Overview of Health Reform: Why and What

September, 2010September, 2010 EQUAL Health NetworkEQUAL Health Network

Overview of Health Reform: Overview of Health Reform: Why and WhatWhy and What

Ellen R. Shaffer PhD MPHEllen R. Shaffer PhD MPHJoe Brenner MAJoe Brenner MA

EQUAL Health NetworkEQUAL Health Networkwww.equalhealth.infowww.equalhealth.info

415-922-6204 [email protected] [email protected]

September, 2010September, 2010

September, 2010September, 2010 EQUAL Health NetworkEQUAL Health Network 22

Historic Achievement Historic Achievement

Congress has passed the most substantial Congress has passed the most substantial health reform since Medicare and health reform since Medicare and Medicaid in 1965Medicaid in 1965

Patient Protection and Affordable Care Act Patient Protection and Affordable Care Act (ACA)(ACA)

Important steps to expand coverage and Important steps to expand coverage and improve quality, begins to control costsimprove quality, begins to control costs

Complex, Complex, somesome misunderstandings misunderstandings


What Do You Think?What Do You Think?

Great law – about time!Great law – about time!

Pretty good, wish it were single payerPretty good, wish it were single payer

All depends how it gets implemented…All depends how it gets implemented…


We Are All AmbassadorsWe Are All Ambassadors

If you’re here today, you stand to benefitIf you’re here today, you stand to benefit

Whether insured or not, employed or notWhether insured or not, employed or not

What you do – or don’t do – will make a What you do – or don’t do – will make a differencedifference


EQUAL Health Network EQUAL Health Network EEquitable, quitable, QQuality, uality, UUniversal, niversal, AAffordable ffordable

health carehealth care

Network for progressive policy and advocacyNetwork for progressive policy and advocacy– Links: Public health, women, seniors, faith Links: Public health, women, seniors, faith

groupsgroups– Policy-makersPolicy-makersCenter for Policy Analysis, anchorCenter for Policy Analysis, anchor


EQUAL’s Program:EQUAL’s Program:Making Health Reform WorkMaking Health Reform Work

EducateEducateHandout and website: summary of the lawHandout and website: summary of the law

ImplementImplement

Comment on regulationsComment on regulations

ImproveImproveNext steps toward EQUAL health careNext steps toward EQUAL health care


Why The Affordable Care Act: Why The Affordable Care Act: Access, Quality, CostsAccess, Quality, Costs

ACA: The Gains ACA: The Gains

Implementing the LawImplementing the Law

Improving the FutureImproving the Future


Why We Needed to Do This: Why We Needed to Do This: The ProblemsThe Problems


People Are SufferingPeople Are Suffering~ ~ Access, Cost, QualityAccess, Cost, Quality

46 million uninsured in U.S. 46 million uninsured in U.S. – 6.7 million in California6.7 million in California

44,000 deaths a year due to lack of insurance44,000 deaths a year due to lack of insurance

60% of U.S. bankruptcies due to health costs 60% of U.S. bankruptcies due to health costs

– – Mostly to people Mostly to people with insurancewith insurance

Highest costs in the world: $2.5 Trillion/yearHighest costs in the world: $2.5 Trillion/year

3737thth in Quality in Quality

Amazing FactAmazing Fact

The More People We Cover The More People We Cover The Better We Can Control The Better We Can Control

CostsCosts


MedicareMedicare

Popular federal government program Popular federal government program covers entire population over age 65covers entire population over age 65

Costs controlled better than insurance Costs controlled better than insurance for people under 65for people under 65

Even though Medicare covers oldest Even though Medicare covers oldest and sickestand sickest


Employment-Based InsuranceEmployment-Based Insurance

Most people under age 65 get insurance through Most people under age 65 get insurance through work – but employers don’t have to provide itwork – but employers don’t have to provide it

Large employers: 96% offerLarge employers: 96% offer

Small employers: 43% offerSmall employers: 43% offer– (fewer than 50 employees)(fewer than 50 employees)


