 Health Care Reform Sarah Kolnik May 14, 2015

Patient Protection & Affordable Care Act March 23, 2010July 30, 1965

Definitions  Medicare (Federal)  Age > 65  Permanent disability w/ SSDI  ESRD  ALS  Medicaid (State)  Children or Adults w/ SSI  Children, pregnant women, parents  Adults (2012) Poverty level: Family of 4 $2,021 /month $24,250 /year

ACA Sections  Expand Coverage  Cost Containment  Improving Quality & Health System Performance  Misc

Expanding Coverage  Medicaid expansion (optional)  All non-Medicare eligible individuals up to 138% of FPL  Premium credits & Cost sharing  Individuals/families from % FPL

Expanding Coverage  Individual mandate  Health insurance ~OR~  Fine Tax of $695 or 2.5% of income  Employer mandates  Businesses > 50 employees  > 200 employees  opt out system

Expanding Coverage  Health Insurance Exchanges  Individuals  Small businesses (<50 employees)

Expanding Coverage  No pre-existing condition exclusions  No lifetime coverage limits  No yearly coverage caps  Coverage for young adults, up to age 26, on parents plans

So what?  Less delayed care due to lack of insurance  Expanded coverage  more reimbursement for providers/hospitals  Profits?  Reinvestment?  Larger market, with fewer barriers  cost savings?

Results  Oregon Health Insurance Experiment

Cost Containment  Medicare  Re structure reimbursement for FFS plans  Establish “Independent Payment Advisory Board”  -may not ration care or change benefits  Creation of ACOs   payments for readmissions & never events

Cost Containment  Private Insurance  Public justification for rate increases >10%  80/20 rule (medical loss ratio)

So what?  Medicare  Reimbursement favors non-FFS models  Good – large centers  Bad – rural, private practices  Private Insurance  Slower increase initially, ??? sustainability

Results  Partners for Kids (pediatric ACO)

Improving Quality  Patient-Centered Outcomes Research Institute (PCORI)  Grants for tort reform implementation  Innovation Center within CMS

So what?  Potential to increase impact of CER  Good ideas  $$$

Miscellaneous  10% bonus to rural primary care and general surgeons  Increase GME positions  Trauma centers  Prevention, public health, wellness programs

Questions?