Health Care Reform Update from Washington Gabrielle de la Gueronniere Legal Action Center February 11, 2010

2 What We’ll Discuss Today National healthcare reform  Where we are and how we got here  Overview of what reform looks like, including similarities and differences between bills  Review of key addiction-related provisions in the bills  Next steps and options for passage

3 Efforts to “fully and equitably include addiction and mental health in healthcare reform” Wellstone-Domenici Parity Act passage created momentum LAC helped organize and continue to lead the Coalition for Whole Health, a coalition of more than 40 national SUD and MH organizations CWH developed recommendations, sign-on letters, responses to draft legislative proposals CWH worked with champions on amendments CWH developed and circulated conference recommendations

4 National Healthcare Reform Timeline More than a year of work, missed deadlines, compromises Passed 5 committees and both chambers  Education and Labor, Energy and Commerce, Ways and Means in the House  Health, Education, Labor and Pensions (HELP) and Finance in the Senate The House passed the Affordable Health Care for America Act (H.R. 3961) on November 7 th  vote The Senate passed the Patient Protection and Affordable Care Act (H.R. 3590) on December 24 th  vote The process for resolving the differences between the two bills had begun; January 19 th Massachusetts election stopped it in its tracks

5 Current Health Insurance Coverage Picture Employer52.3% Individual4.7 Medicaid14.1 Medicare12.4 Other Public1.2 Uninsured15.4 Source Percent Source: StateHealthFacts.org

6 Key Similarities Between Bills Insurance reforms and consumer protections Individual mandate Sliding-scale subsidies for those up to 400% FPL to buy/take up offers of insurance Medicaid expansions: everyone (including childless adults) under certain income would be eligible

7 Key Similarities Between Bills (cont’d) Health insurance exchange(s) created for small employers and individuals to buy insurance and pool risk Minimum benefits packages for the exchange Investments in workforce and prevention/wellness

8 Key Differences Between Bills Medicaid expansion:  Senate bill expands Medicaid to 133% FPL, restricts flexibility to disregard certain types of income, and requires newly eligible adults enroll in less comprehensive “benchmark” plans  House bill expands Medicaid to 150% FPL, preserves income disregard flexibility, and extends traditional benefits to childless adults Exchange(s) for small businesses & individuals to purchase insurance:  The Senate creates state-based exchanges  The House creates one national exchange, which includes public option Subsidies for individuals up to 400% FPL to purchase insurance:  The House provides much greater support for premiums and reduced cost- sharing for individuals and families at or below 300% FPL  The Senate provides greater support for premiums for families between 300% and 400% FPL

9 Key Differences Between Bills, Continued Mandates:  Both bills include a mandate for individuals to have health insurance  The House bill also requires employers to offer insurance to their employees Minimum benefits requirements:  Both bills have similar minimum benefit requirements for the exchange  The House bill also requires large employers to meet requirements Start date for coverage and exchange:  The Senate date for implementation is January 1, 2014  The House date for implementation is January 1, 2013 There are a number of other differences in financing, tax changes, public option, abortion, and other issues to be worked out.

10 Key Addiction and Mental Health Provisions in the Bills Both bills require SUD/MH services as part of the minimum benefit package  Senate bill exempts large employers. Both require that individual, small, & large group plans comply with Wellstone/ Domenici Both prohibit insurance discrimination against individuals with pre-existing conditions Both prohibit discrimination against individuals based on health status  Senate bill specifically includes SUD/MH in this requirement.

11 Key Addiction and Mental Health Provisions in the Bills (cont’d) Medicaid expansions  House bill: –Newly eligible childless adults would receive traditional benefits –Bill prohibits states from enrolling these individuals into managed care unless they show the MCO could meet their health, MH, and SUD needs  Senate bill: –Newly eligible childless adults would be enrolled in a generally less-comprehensive “benchmark” plan that would include SUD/MH services at parity

12 Key Addiction and Mental Health Provisions in the Bills (cont’d) Workforce development provisions  Senate bill: –Loan repayment provisions –Grants to higher education institutions for MH/SUD professionals  House bill: –Workforce grants for MH/SUD service providers

13 Key Addiction and Mental Health Provisions in the Bills (cont’d) Chronic disease prevention, wellness promotion and screening/briefing intervention provisions  Senate bill: –Medical home grants –Inclusion of SUD in National Prevention, Health Promotion, and Public Health Council –SUD/MH services at school-based community health centers –State and local health dept grantees work with MH/SUD providers.  House bill: – Authorizes $30m SBIRT grant program

