Health care reform at the state and federal levels: Role of the Health Insurance Exchange Louis “Lou” Giancola, CEO, South County Hospital Working group participant, HealthRIght Konstantine "Nick" Tsiongas, MD Founding chair, HealthRIght board.

Quick PC introduction Why this topic? Why this topic? Psychological Centers’ position Psychological Centers’ position

The role of the health insurance exchange in health care reform Health care reform will bring a number of changes to behavioral and medical care in RI Health care reform will bring a number of changes to behavioral and medical care in RI One of the most important will be the mandatory creation of a health insurance exchange, through which individuals, small businesses, and possibly many others will be able (or required) to purchase their health insurance coverage One of the most important will be the mandatory creation of a health insurance exchange, through which individuals, small businesses, and possibly many others will be able (or required) to purchase their health insurance coverage

Today’s training The basic definition and possible configurations of the health insurance exchange The basic definition and possible configurations of the health insurance exchange Rhode Island's current proposed exchange legislation Rhode Island's current proposed exchange legislation Implications of different possible exchange configurations and policy decisions that are relevant to how the exchange is designed Implications of different possible exchange configurations and policy decisions that are relevant to how the exchange is designed Discussion of how Rhode Island's behavioral health community should respond to the health insurance exchange’s inherent potential and threats Discussion of how Rhode Island's behavioral health community should respond to the health insurance exchange’s inherent potential and threats

Learning objectives Participants will be able to: 1. accurately describe what constitutes a health insurance exchange under federal legislation 2. identify at least three critical considerations for how best to design a health insurance exchange 3. articulate their own preferences for how a health insurance exchange be designed for RI 2 CE/CEUs for psychologists, social workers, mental health counselors, marriage and family therapists, and Psychiatric Clinical Nurse Specialists who attend the entire session

The health insurance exchange: An easy purchasing website?

The health insurance exchange: Or much, much more? A robust exchange uses its purchasing power: Designs benefit packages service delivery standards payment design quality control Negotiates terms to offer its customers controls costs maximizes consumers’ purchasing power

Reforming healthcare is easy: Everyone has an answer! Everyone’s efforts cancel each other out Answer The current result:

Everyone has an answer

An effective Health Insurance Exchange uses purchasing power and its managers’ expertise in health care financing and policy to improve the health care system and control costs. An effective exchange is an active purchaser, designing benefit packages and negotiating terms to offer its customers. The Health Insurance Exchange assembles these answers into a solution : Representatives across health care interest groups finding consensus around an effective exchange The solution: A high-quality, equitable, affordable health care system for all An effective exchange is: Consumer driven and accountable Easy to use Integrated, offering access to private and public (including Medicaid) coverage based on users’ eligibility Accessible, actively linking individuals, employers and other purchasers to available health care supports Empowering, enabling consumers to understand and make the best health care choices for themselves

Our health care system is broken… It’s time to make it RIght Contact: Dr. Amy Black, Director, HealthRIght Telephone: ext Website:

Lou Giancola President and CEO, South County Hospital President and CEO, South County Hospital Introduction: Introduction: Headline of why I support a robust Health Insurance Exchange

The challenge Too many Rhode Islanders are uninsured Too many Rhode Islanders are uninsured Health insurance costs are unacceptable and unsustainable Health insurance costs are unacceptable and unsustainable Healthcare access, quality, equity, and design are inadequate Healthcare access, quality, equity, and design are inadequate Rhode Island’s leadership in coverage of citizens is declining (from 6th in overall ranking in 2007 to 11th in in 2009) Rhode Island’s leadership in coverage of citizens is declining (from 6th in overall ranking in 2007 to 11th in in 2009) Rhode Island lags at controlling care for cost- effectiveness (e.g., 35th in 2009 for minimizing avoidable hospital use and costs) Rhode Island lags at controlling care for cost- effectiveness (e.g., 35th in 2009 for minimizing avoidable hospital use and costs)

HealthRIght’s guiding principles Access to quality care Access to quality care Sustainable costs Sustainable costs

