© Ascension Health System Office Advocacy and Access Department, August 2009 Healthcare Reform Update: Healthcare That Leaves No One Behind

2 A Historic Time for Healthcare Reform © Ascension Health System Office Advocacy and Access Department, 2008, Beth Fuchs author 1930s & 1940s Private Health Insurance Employee Benefits State Insurance Regulation Hospital Construction Universal Coverage Fails 1980s Reconciliation Bills Initiated Full Risk Plans Enter Medicare Medicare Prospective Payments Means Testing for Catastrophic Benefits 1990s HIPAA FAS 109 (Retiree benefits) State Child Health Insurance Program Universal Coverage Fails -- Again Present Medicare Drug Benefit More Incentives for Private Plans Quality Reporting/Payment Patient Safety New Administration Health Care Coverage Redefined as an Economic Issue Stakeholders Blink 1960s Medicare & Medicaid Community Health Centers 1970s  National Health Planning (CON) ERISA HMO Act Price/Hospital Cost Controls Congressional Budget Act Universal Coverage Fails -- Again

3 What, and For Whom, is 100% Access and 100% Coverage? 100% access and 100% coverage means that all persons, particularly those persons who are uninsured or underinsured, receive healthcare services and health insurance that: 2020 Goal and Associated Strategies of Healthcare That Leaves No One Behind 1.Creates and supports the best journey to improved health outcomes for each individual, and 2.Is financed in an adequate and sustainable fashion. National Legislative Leader National Public Policy Partner Access Model Catalyst Voice of the Voiceless 2020 Goal Strategies © Ascension Health System Office Advocacy and Access Department, August 2009

4 Our Guiding Features of a Reformed Healthcare Policy Ensure 100% Access to Healthcare Services Achieve Destination of 100% Coverage Reform Insurance Rules; Shared Obligation and Responsibility for Coverage Make Health Insurance Affordable and Equitable Eliminate Coverage and Service Gaps, Particularly for the Vulnerable Ensure Economic Viability Through Shared Financial Responsibility Improved Health for Our Community We are committed to redesigning the healthcare delivery system and partnering with policymakers to achieve 100% access and 100% coverage. Approved by Ascension Health Board of Trustees, December 2007 © Ascension Health System Office Advocacy and Access Department, August 2009

Ascension Health’s Guiding Feature Congressional Health Reform Proposals Ensure 100% Access to Healthcare Services The bills include delivery system initiatives to improve quality, value and transparency, and seek to improve patients’ capacity to navigate the healthcare delivery system. Ascension Health will continue to monitor proposals to assure that the role of the federal government in delivery system initiatives is to accelerate the delivery system’s effectiveness. Achieve Destination of 100% Coverage The Administration and Congress have set as a reform goal coverage for all (excepting undocumented immigrants). Coverage expansions are expected to begin as of 2013, with the target of 97% coverage in all bills. Premium subsidies at 400% of the federal poverty line in the House bills would provide needed assistance to many low income Americans to purchase health insurance. Ascension Health will continue to offer constructive policy options leading to 100% access, recognizing, however, that staging may be needed in order to be sustainable. Reform Insurance Rules: Shared Obligation and Responsibility for Coverage The bills include reforms in the individual and group markets to require guaranteed issue, eliminate pre- existing condition exclusions, and limit price differences based on health status. Bills include a version of an individual and employer mandate to purchase and offer insurance respectively. Ascension Health will continue to support financing options that spread burdens fairly and do not harm our most vulnerable citizens. Make Health Insurance Affordable and Equitable All the bills include rating rules and other insurance reforms as referenced above. All include premium and cost sharing subsidies to help lower-income Americans purchase health insurance and medical services. All will likely require benefit packages to meet a minimum level of coverage and reasonable cost sharing. Ascension Health will continue to scrutinize the details of the proposals to assess where affordability gaps may be found. Eliminate Coverage and Service Gaps, Particularly for the Vulnerable Medicaid expansions are a part of each reform proposal. The benefit package includes key services such as mental health and pharmaceuticals which are critical for vulnerable populations. The provision for adequate and ongoing safety net funding will continue to be a concern. Ensure Economic Viability Through Shared Financial Responsibility The proposals rely on a variety of techniques to fund coverage expansions that require individual, employer, physician, hospital and insurance company participation in funding. Ascension Health will seek financing solutions that share the financing burden in a fair and sustainable way. 100% Campaign: Ascension Health’s Guiding Features Compared to the Health Reform Bills Under Consideration August – Early September 2009 © Ascension Health System Office Advocacy and Access Department, August 2009

6 Health Reform Timeline February March March 24: Insurers release letter supporting guarantee issue coupled with an individual mandate March 27: Health Reform Dialogue group (“strange bedfellows”) issues reform recommendations Feb 4: President Obama signs HR 2, the Children’s Health Insurance Reauthorization Act of 2009 (CHIPRA), expanding coverage for 4 million children at a cost of $30 billion paid with tobacco tax Feb 17: HR 1, the American Reinvestment and Recovery Act, is passed and includes $150 billion in new healthcare spending Feb 24: President Obama releases FY 2010 Budget that includes $634 billion reserve fund for health reform © Ascension Health System Office Advocacy and Access Department, August 2009

7 Health Reform Timeline April May May 7: President Obama issues 8 principles for healthcare reform; New Democrat Coalition (progressive House Ds) release “Prescription for Health Care Reform” May 8: Blue Dog Coalition (fiscal conservative House Ds) issue “Principles for Health Care Reform” April 2: House and Senate Budgets passed (without GOP support) with “deficit-neutral” health reform reserve fund and back-up reconcil- iation clause April 8: Executive Order signed establishing new White House Office of Health Reform May 6: Health Care Solutions Group (GOP) – “Vision of Health Care Reform” released April 28: Senate Finance Committee releases policy options for transforming healthcare delivery system © Ascension Health System Office Advocacy and Access Department, August 2009

8 Health Reform Timeline May May 20: Patients’ Choice Act of 2009 (Republican alternative) is introduced by Senators Burr (R-NC) & Coburn (R-OK) and Reps. Ryan (R-WI) & Nunes (R-CA) May 11: Finance Committee releases policy options to expand healthcare coverage May 13: President Obama meets with Speaker Pelosi, who pledges to have a health reform bill out of the House before August recess May 11: President Obama hosts the “Gang of Six” at the White House; Stakeholders agree to “voluntarily” reduce healthcare costs by 1.5% over 10 years (AHA,AHIP, PhRMA, AMA,SEIU, AdvaMed) May 18: Senate Finance Committee releases policy options to finance healthcare reform © Ascension Health System Office Advocacy and Access Department, August 2009

9 Health Reform Timeline: Looking Ahead June July Late July-Early September: House E & C passes health reform legislation 7/31. House to bring legislation to the floor vote as early as the week of 9/7 June 1- June 12: HELP Committee draft released 6/9; HELP & Finance Cmte. Member Walk-thrus. President Obama meets with Dem. Leadership to finalize timeline for reform Week of June 15: HELP markup beginning 6/17; Finance Cmte. continues deliberations. House draft bill released June 19. July 14 - House releases “America’s Affordable Health Choices Act of July 15 - Senate HELP Committee reports out comprehensive health bill. Senate Finance continues deliberations in search of bipartisanship. July 17- W&M and Ed. & Labor pass House reform legislation out of committee Mid September-October ’09: Finance committee to release bill by September 15. Senate aiming for floor vote by early October. Congress aiming for Final vote on conference report to meet President Obama’s deadline for a bill “on the desk” by the end of October. AugustSeptember/October © Ascension Health System Office Advocacy and Access Department, August 2009

10 Status of Health Reform Bills Status of Health Reform Bills Moving Through Congress Senate HELP (Health, Education, Labor and Pensions) Committee Kennedy bill, not yet numbered, approved on 7/15/09. Senate Finance CommitteeSenators Baucus, Grassley, Conrad, Bingaman, Enzi and Snowe (the “ gang of six ” ) continue to try to develop a bipartisan draft proposal. Timing of committee action unclear. Full SenateTiming unclear. Democrats may have to use the budget reconciliation procedures to avoid GOP filibuster. House Education and Labor CommitteeHR 3200, as amended, approved on 7/17/09. House Energy and Commerce CommitteeHR 3200, as amended, approved on 7/31/09. House Ways and Means CommitteeHR 3200, as amended, approved on 7/17/09. House Rules CommitteeWill work with Democratic Chair and Leadership to produce a melded version of HR 3200 for a floor vote. Full HouseVote possible in late September. Conference Committee of the Senate and House ??? House and Senate chambers vote approval of conference report In time for House and Senate adjournment in late Presidential signature??? Senate House Joint Presi- dent © Ascension Health System Office Advocacy and Access Department, August 2009

11 Post Health Reform OpportunitiesChallenges Americans Access to Affordable Health Insurance Focus on Prevention, Primary Care to Improve Health Transparency to Improve Personal Responsibility Unknowns on New Costs/Taxes to Consumers Individuals with Rich Benefit Packages May See Changes Young People May See Premiums Increase Self-insured Employers ERISA Plans Untouched Tax on Employee Benefits Above $ Value Future Premium Cost Shift? Small Businesses Employees Gain Access to Affordable Insurance Mandate to Offer / Contribute Healthcare Services Patients Have Access to Insurance Charity Care/Bad Debt Obligations Contained Future Payment Rates Unknown Health Insurance Industry Mandate to Purchase Insurance Pools Broadened New Customers Insurance Rules Tightened Limits on Premiums Competition no Longer on Risk Selection Pharmacy Industry Drug Coverage Likely Part of any Credible Coverage Expansion of 340B to Inpatient May Be Part of Health Reform Pressure to Reduce Costs to Help Fund Health Reform Government States Given Transitional Federal Assistance to Expand Medicaid Federal Government will Lead Health Reform Parameters © Ascension Health System Office Advocacy and Access Department, August 2009

12 Trajectory Towards Healthcare Reform Unwavering Presidential Intent Insurance, Drug, Hospital Interest Groups Began by Supporting Coverage Expansions and Insurance Reforms Democratic “Filibuster Proof” Majority Public Support for Healthcare Reform Due to Economic Realities Personalizing the Fear of Losing Health Insurance Healthcare Reform Defined as Democrat’s Agenda Country is Divided Politically and Vulnerable to Rhetoric State Healthcare Reform Efforts on Hold Momentum Stalled for Early Bill Passage Interest Groups are Positioning Their Business Interests for “Post-Reform” World and Beginning to Distract the Focus Political Stakes for the Republican Party May Trump Healthcare Issues CBO Has Not Scored Adequate Funding to Pay for Any Bill © Ascension Health System Office Advocacy and Access Department, August 2009

13 System Influence: New Administration and Congressional Leadership Health Ministries’ Influence: Congressional Delegation and Governors Partnerships, Coalitions, Forums Voice to Maintain Momentum The Role of Ascension Health Leaders © Ascension Health System Office Advocacy and Access Department, August 2009

14 © Ascension Health System Office Advocacy and Access Department, August 2009

15 Leaders’ Obligation Lead Health Reform Momentum –Statesmen and Stateswomen Raise Positive Voices During August Congressional Recess –Voice with Members, Staff –Leadership Voice in Our Communities Remember Who We Are –Mission Compels Us © Ascension Health System Office Advocacy and Access Department, August 2009