14 Key Addiction and Mental Health Provisions in the Bills (cont’d) Inclusion of relevant MH/SUD agencies in federal studies or working groups:  Senate bill: –HHS education and outreach campaign on benefits of prevention –Requires dissemination about prevention work done by SAMHSA –Requires states to consult and coordinate with SAMHSA on MH/SUD for Medicaid medical home option –Includes SAMHSA as agency in “Interagency Working Group on Heath Care Quality.”  House bill: –Adds SAMHSA to list of agencies consulted for the development of national prevention and wellness plan

15 Strong Public Support for Including Addiction in Healthcare Reform According to a recent poll commissioned by the Closing the Addiction Treatment Gap initiative of the Open Society Institute:  77% of Americans support including addiction treatment in healthcare reform, including Democrats (88%), Independents (72%), and Republicans (72%)  69% say they would support paying $2 more per month in premiums to make treatment more accessible & affordable  83% agree that, like diabetes, addiction is a health condition that requires ongoing attention and support, including Democrats (88%), Independents (78%), and Republicans (82%)

16 Strong Public Support for Including Addiction in Healthcare Reform (cont’d) 88% say treatment is important, including Democrats (92%), Independents (85%) and Republicans (87%) 87% see treatment as an ongoing process. Additionally, the public sees treatment as effective, even if individuals relapse and need another period of treatment. Only 26% say there are enough affordable, accessible, quality treatment centers/services in their community. Of those who know someone who has looked for treatment, 46% report difficulty finding affordable, quality services. Additionally, a poll conducted in 06/2009 found that 49% of Americans feel they couldn’t afford treatment if they or a family member needed it.

17 Possible Next Steps for National Healthcare Reform Unclear how Congress will proceed… Options include:  Do nothing –Pelosi: “I don’t see that as a possibility. We will have something.”  Both chambers could pass a bill that bridges differences  Pass scaled-back bill that might gain Republican support  House could pass Senate bill

18 Passing a Compromise Bill? The House and Senate could pass a compromise bill  The Democratic Congressional leadership seemed close to compromise before Massachusetts election  Multiple roadblocks to address  Difficult to envision bill with bi-partisan Senate support and approval by the House…

19 Scaled-Back Insurance Reform Bill? Could include requiring insurers to cover anyone who applies (guaranteed issue) and prohibiting insurers from charging higher premiums based on health status and other factors (community rating) Difficult to make this work…  Insurance market reforms won’t work in isolation  Adverse selection problem: sick people rush in, premium costs rise, healthy people rush out, making insurance unaffordable for everyone

20 House Pass Senate-Approved Bill? The House could pass the Senate bill as is, and it would go to the President’s desk for signature Also not so easy…  House has a number of concerns with the Senate bill  Pelosi: House doesn’t have the votes to pass the Senate bill in its current form Possible if House has assurance that Senate will make fixes through reconciliation  Limits of reconciliation

21 If Healthcare Reform Passes, What Could this Mean? Nearly everyone would have health insurance Everyone obtaining insurance through the individual or small group markets would be covered for SUD & MH services Wellstone/Domenici parity requirements would be expanded to all qualified plans Insurers would be prohibited from discriminating against individuals based on health status, including addiction histories Medicaid expansion to all parents and childless adults, increased federal share of costs Increased federal commitment to prevention and wellness and workforce development

22 Next Steps Following Passage of Healthcare Reform Benefit design must be adequate Ensure access to care  Outreach and education  Regulate managed care Must be in chronic disease prevention & wellness initiatives Strengthen workforce Strengthen programs’ infrastructure and capability Remove barriers to recovery, such as  Employment  Food Stamps/TANF (cash assistance)  Housing  Higher education  Driver’s licenses  Voting

23 If healthcare reform doesn’t pass this year… The issue isn’t going away, and the problems will only get worse Develop strong relationships with Members of Congress, educate them on the issues Need to continue to identify and cultivate champions Continue momentum from parity and healthcare reform to increase resources and expand treatment Action on recently released parity regulations  Analysis  Public comment period until May 3 rd  Outreach and education on compliance; enforcement Proposed ONDCP and SAMHSA initiatives  Closing the addiction treatment gap  Collaborating more closely with primary health care  Expanding interventions/treatment for criminal justice-involved people

24 Additional Information Keep yourself informed about healthcare reform developments:  Coalition for Whole Health documents on LAC website at under “National Healthcare Reform” linkwww.lac.org  Additional legislative updates from Legal Action Center and other field groups