-+"&k3((>5%&(2%11(-'+91-(*5-)(*#(create new community health centers in underserved areas, expand services in existing sites and double the number of 19 million patients served in 2010 to nearly 40 million by 2015. There will also be expanded telehealth services in Medicare, and increases in

*5-("-%)96"&-)-'*(V##"&(+'0(!+F)-'*(bonuses for rural providers.

Q: Why was the health care &)3%1&#*%0"'751.)/'*.7053.,''=05&/">*'it have been better to go slowly, fully consider all the options and address *.)'$0"$)7"1'08'*.)'0((0")"*1,

A: Attempts to establish affordable health care for all have been underway for nearly 100 years beginning with President Theodore Roosevelt in 1912. Roosevelt sought universal health insurance as part of the Bull Moose Party platform but the outbreak of WW I derailed the plan. Franklin D. Roosevelt’s administration added provisions for publicly funded health care to Social Security, but they were removed from the legislation. President Harry S. Truman endorsed a universal health care bill in 1945. The bill failed, but Truman developed a plan to provide 60 days of free hospital care for Social Security recipients which later became a central component of Medicare. Under President Lyndon B. Johnson, the Medicare and Medicaid programs enacted in 1965 were a scaleddown version of universal health care. President Richard Nixon worked with Senator Edward Kennedy to develop the NixonKennedy Healthcare plan of 1974. The momentum for that effort was lost with the Watergate scandal. During President Bill Clinton’s administration, renewed attempts to provide universal health care failed largely due to heavy criticism, its complexity, and negative national ad campaigns.65 The passage of the ACA in 2010 was the culmination of one hundred years of history, numerous public hearings and untold numbers of policy research documents.

Q: What will happen if the state government refuses to establish an )?$.#"3),

A: If a state does not establish an exchange, the federal government will do it. The federal funds the state would have received to set up the exchange will be redistributed to other states.

Q: Why does Congress require health care reform for Americans when they have very good coverage *.)61)&<)1,

A: The health insurance exchanges are modeled after the Federal Employees ;-+1*5(<-'-8*(]"#/"+)(%'(25%.5(,-0-"+1(employees and Congress participate. In 2014, members of Congress will also participate in an exchange plan.

Q: Will I be able to choose my doctor #"/'.01(%*#&,''=%&&'$5*1'*0'@)/%$#7)'&%6%*'6+'#$$)11'*0'1)7<%$)1A2)")!*1,

A: There will be a choice of doctors +'0(5#&!%*+1&(+&(&!-.%8-0(%'(IJKJ("61-&3((In addition, employees will be able to change jobs without losing health insurance. The cuts to Medicare are principally to the Medicare Advantage (MA) plans that are currently receiving excessive reimbursement subsidized by +11(P-0%.+"-(9-'-8.%+"%-&(25-*5-"(*5-F(are in an MA plan or not. In addition, subsidies to insurance companies for providing the Part D prescription drug plans will be eliminated.

BC''=.#*'%1'*.)'DEFGG'F$*,

A: The Community Living Assistance Services and Support (CLASS) Act is a voluntary, federally administered, -)!1#F--@8'+'.-0(%'&6"+'.-(!1+'('#2(!+"*(#,(*5-(GHG3((4*(!"#$%0-&(E6+1%8-0(participants who become functionally 1%)%*-0(2%*5(9-'-8*&(*#(!+F(,#"(+&&%&*+'.-(so they can maintain independence at home or in a nursing facility.

Q: Who will be eligible to enroll in the CLASS program and how much -%&&'%*'$01*,

A: All Americans age 18 and older who are “actively at work.” Workers cannot be excluded because of preexisting conditions. The activelyatwork requirement includes parttime workers and those who are selfemployed. The Secretary of Health and Human Services will develop the details of the work requirements. The premiums are rough estimates because details of the plan have not yet been determined, but an early CBO estimate was approximately $123 per month.64

BC''=%&&'*.%1'#88)$*'<)*)7#"1>'2)")!*1,

A: No. The ACA does not affect the .6""-'*(5-+1*5(.+"-(&-"$%.-&(+'0(9-'-8*&(provided by the Veterans Administration. Enrolled veterans are deemed to meet the individual responsibility requirement to maintain health coverage.

