2. 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

3. 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

4. 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
True or False?

5. 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?

6. "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?

7. 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

8. 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

9. 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

10. 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

11. 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

12. 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

13. 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%

14. 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

15. 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 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

16. 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

17. 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

18. 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

19. 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.

20. Alexander-Murray Act: Congressional Budget Office (CBO) Assessment (10/25/17)
No significant federal budget effect
Reduces federal deficit by $3.8 B
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 outreach & enrollment
Small overall effect on state, local, tribal governments or private sector

21. “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 :
$ 338 B savings
13 M+ Americans lose health insurance
(Dec. 2016: CBO estimated ten-year savings of $ 416 B; 15 M lose health insurance)

22. 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

23. 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

24. 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

25. Teaching Resources for Instructors and Students
Following provide continuous updates on the ACA and MACRA’s status with links to additional resources:
ACA
MACRA & CHIP

26. 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

27. Thank you for participating!
Sophie Teague Recorded webinar will be posted on the LinkedIn Public Health Faculty Lounge: