Kristina M. Young, MS Clinical Assistant Professor, Emerita Department of Epidemiology and Environmental Health, School of Public Health and Health Professions, State University of New York at Buffalo 20 years experience teaching graduate courses in health care organization and health policy for students in the fields of public health, law, and management

Philip J. Kroth, MD, MS Professor, University of New Mexico, School of Medicine Director of the Biomedical Informatics Research, Training, and Scholarship unit at the University of New Mexico Health Sciences Library and Informatics Center Section Chief of Clinical Informatics, University of New Mexico, Department of Internal Medicine

The Children's Health Insurance Program (CHIP), a program that provides federal safety net health insurance for approximately 9 million low income children, has been re-authorized by congress for 2018-2020. True or False?

POTUS Executive Order (10/27/17) would allow states to define "Essential Benefits" under the ACA and may exclude several benefits originally included in ACA such as maternity care and  mental health services. New rules must be written and approved prior to  implementation. True or False?

"Meaningful Use" (AKA: "Advancing Care Information" (ACI)  electronic health record technology implementation financial incentives were deleted by POTUS Executive Order under MACRA.  True or False?

MACRA (2015) & ACA (2010): Separate, Complementary Laws ACA Major Features Promote value over volume-based care Expand coverage & control costs Insurance marketplaces Medicaid expansion Define baseline quality insurance Promote population health & prevention Incentivize care coordination MACRA Major Features Promote value over volume-based care: Merit-based Incentive Payment System (MIPS) Alternative Payments Models (APMs) Standardize quality reporting metrics Reauthorized CHIP through 2017 Shifts Medicare fee-for-service to APM incentive models by 2018

MACRA Bipartisan Support Pays for value, not volume: rewards cost savings and quality care Standardizes the quality reporting systems between existing programs Subsumes the Meaningful Use Program Physicians have two options: MIPS or APMs

MACRA Selected Highlights (1) “Doc-fix” provides permanent, predictable physician Medicare reimbursement MIPS composite score reimbursement adjustments (upward, downward or none): Quality: 30% Resource Use: 30% Clinical Practice Improvement Activities: 15% Meaningful Use of EHR Technology: 25% Adjustments are 2 years in arrears

MACRA Selected Highlights (2) APMs not subject to MIPS adjustments Annual lump sum payment based on 5% of previous year’s estimated aggregate expenditures according to fee schedule For individual physicians, working for APMs is easier than dealing with MIPS

MACRA TODAY (Nov. 10, 2017) “Doc Fix” with accountability structure for physician quality reporting & reimbursement via APMs & MIPs is proceeding Children’s Health Insurance Program (CHIP) funding reauthorization stalled in Congress, with 9-million children’s health care at risk; states scrambling to find funds

ACA Components Requiring Legislation to Change Family coverage for children up to 26 years Banning insurance denials for pre-existing conditions Changing baseline 10 “Essential Benefits” Reinstating annual dollar limits for covered benefits Reinstating co-pays for preventive services Executive orders change nothing in ACA law

Recent Efforts to Unravel the ACA Advertisement/public media budget for ACA enrollment reminders reduced by 90% Enrollment period shortened from 3 months to 6 weeks “Navigators”/enrollment assistance budget cut 41%

ACA: POTUS Executive Order (1) (10/12/17) Rescinds funding for “Cost-sharing reduction subsidies” (CSRs) for insurers of low-income consumers “Association” health plans released from ACA regulations on lifetime benefit caps & essential services Mostly healthy individuals Moves more high risk individuals to state-subsidized plans

ACA: POTUS Executive Order (2) October 18, 2017: 18 states’ attorneys general and D.C. filed a brief in California vs. Trump seeking preliminary order to prevent CSRs rescindment October 25, 2017: U.S. District Court Judge Vince Chhabria denied request for preliminary order Bottom Line: Many insurers anticipated cuts and built added costs into 2018 premiums Rescinding CSRs has little effect because impacted consumers will receive higher tax credits Defunding CSRs will cost federal government approx. $ 200 B over 10 years