Q: Do the required services in the exchanges and changes in Medicare include dental, vision and hearing 1)7<%$)1,


Endnotes1AARP Public Policy Institute. Ari Houser, Mary Jo Gibson, and Donald L. Redfoot. Trends in Family Caregiving and Paid Home Care for Older People with Disabilities in the Community: Data from the National LongTerm Care Survey. #201009.2 AARP Public Policy Institute. Ari Houser. Women and LongTerm Care. April 30, 2007. 3 Katharine Donato, and Chizuko Wakabayashi. Women Caregivers are More Likely to Face Poverty. The magazine of Rice

University. Spring 2005, Vol. 61, No. 3.4 Bureau of Labor Statistics. Current Population Survey, 2010. Table 3. Employment status of the civilian noninstitutional

population by age, sex, and race . 5 Commonwealth Fund. Women’s Health Insurance Coverage 19802005, 2008. 6 Commonwealth Fund. Women Are More Likely Than Men to Have CostRelated Access Barriers, Health Policy and Women’s Health: Current Status and Future Priorities. Edward N. Brandt Jr. Memorial Lecture, George Washington University November 18, 2008.7 AARP Public Policy Institute. 2007.8 Commonwealth Fund. The Affordable Care Act Could Save Families Over $3,000 Per Year. December 20109 The United State Preventive Services Task Force (USPSTF), an independent panel of medical experts in prevention, develops recommendations for preventive health care services.10 Strengthening the Health Insurance System: How Health Insurance Reform Will Help America’s Older and Senior Women. www.healthreform.gov. Hereafter referred to as Strengthening the Health Insurance System.11 National Cancer Institute. www.cancer.gov/cancertopics/factsheet/detection/mammograms.12 Strengthening the Health Insurance System.13 Interagency Form on Aging.14 Institute of Medicine. !!!"#$%"&'()*+,#-#,#&.)/&01,23&4-#+&.)5..&6,#01/&01,27&6&8,."9:2&9;<=9!#1196$,9'&86&9.>&+#8+9.&4-#+&9&1&%&6,.9$?9,2&9@&6&8,9>0+A0B&9@(,9!#1194&-#&!92$!9#6.(4&4.9'&,&4%#6&9+$-&4&'9@&6&8,.906'9%&'#+0196&+&..#,C9and will provide guidance on the policy principles and criteria for the Secretary to take into account for appropriate balance among categories of care; the health care needs of diverse segments of the population; and nondiscrimination based on age, disability, or expected length of life. 159D&#4'4&932&.B4&&6"99/&01,29&E>&4,.9.,4(BB1&9!#,29,2&9F(&.,#$6G9HI20,J.9069&..&6,#019@&6&8,KJ99:2&9L$66&+,#+(,9=#44$4"99March 9, 2011. 16 Federal Interagency Forum on Aging—Related Statistics. Older Americans 2010. Key Indicators of Well Being. Updated 1/14/11. www.agingstats.gov.17 National Diabetes Education Program. The Facts About Diabetes: A Leading Cause of Death in the U.S. www.ndep.nih.gov/diabetesfacts .18 Centers for Medicare and Medicaid Services. Medicare and You 201119 The White House. The Affordable Care Act: Supporting Innovation, Empowering States. Fact Sheet. February 28, 2011.20 Federal Interagency Forum on Aging.21 Strengthening the Health Insurance System.22 Implementation Center. Department of Health and Human Services. At Risk: Preexisting Conditions Could Affect 1 in 2 Americans: 129 Million People Could be Denied Affordable Coverage Without Health Reform. www.healthcare.gov23 Jennifer Haberkorn. Health reform program goes broke. Politico. March 31, 2011.249L$6B4&..#$60197('B&,9<?8+&"99*601C.#.9$?9,2&9/&01,29;6.(406+&9M4&%#(%.9(6'&49,2&9M0,#&6,9M4$,&+,#$6906'9*??$4'0@1&9Care Act. November 30, 2009.25 AARP Public Policy Institute. Insight on the Issues. Update: Age Rating Under Comprehensive Health Care Reform. 201026 U.S. Census Bureau. 2009 American Community Service Survey.27 Strengthening the Health Insurance System28 Federal Interagency Forum on Aging. 29 Ibid.30 Alliance for Retired Americans Educational Fund. Understanding Medicare’s Preventive Services. Issue Brief. August 2006.31 M. Greenberger and L. Codispoti. What Health Reform Means for Women. Human Rights: Journal of the Section of Individual Rights and Responsibilities, 37(3), 5. 2010.32 Federal Interagency Forum on Aging.33 Centers for Disease Control. Estimating Health Care Associated Infections and Deaths in U.S. Hospitals, 2002. www.cdc.gov/ncidod/dhqp/pdf/infections_deaths.pdf

Q: Does the ACA provide for research 807'%6(70<%"3'-06)">1'.)#&*.,

A: Yes. The legislation provides for the -&*+91%&5)-'*(#,(+'(S,8.-(#,(O#)-'d&(Health in the Department of Health and Human Services, the Centers for Disease Control and Prevention, the Agency for Healthcare Research and Quality, the Health Resources and Services Administration, and the Food and Drug Administration. However, the authorizations for establishing *5-&-(#,8.-&(+"-(B&6.5(&6)&(+&()+F(be necessary” for 20102014. Thus, appropriations may not necessarily follow.

Q: What mental health services are %"$&5/)/'%"'*.)'FDF,

A: Mental health and substance use disorder services will be part of the =&&-'*%+1(;-+1*5(<-'-8*&(!+.:+/-(6'0-"(the exchanges and Medicaid. Beginning in 2014, those with a mental health condition may not be denied health insurance coverage due to a preexisting condition.

2011 OWL MOTHER’S DAY REPORT 42

There is no age requirement to join OWL! We advocate for:

HEALTH?( Universal, affordable, accessible, and quality physical and mental health care?( Expansion of Medicare and Medicaid to include the full range of services needed by midlife and older women

?( Longterm and chronic care assistance

ECONOMIC SECURITY?( Preservation of the social insurance principles of Social Security?( Better pensions and other retirement plans for women?( Laws barring age and gender discrimination?( An adequate, equitable wage for women?( Monetary credit for caregiving

QUALITY OF LIFE?( Safe, accessible, nondiscriminatory and affordable housing?( Public transportation that meets the needs of older persons?( The elimination of exploitation and abuse of older women?( The right of all persons to remain in control of decisions throughout their lives?( Improving the image of midlife and older women

789':'/0"';(15"'(6'<1*)16"'2#*'7)*"+'8(-"#',2&'6(4#*"*'1#'?aO>g'789'1&'%0"'(#)E'#2%1(#2)'C+2&&+((%&'(+C2#1D2%1(#'*"*152%"*'"#%1+")E'%('2**+"&&1#C'%0"'5(#5"+#&'(6'-1*)16"'2#*'()*"+',(-"#.'["5(-"'2#'789'-"-!"+'2#*'&0(,'3()15E-2S"+&'%02%',"',(#T%'+"&%'4#%1)'%0"'<"*152+"'and Social Security systems truly serve the needs of older women!