Goals for health reform All Rhode Islanders covered by 2020 All Rhode Islanders covered by 2020 Universally available high quality care Universally available high quality care Cost increases limited to Consumer Price Index or less Cost increases limited to Consumer Price Index or less Evidence-based, systematically evaluated health care Evidence-based, systematically evaluated health care Robust health planning Robust health planning

Strategies A powerful, strategically operated exchange serving as many Rhode Islanders as relevant A powerful, strategically operated exchange serving as many Rhode Islanders as relevant Promotion of value- and evidence-based purchasing Promotion of value- and evidence-based purchasing Strategic use of all health care dollars to promote cost-effective achievement of health outcomes Strategic use of all health care dollars to promote cost-effective achievement of health outcomes Exchange-driven incentives for documented quality Exchange-driven incentives for documented quality Coordination of exchange operations with a robust state-wide health planning process Coordination of exchange operations with a robust state-wide health planning process

What is a health insurance exchange? Establishment of a health insurance exchange is now required under federal health care reform Establishment of a health insurance exchange is now required under federal health care reform The goal of these exchanges is to make it easier for individuals and small businesses to shop for comparable coverage The goal of these exchanges is to make it easier for individuals and small businesses to shop for comparable coverage They’re also intended to make it easier for low-income people to apply for Medicaid and help business owners and moderate-income individuals apply for federal tax credits They’re also intended to make it easier for low-income people to apply for Medicaid and help business owners and moderate-income individuals apply for federal tax credits

What PPACA requires States indicate to HHS whether they will operate an American Health Benefit Exchange States indicate to HHS whether they will operate an American Health Benefit Exchange Date: January 1, 2013 Date: January 1, 2013 State-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges in operation State-based American Health Benefit Exchanges and Small Business Health Options Program (SHOP) Exchanges in operation Individuals and small businesses with up to 100 employees can purchase qualified coverage, including through Medicaid and CHIP programs. Individuals and small businesses with up to 100 employees can purchase qualified coverage, including through Medicaid and CHIP programs. Date: January 1, 2014 Date: January 1, 2014

Benefits (and risks) of a robust vs. minimal exchange? Purchasing power to control costs Purchasing power to control costs Control over benefit design Control over benefit design Potential for influence over payment design Potential for influence over payment design Potential for influence over quality control Potential for influence over quality control

RI’s current proposed exchange legislation (SB 87) Placeholder intention (and necessity under PPACA) Placeholder intention (and necessity under PPACA) Minimal design requirement Minimal design requirement Board composition Board composition 6 month study and report to legislature 6 month study and report to legislature Potential and likely outcomes (and implications) Potential and likely outcomes (and implications)

RI’s current proposed exchange legislation (SB 87) Placeholder intention (and necessity to receive federal funding for exchange planning and development) Placeholder intention (and necessity to receive federal funding for exchange planning and development) SB 87 establishes the infrastructure for a health insurance exchange

RI’s current proposed exchange legislation (SB 87) Minimal design requirement: Minimal design requirement: The functions and operations of the exchange shall not expand beyond the minimum requirements of the federal act. No later than January 1, 2012, the board shall submit a report to the governor and general assembly

RI’s current proposed exchange legislation (SB 87) Board composition The exchange shall be governed by an executive board which shall consist of eleven members: (1) Director of the department of administration (DOA) or his or her designee; (2) Commissioner of the office of the health insurance commissioner (OHIC) or his or her designee; (3) The secretary of the executive office of health and human services (EOHHS) or his or her designee; and,

RI’s current proposed exchange legislation (SB 87) Board composition The eleven members: (4) Eight shall be appointed by the governor from the general public, with the advice and consent of the senate, two of whom shall represent a consumer organization and two of whom shall represent small businesses. The balance of the appointments to the board shall be made to provide demonstrated and acknowledged expertise in a diverse range of health care areas including, but not limited to: (i) Individual health care coverage; (ii) Small employer health care coverage; (iii) Health benefits plan administration; (iv) Health care finance; (v) Administering a public or private health care delivery system; (vi) Purchasing health plan coverage; and (vii) State employee health purchasing