52%

56%

60%

64%

68%

72%

1979 1985 1991 1997 2003Per

cen

t co

vere

d b

y o

wn

em

plo

yer

insu

ran

ce

Private employer-provided health

insurance

The Great Risk Shift in Health CareThe Great Risk Shift in Health Care69.0%

54.9%

Over 15 percentage point decline

Source: Economic Policy Institute, State of Working America, 2006/2007


Fragmented Coverage Drives Up Fragmented Coverage Drives Up Costs. Costs. (Other reasons too…)(Other reasons too…)

Without mandates (or universal coverage): Without mandates (or universal coverage): Healthy people will opt out.Healthy people will opt out.If premiums based on health status, sick people can’t If premiums based on health status, sick people can’t afford them. afford them. Insurance industry uses expensive administrative tools to Insurance industry uses expensive administrative tools to weed out sick people from coverage.weed out sick people from coverage.Uninsured delay care, need more costly treatment if/when Uninsured delay care, need more costly treatment if/when they do get care.they do get care.– Uninsured pay more for same services than the insured.Uninsured pay more for same services than the insured.– Some costs shifted to the insured.Some costs shifted to the insured.

Are there other factors driving up health care costs? Yes:Are there other factors driving up health care costs? Yes:

inadequate bargaining power with providers, too many specialists and acute care, inadequate bargaining power with providers, too many specialists and acute care, administration, profit.administration, profit.

But expanding coverage is indispensible to controlling But expanding coverage is indispensible to controlling costscosts..


ACA: The GainsACA: The Gains


TimelineTimeline: : ACA Benefits Phased In ACA Benefits Phased In

2010-20132010-2013– Consumer protections from insurance co. practicesConsumer protections from insurance co. practices– Affordability and quality improvementsAffordability and quality improvements

2014: Major coverage expansions2014: Major coverage expansions– Health Insurance ExchangesHealth Insurance Exchanges

For individuals, small business employeesFor individuals, small business employeesIndividual Mandate Individual Mandate

– Subsidies to 400% of poverty ($88,000/yr family of 4)Subsidies to 400% of poverty ($88,000/yr family of 4)

Employers contribute to Exchange if employees use subsidyEmployers contribute to Exchange if employees use subsidyMembers of Congress and staff must buy thru ExchangesMembers of Congress and staff must buy thru Exchanges

– Medicaid ExpandedMedicaid ExpandedEveryone up to 133% of poverty levelEveryone up to 133% of poverty level

2020: “Donut hole” in Medicare drug coverage gone 2020: “Donut hole” in Medicare drug coverage gone


Immediate ImprovementsImmediate Improvementsin 2010in 2010

Coverage:Coverage:– New High Risk Pool for uninsuredNew High Risk Pool for uninsured– Coverage for Young Adults through Age 26 on Coverage for Young Adults through Age 26 on

parents’ plansparents’ plans

Affordability:Affordability:– Small business tax credits of up to 35%Small business tax credits of up to 35%– Rebates begin to close gaps in Medicare coverage for Rebates begin to close gaps in Medicare coverage for

drug costs – the “donut hole”drug costs – the “donut hole”– Reduces cost of early retiree coverageReduces cost of early retiree coverage

Down payments on Cost Control: Down payments on Cost Control: – Quality Improvements, Primary care, Public Health Quality Improvements, Primary care, Public Health

and Prevention, Rate Regulationsand Prevention, Rate Regulations


Immediate ImprovementsImmediate Improvements

Stops Insurance Abuses:Stops Insurance Abuses:– Discrimination against children with pre-existing Discrimination against children with pre-existing

conditions prohibitedconditions prohibited– Rescissions Illegal (withdrawal of care)Rescissions Illegal (withdrawal of care)– Bans lifetime limits on coverage Bans lifetime limits on coverage