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34 Strengthening the Health Insurance System.35 Medicare Payment Advisory Commission. Reforming American’s health care delivery system. Statement of Glenn M. Hackbarth, J.D. www.medpac.gov/documents/36 AARP. Teresa A. Keenan. Home and Community Preferences of the 45+ Population. November 2010.37 AARP Public Policy Institute. #201009; and Donald L. Redfoot and Ari Houser. More Older People with Disabilities Living in the Community: Trends from the National Long –Term Care Survey, 19842004. #201008. 389=#11C93#1-0"99N$6BO:&4%9L04&9I$4A&4."99I$%&6906'9N$6BO:&4%9L04&P9I2&4&9I#119;9N#-&G906'9I2$9I#119:0A&9L04&9$?9%&K99OWL, 2006.399*"9=(66&11G906'9Q9/(4!#R"99I20,9#.9HLN*33JK906'9I#119;,9I$4AK99;..(&9#6974#&?G9S(%@&49TTOUG9L&6,&49?$49V&,#4&%&6,9Research at Boston College, 2011. www.crr.bc.edu 40 Munnell and Hurwiz.41 U.S. Administration on Aging. 2008 Annual Report. 42 Strengthening the Health Insurance System.43 OWL joined with the Elder Justice Coalition to push Congress to enact federal protections against elder abuse. 44 Sources for the Elder Justice Act section include: Congressional Research Service. Table 9. PPACA Discretionary Funding: Elder Justice: Subject to Appropriations; National Health Policy Forum. Addressing Elder Abuse, Neglect, and Exploitation. George Washington University. November 30, 2010; and An Age for JusticeConfronting Elder Abuse in America DVD. There is a guide available to encourage hosting a screening of the DVD. www.elderjusticenow.org. 45 Federal Interagency Forum on Aging. 46 OWL. Elder Abuse: A Women’s Issue. Mother’s Day Report. 2009.47 SC Redhead and Ed Williams, Coordinators. Public Health, Workforce, Quality, and Related Provisions in PPACA: Summary and Timeline. Washington, DC: Congressional Research Service, September 2, 2010. http://healthyamericans.$4B)0..&,.)81&.)LV3WXYV&>$4,WXYZOX">'?48 Ibid.49 Sec. 10503 of ACA both authorizes and then appropriates money for the community health centers program.50 Redhead and Williams.51 Kaiser Family Foundation. www.kff.org/kaiserpolls52 Kristof Stremikis, Karen Davis, and Rachel Nuzum. Health Care Opinion Leaders’ Views on Health Reform, Implementation, and PostReform Priorities. Commonwealth Fund. April 2010 www.cmwf.org539L$6B4&..#$60197('B&,9<?8+&"99*69*601C.#.9$?9/&01,29;6.(406+&9M4&%#(%.9[6'&49,2&9M0,#&6,9M4$,&+,#$6906'9*??$4'0@1&9Care Act. November 30, 2009. www.cbo.gov 54 Paul N. Van de Water. Center for Budget and Policy Priorities. Testimony before the U.S. House Committee on Education and the Workforce. February 9, 2011.559L$6B4&..#$60197('B&,9<?8+&"99S$-&%@&49UYG9XYYZ"569L$%%$6!&01,29\(6'"99I#,2$(,9V&?$4%G9\0%#1C9/&01,29L04&93>&6'#6B9,$93AC4$+A&,P9U]W9;6+4&0.&9@C9XYT^G9_ZW9@C92020. March 2011.579L$6B4&..#$60197('B&,9<?8+&"99:2&97('B&,906'95+$6$%#+9<(,1$$AP9*69[>'0,&"99*(B(.,9XYTY"589L$6B4&..#$60197('B&,9<?8+&"99D$(B10.9I"951%&6'$4?G9D#4&+,$4"99N&,,&49,$9,2&9/$6$40@1&9Q$2697$&26&4G9Q06(04C9`G9XYTT"599L$6B4&..#$60197('B&,9<?8+&"9*(B(.,9XYTY"609L$6B4&..#$60197('B&,9<?8+&"9N&,,&49,$9,2&9/$6$40@1&9Q$2697$&26&4"99\&@4(04C9TaG9XYTT"61 Paul N. Van de Water. Understanding the CMS Actuary’s Report on Health Reform. Center for Budget and Policy Priorities. May 17, 2010.62 Randall R Bovbjerg, Barbara A. Ormond, and Vicki Chen. State Budgets under Federal Health Reform: the Extent and Causes of Variations in Estimated Impacts. The Urban Institute. February 2011.639L$6B4&..#$60197('B&,9<?8+&"99:2&9N$6BO:&4%9<(,1$$A9?$49/&01,29L04&93>&6'#6B"64 LeadingAge, formerly the American Association of Homes and Services for the Aging. CLASS Act. www.leadingage.org 65 *11#.$69/&#.'$4??&4"99:;=5N;S5P9M4&.#'&6,#019#6b(&6+&9$692&01,29+04&94&?$4%9,24$(B2$(,9,2&9XYth century. Columbia Missourian. March 23, 2010. www.columbiamissourian.com. Robert McRoberts. U.S. Presidents and Health Care Reform: The History of Public Health Politics in America. Sept. 10, 2008. www.suite101.com

/01&'1&'2'34!)152%1(#'(6'789':'/0"';(15"'(6'<1*)16"'2#*'7)*"+'8(-"#.''789'1&'2'=>?@5A@BA''(+C2#1D2%1(#'%02%'6(54&"&'&()")E'(#'1&&4"&'4#1F4"'%(',(-"#'2&'%0"E'2C".'G'789'H2%1(#2)I'<2E'J>??.'K"+-1&&1(#'%('+"3+(*45"'2))'(6'32+%'(6'%01&'+"3(+%'1&'C1V"#',1%0'%0"'6())(,1#C'5+"*1%')1#"W''R"3+1#%"*'@(+'"^5"+3%"*A',1%0'3"+-1&&1(#'(6'789':'/0"';(15"'(6'<1*)16"'2#*'7)*"+'8(-"#.

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