RI’s current proposed exchange legislation (SB 87) Board composition Board members shall not be employed by, consultants to, members of the board of directors of, members of, affiliated with, or otherwise a representative of an insurer a health insurance agent or broker a health care provider (unless he or she receives no compensation for rendering services as a health care provider and does not have an ownership interest in a professional health care practice) a health care facility or health clinic a trade association of insurers The board shall conduct a training course for newly appointed and qualified members within six months

RI’s current proposed exchange legislation (SB 87) Requires data-driven decisions to be made regarding the design and potential of the exchange on the basis of the 6 month study and report to legislature: “Data analysis and recommendations regarding the costs, benefits, and market impacts associated with any expansion of the exchange functions and scope beyond the duties articulated in section 1311 of the federal act. Include in this analysis an assessment of the basic health plan option, as well as the estimated impact on premiums associated with mandating expanded participation in the exchange by groups not included in section 1311 of the federal act”

RI’s current proposed exchange legislation (SB 87) Potential and likely outcomes Potential and likely outcomes (and implications)

HealthRIght’s vision of the RI exchange Who are HealthRIght and why they should be trusted Who are HealthRIght and why they should be trusted “Robust” exchange- what it would include and how it would operate/achieve goals “Robust” exchange- what it would include and how it would operate/achieve goals Key reform elements of an effective exchange: Key reform elements of an effective exchange: Purchasing power Purchasing power Design expertise Design expertise Stake in what’s best for entire system vs. for any specific elements or agents within it Stake in what’s best for entire system vs. for any specific elements or agents within it

HealthRIght’s vision of the RI exchange Who are HealthRIght and why should they (we) be trusted? Who are HealthRIght and why should they (we) be trusted? HealthRIght is made up of a broad and inclusive group of representatives from small business, labor groups, insurers, healthcare provider organizations, academic and health policy professionals, the faith community and a variety of healthcare advocacy groups to work together to ensure that all Rhode Islanders have universal access to a quality health care system that is affordable, efficient, sustainable, easy-to-use and equitable

HealthRIght’s vision of the RI exchange “Robust” exchange- what it would include and how it would operate/achieve goals “Robust” exchange- what it would include and how it would operate/achieve goals HealthRIght’s belief: a robust exchange is an opportunity to create a mechanism to transform health care, improve public health, and assure that access to coverage will be more affordable

HealthRIght’s vision of the RI exchange Purchasing power Purchasing power Design expertise Design expertise Stake in what’s best for entire system vs. for any specific elements or agents within it Stake in what’s best for entire system vs. for any specific elements or agents within it

What would be required to achieve a robust exchange? Policy decisions about exchange design Policy decisions about exchange design Who will oppose which elements Who will oppose which elements (and why) Political process involved/required to achieve specific design outcomes Political process involved/required to achieve specific design outcomes

What would be required to achieve a robust exchange that could meet these goals? Policy decisions about exchange design Policy decisions about exchange design Who will be mandated to participate Who will be mandated to participate What coverage elements can be controlled by the exchange What coverage elements can be controlled by the exchange What expertise will be available to the exchange to make these decisions What expertise will be available to the exchange to make these decisions What role will be played by various current stakeholders (e.g., brokers, insurance companies) What role will be played by various current stakeholders (e.g., brokers, insurance companies)

What would be required to achieve a robust exchange that could meet these goals? Who will oppose which elements (and why): Who will oppose which elements (and why): Broader mandated participation Broader mandated participation More coverage elements controlled by the exchange More coverage elements controlled by the exchange Whose expertise the exchange relies on to make these decisions Whose expertise the exchange relies on to make these decisions Narrower roles played by current stakeholders Narrower roles played by current stakeholders

What would be required to achieve a robust exchange that could meet these goals? Political process involved/required to achieve specific design outcomes Political process involved/required to achieve specific design outcomes

Discussion of implications for behavioral health