ACA: POTUS’s Executive Order (3) EO implementation takes at least many months: Writing new rules Rule publication in Federal Register & public comment period Compilation/deliberation of public comments Final rule issuance and implementation process

Rulemaking Example: CMS Reinterprets ACA “Essential Benefits” (10/27/17) Proposed rule allows states to define “Essential Benefits” “Essential Benefits” benchmarks may be derived from any “typical employer plan” with 5,000+ employees (may not be more generous than a state currently offers) States can select plans that exclude e.g. maternity, mental health, HIV/AIDS, emergency, drug coverage State role may be illegal: ACA law mandated 10 “Essential Benefits;” questionable transfer of this authority to states Proposed rule comments due Nov. 27

Alexander-Murray Bipartisan Health Care Stabilization Act of 2017 (1) Oct. 19, 2017: Proposal to stabilize insurance markets: 2-year extended funding of cost-sharing reduction subsides (CSRs) Restore ACA enrollment outreach funds Expedite state waivers for premium subsidies Enforce “individual mandate,” and shared responsibility of employers of 50+ employees

Alexander-Murray Act (2) Public confusion due to anti-ACA rhetoric, e.g., POTUS statements such as, “Obamacare is finished. It’s dead. It’s gone. It’s no longer, you shouldn’t even mention it.” Approx. 10 M citizens enrolled in ACA marketplaces; enrollment is tiny fraction of 250 M people who get health insurance from employers, Medicare & Medicaid.

Alexander-Murray Act: Congressional Budget Office (CBO) Assessment (10/25/17) No significant federal budget effect Reduces federal deficit by $3.8 B 2018-2027 CSRs termination cost of $194 B already included in budget baseline of funded entitlements No material change in numbers of insured User fees fund DHHS 2018-19 outreach & enrollment Small overall effect on state, local, tribal governments or private sector

“Individual Mandate” Repeal in Tax Bill October 30, 2017 Senate Republican leaders include repeal in tax bill (House version awaited) November 8, 2017 CBO estimates 2018-2027: $ 338 B savings 13 M+ Americans lose health insurance (Dec. 2016: CBO estimated ten-year savings of $ 416 B; 15 M lose health insurance)

The ACA Today ACA Medicaid expansion & consumer protections are popular, working well Costs for ~ 155 M Americans with employer-sponsored health insurance rose only 3% in 2017 Nov. 7, 2017: Maine overwhelmingly approved referendum adopting ACA Medicaid expansion Nov. 15, 2017: Open enrollment totals increased 46% over same period in 2016

Bottom Lines ACA Legislative change requires Congressional action on extremely complex issues; numerous failed votes to “repeal and replace” illustrate difficulty Individual mandate repeal through tax bill would be the first change to ACA law Open enrollment surge suggests popular support with political implications MACRA Strong bipartisan support for continued push toward value & quality suggest survival in its present form CHIP reauthorization likely

ACA & MACRA Future Prospects MACRA proceeds as planned; CHIP re-authorization awaits Congressional action No changes to ACA existing law to date Tactics to impede ACA enrollment appear unsuccessful No effects of EO on CSRs to date Alexander-Murray Bill awaits uncertain Congressional action

Teaching Resources for Instructors and Students Following provide continuous updates on the ACA and MACRA’s status with links to additional resources: ACA http://www.khn.org http://commonwealthfund.org https://cbo.gov/publications MACRA & CHIP https://qpp.cms.gov/#scroll-content https://ehrintelligence.com/tag/macra http://www.healthaffairs.org/do/10.1377/hblog20170921.062102/full/

Sultz & Young's Health Care USA Understanding Its Organization and Delivery NINTH EDITION Visit go.jblearning.com/HealthCareUSA to: Request a complimentary instructor’s copy Download sample chapters Request access to instructor materials

Thank you for participating! Sophie Teague steague@jblearning.com Recorded webinar will be posted on the LinkedIn Public Health Faculty Lounge: http://go.jblearning.com/PHLinkedIn