Patient-Centered Primary Care Collaborative of Central Ohio Q3 Learning Session – July 24, 2012 Objective: to improve our collective knowledge on local, state and national implications of Supreme Court rulings on Patient Protection and Affordable Care Act (PPACA or ACA) Please save Friday, December 7 for our next learning session from 8:00-10:30AM Access HealthColumbus is a non-profit, public-private partnership working to improve the delivery of local health care by coordinating collaborative projects focused on improving patient-centered primary care. Please visit our website to learn more: www.accesshealthcolumbus.org
Patient-Centered Primary Care Collaborative of Central Ohio WHY are we coordinating the Collaborative? To improve access to patient-centered primary care as the foundation of accountable health care delivery to achieve better care, better health, and better value in our community WHAT are the objectives? Improve the health of the people in our community Improve the patient experience of care Improve value of health care expenditures Participating Primary Care Providers: Over 200 primary care providers practicing in private practice, hospital-affiliated, and federally qualified health centers serving over 350,000 patients with Commercial insurance, Medicaid, Medicare, and the uninsured Participating Health Plans & Purchasers: 7 health plans & 7 self-funded employers from the private and public sector
Funding from the following public-private partners supports our collaborative work in the community! Lead Supporter
Major Supporters
Additional Supporters 100% Access HealthColumbus Board & Staff
Individual & Corporate Donations
why? To objectively improve our collective knowledge on local, state and national implications of the Supreme Court rulings on Patient Protection and Affordable Care Act (PPACA or ACA)
what? Welcome & framing Legal briefing Panel discussion Q&A
Expansion of Medicaid
Health Benefit Exchanges
Near Universal Insurance Coverage
Affordable Care Act
Improvement Programs (and grants)
Subsidized commercial insurance for middle-income families (market based) Guaranteed Issue & Insurance Mandate
Health coverage sources for Ohioans in 2014
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Health coverage sources for Ohioans in 2014
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Near Universal Insurance Coverage
Health Benefit Exchanges
Affordable Care Act
Improvement Programs (and grants)
Guaranteed Issue & Insurance Mandate
Near Universal Insurance Coverage
Health Benefit Exchanges
Affordable Care Act
Improvement Programs (and grants)
Guaranteed Issue & Insurance Mandate
Current Exchange Status • 15 Established State Exchange • 1 Planning for Partnership Exchange • 18 Studying Options • 11 No Significant Activity
• 6 Decision Not to Create State Exchange
Near Universal Insurance Coverage
Health Benefit Exchanges
Federal departments proceeding with improvement programs and grants
Affordable Care Act
Improvement Programs (and grants)
Guaranteed Issue & Insurance Mandate Congressional funding approval required for many programs and grants
National/State Primary Care Activity Monitor July A.
Medicare and Medicaid: Comprehensive Primary Care Initiative Demonstration
B.
Medicare: Federally Qualified Health Center (FQHC) Advanced Primary Care Practice Demonstration
C.
Medicare: Multi-payer Advanced Primary Care Practice Demonstration
D.
Medicare: Independence at Home
E.
Medicare Physician Payment Formula – 27.4% pay cut delayed through 1/1/2013
F.
Commercial Health Plans Shifting Resources to Primary Care
G.
Ohio Medicaid Health Homes - Oct. 1 in Butler, Adams, Scioto, Lawrence and Lucas counties - remaining counties phased in by next July
Legal briefing and reflections
Douglas L. Anderson Of Counsel Bailey Cavalieri LLC | 10 W. Broad Street, Ste. 2100 Columbus, Ohio 43215-3422 d: 614.229.3301| c: 614.264.2773| f: 614.221.0479 Doug.Anderson@baileycavalieri.com | www.baileycavalieri.com
Taft / Kevin M. Hilvert / Partner Taft Stettinius & Hollister LLP 65 E. State Street, Suite 1000 Columbus, Ohio 43215 Tel: 614.221.2838 • Fax: 614.221.2007 Direct: 614.220.0238 • www.taftlaw.com / khilvert@taftlaw.com
Supreme Court’s Ruling
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Anti-Injunction Act – Is the Supreme Court barred from deciding the constitutionality of the Affordable Care Act by the Anti-Injunction Act? – A tax may only be challenged after it is paid by suing for a refund. Therefore, does the Court have to wait until 2014 when the individual mandate becomes effective and is enforced against an individual before it can challenged? – Does not apply because Congress used “penalty” not “tax.”
Individual Mandate – What is the individual mandate? – The mandate commands individuals to purchase insurance.
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Unconstitutional under the Commerce Clause.
– The mandate is a tax on those without insurance.
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Constitutional under Congress’s taxing powers.
Supreme Court’s Ruling (cont.) • Medicaid Expansion
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– Does conditioning all Federal Medicaid funding on the States agreeing to expand Medicaid exceed Congress’ authority under the Spending Clause of the Constitution? – Medicaid Expansion violated the Constitution since it threatened revocation of existing Medicaid funds which was unduly coercive. – Additional funding can be conditioned on States’ participation in the Medicaid expansion.
Severability – If any part of the Accountable Care Act is unconstitutional, can the rest of the Act stand?
Supreme Court Ruling
The insurance market reforms and subsidies were upheld and will go into effect.
Insurance market reforms
The 2010 insurance reforms will remain in effect – – – –
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No lifetime limits and restricted annual limits Coverage of dependents up to age 26 No rescissions except for fraud No pre-existing condition exclusions for children Preventive care at no co-pays or cost sharing
Insurance market reforms
The 2011 insurance reforms will remain in effect –
Medical Loss Ratio Limits
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Medical loss ratios must be at least 85% for large group coverage and 80% for small group and individual coverage.
Premium Rates Review standards (2011).
