Stan Dorn's Health Care Reform Rundown

Health reform passed—now what? Some overlooked stories

National Health Journalism Fellowships

July 12, 2010

Stan Dorn

The Urban Institute

[email protected] 202.261.5561

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Overview

Little-known aspects of health reform legislation

Health policy outside the new law Implementation issues

Part I

Little known aspects of the reform law

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Introduction

Patient Protection and Affordable Care Act (PPACA or ACA)

Some “early deliverables” Main provisions effective in 2014

SubsidiesExchangeShared responsibility Insurance reforms

Conservative provisions

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Guns

Ban on compelled disclosure of gun ownership

Ban on health plan discrimination based on gun ownership

History

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Health insurance exchange

Consumer-driven choice

Diverse offeringsAV standardMultiple AV levels

Extensive consumer information to guide choiceBoth plan and provider

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Other conservative provisions

$500 million in funding for abstinence-only education

Limited Medicaid benefits for newly eligible adults

History

New models of health care delivery

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Theories of cost control

Traditional argument From the right, demand-side management From the left, supply-side management

Common assumption: health care is a fixed widget

Third way: what if we change the widget? Intuition: we’re paying for things we don’t need

o The incentives are wrong Examples of success: Geisinger, Mayo

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But how do we move from

TO

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CMS Center for Medicare and Medicaid Innovation

$10 billion through 2019$5 million in planning

money for FY 2010Similar funding thereafter

Broad mandate - test and expand many models

Substantively open-ended

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Models specified in law

Patient-centered medical home (PCMH)

Move from FFS to comprehensive or salary-based payment

Care coordination for chronically ill elders

Preventing hospitalization of high-risk patients through disease registry, care coordination, home telehealth

Patient decision-making tools

Fully integrating care and funds for Medicaid/Medicaid dual eligibles

All-payer payment reform Outpatient care where non-

physicians determine Pharmacist-based

medication management

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Key concepts of the Patient-Centered Medical Home

Care coordination Integrated into medical

practiceManage care transitions

Patient education 24/7 availability Aided by HIT

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More nudges towards a new health care approach

Quality standards in the exchange Care coordination, including PCMH Effort to prevent hospital readmission

Medicaid PCMH option Community health teams Primary care extension centers Medicare reimbursement reforms

Value-based payments for hospitals and doctors Penalties for hospitals with high rates of readmission, hospital

acquired infection ACOs

Conflict-of-interest disclosures

Covering the low-income uninsured

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21st-century enrollment

Traditional public benefits PPACA streamlining

One form, one eligibility determination process for all programs

Data warehousePotential for eliminating traditional application

formsKey question: will Medicaid come along?

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Medicaid revolution

Shift from categorical to income-based eligibility

Radical simplification Hints at reimbursement

equity

Part II

Health policy outside PPACA

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Waiting for 2014 Why the delay?

Cost Implementation

Bad news in the meantime Economic downturn causes cuts to need-based

health programs Health costs continue to rise Employer-sponsored insurance (ESI) continues to

fray Health insurers continue to discriminate Politics: who gets the blame when things go wrong?

Some potentially good news: HIT investments

Part III

Implementation of national health reform

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“Early deliverables” that have gone largely uncovered

Coverage and access Small employer tax credits Reinsurance for early retirees Community health center expansion Health consumer assistance programs

Insurance reforms Preexisting condition exclusions for children Rescissions Lifetime and annual limits Premium review

Delivery system changes do not wait for 2014

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Preparing for 2014

States Extraordinary chance to reform

health care Daunting duties to expand health

coverage Great money-saving opportunities Very limited administrative capacity Specific question: the exchange

o State or federal operation?o What basic philosophy towards

insurers? Federal administrative capacity

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Conclusion

Huge changes under way

Enormous potential

How much of the potential will be realized?