QualityQuality– First dollar coverage of preventive careFirst dollar coverage of preventive care– Increased funding for Community ClinicsIncreased funding for Community Clinics


Insured Through Work?Insured Through Work?New ProtectionsNew Protections

Bankruptcy protection:Bankruptcy protection:Limits on out-of-pocket spendingLimits on out-of-pocket spending

No co-payments on preventive health careNo co-payments on preventive health care

Insurance abuse protection:Insurance abuse protection:No recissions: cannot withdraw coverage No recissions: cannot withdraw coverage

Workplace abuse protection:Workplace abuse protection:You don’t have to keep your job to keep your You don’t have to keep your job to keep your

health insurancehealth insurance


MedicareMedicare

Insolvency delayed almost 2 decadesInsolvency delayed almost 2 decades

Changes to Medicare AdvantageChanges to Medicare Advantage

Promising trials on quality improvementPromising trials on quality improvement


Making It Work:Making It Work:Implementing the LawImplementing the Law


Implementing the LawImplementing the Law Comment on Regulations to HHS Comment on Regulations to HHS

ISSUEISSUE ONLY CONCERNS ONLY CONCERNS WONKS WHO…WONKS WHO…

Rate ControlRate Control Care about costsCare about costs

Medical Loss RatioMedical Loss Ratio Care about costsCare about costs

Determining Determining Prevention Benefits Prevention Benefits - Contraception- Contraception

Might’ve ever used a Might’ve ever used a contraceptive…I don’t contraceptive…I don’t really know… have toreally know… have to

ask around…ask around…


California Reforms PendingCalifornia Reforms Pending

Create an Insurance Exchange:Create an Insurance Exchange: AB 1602 (Bass) & AB 1602 (Bass) & SB 900 (Alquist). SB 900 (Alquist). To offer transparent rates and To offer transparent rates and benefits, available to buyers inside and outside the benefits, available to buyers inside and outside the ExchangeExchange

Facilitate a public health insurance option: SB 56 Facilitate a public health insurance option: SB 56 (Alquist). C(Alquist). County-organized health plans and other ounty-organized health plans and other health benefits programs can form joint ventures.health benefits programs can form joint ventures.

Reform individual insurance:Reform individual insurance: SB890 (Alquist). SB890 (Alquist). Specific plans with basic benefits so consumers can Specific plans with basic benefits so consumers can do “apples-to-apples” comparisons:do “apples-to-apples” comparisons:


Improving the FutureImproving the Future


Policy Issues for the FuturePolicy Issues for the Future

Reproductive health careReproductive health care

Immigrants’ inclusionImmigrants’ inclusion

AffordabilityAffordability

State options for innovative approaches State options for innovative approaches – Single payerSingle payer


What To Do NowWhat To Do Now

Analyze/EducateAnalyze/Educate– Get the facts about the lawGet the facts about the law– Spread the wordSpread the word

Implement The LawImplement The Law– Make It WorkMake It Work

Improve The LawImprove The Law


Network with EQUAL toNetwork with EQUAL to Help Make History! Help Make History!

Join the EQUAL ListservJoin the EQUAL Listserv Send a blank message toSend a blank message to [email protected]@list.equalhealth.info

See our website:See our website:www.equalhealth.infowww.equalhealth.info

Thanks for contributions to this presentation to EQUAL partners Thanks for contributions to this presentation to EQUAL partners including Deborah LeVeen, Elinor Blake, Karl Keener, Joel including Deborah LeVeen, Elinor Blake, Karl Keener, Joel Adelson, Lee Lawrence, Robert Mason, Keely Monroe (Lisa Kernan Adelson, Lee Lawrence, Robert Mason, Keely Monroe (Lisa Kernan Social Justice Fellow), Jeoff Gordon, UULM-CA Social Justice Fellow), Jeoff Gordon, UULM-CA Other source: Health Access CAOther source: Health Access CA

Overview of Health Reform: Why and What

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