Premium rates in excess of 10% must undergo heightened review.
Permanent Market Reforms •
The 2014 permanent market reforms were upheld. – –
Guaranteed issuance of coverage Modified community rating of coverage •
• • •
Rates can only vary by age (3 to 1) and smoking status (1 ½ to 1).
No pre-existing condition exclusions Individual mandate Employer mandate
Low Income Subsidies
The 2014 low income subsidies were upheld. – –
Sliding scale subsidies are available at incomes between 100% to 400% FPL At 100% FPL, the cost of coverage will be: $223 per year or $18.50 per month for individuals; or $461 per year or $38.40 per month for a family of 4.
Health Insurance Exchanges
Exchanges were upheld. – –
Each state shall establish a qualified Exchange by January 1, 2014. If a state chooses not to operate an exchange, the federal government will do so.
Exchange Options 1. 2. 3.
An Ohio Exchange A Federal Exchange A Hybrid Exchange – States control plan management including certification of qualified plans – States operate the consumer assistance function – HHS retains authority and approve state partners – States may control reinsurance and Medicaid eligibility determinations
Timeline
Reforms already in effect: – –
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2010 Insurance Benefit Reforms Medical Loss Ratios Premium Rate Review
November 6, 2012 - The Election –
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Change in direction as to implementation Can’t change requirements on insurance companies
Timeline
November 16, 2012 –
States must submit an Exchange Blueprint to HHS, including (1) a Declaration of Intent signed by the Governor and (2) an Application indicating the state’s intentions.
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A state may submit a “Blueprint” for an exchange which will become operational after 2014, but November 16th is the deadline.
Timeline
January 1, 2013 –
HHS must certify state exchanges that become operational on January 1, 2014.
The state must demonstrate “the ability to satisfactorily perform all required Exchange activities.”
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Conditional approval can be granted to states making “significant progress” if they will be ready by October, 2013.
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It is hard to believe a state filing a “Blueprint” after the election could establish a 2014 exchange.
Timeline
2012 - 2013 – –
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IT/Consumer Infrastructure established Qualified health plans certified Vendor/partner agreements executed
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Agents/Navigators
Operations established Marketing/outreach to consumers
Fall, 2013 –
People begin to enroll in exchanges
Timeline
January, 2014 –
Permanent reforms take effect
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Low income subsidies start
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Mandates take effect
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Coverage through exchanges becomes effective
Impact of Court’s Ruling on Medicaid Expansion • Original Act – The “Medicaid Expansion” creates a newly eligible group of Medicaid beneficiaries
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Individuals age 19-64 who – – – –
Are below 133% of FPL. Meet citizenship requirements. Are not incarcerated. Are not entitled to Medicare.
– Conditions all existing Medicaid funding on a State’s agreement to expand Medicaid coverage to the new group of Medicaid eligible individuals. – For States that participate in the Medicaid expansion, the Federal government will pay 100% of the expansion for three years, 95% for the next 3 years, and 90% thereafter.
Impact of Court’s Ruling on Medicaid Expansion (cont’d) • Supreme Court held
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– Medicaid expansion is unconstitutional under the Spending Clause because conditioning all Medicaid funds on participation in the expansion is unduly coercive. – The Medicaid expansion may nonetheless be implemented under the ACA, but the Federal government can only condition access to new Medicaid funding on a State’s participation.
Implications of the Court’s ruling on Medicaid expansion – Implementation of the Medicaid expansion is now “optional” by the States. – Many low-income people may remain uninsured. – Who carries burden of cost of uninsured?
Other Issues to Consider after the Ruling • State decisions on Medicaid expansion
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– “Hell No” states (Texas, Florida, Mississippi, Louisiana, South Carolina, Nebraska) – Wait and See approach – Impact on Hospitals
State decisions on Insurance Exchanges – – – – –
15 have established state exchanges 1 is planning a partnership exchange 18 are studying their options 12 are not showing any significant activity 5 have decided not to create an exchange
http://healthreform.kff.org/en/the-states.aspx
Other Issues to Consider after the Ruling (cont’d) • Ohio Issue 3 (amendment to the Constitution of the State of Ohio) – … “In Ohio, no law or rule shall compel, directly or indirectly, any
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person, employer, or health care provider to participate in a health care system.” Supremacy Clause prevents Issue 3 from “overruling” ACA. But….other consequences
Other challenges to the ACA
Sharing of Reflections
Consumer perspective: Isi Ikharebha, Executive Director, Physicians CareConnection
Payer perspective: Miranda Motter, President and CEO, Ohio Association of Health Plans
Provider perspective: Bill Wulf, M.D., Corporate Medical Director, Central Ohio Primary Care Physicians
Purchaser perspective: Mike Stull, Regional Vice President, Employers Health
Health coverage sources for Ohioans in 2014
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Health coverage sources for Ohioans in 2014
Source: Supreme Court Policy Brief, Health Policy Institute of Ohio, July 2012, http://bit.ly/SjDBca
Current Exchange Status • 15 Established State Exchange • 1 Planning for Partnership Exchange • 18 Studying Options • 11 No Significant Activity
• 6 Decision Not to Create State Exchange
Q&A In the interest of our limited time this morning: ďƒ˜ please be concise with your question
ďƒ˜ please no testimonials or advocacy
Want to learn more about the Affordable Care Act? Health Policy Institute of Ohio - Supreme Court Policy Brief: http://bit.ly/SjDBca Kaiser Family Foundation - A Guide to the Supreme Court's Affordable Care Act Decision: http://www.kff.org/healthreform/upload/8332.pdf
Special thanks to Doug, Kevin, Isi, Miranda, Mike, and Dr. Wulf for donating their time to help us improve our collective knowledge!