1. Health Care Reform Implementation Through the Cancer Lens ACS CAN Policy Team April 2010

2. 2010201120122013201420152016201720182019 Medicare Savings: MA payment reductions, productivity offset to FFS updates Medicare/Medicaid Savings: DSH reductions, IPAB Medicare proposal Coverage: Small business premium tax credit Immediate Insurance reforms: high risk pool, dependent coverage to age 26, no pre-ex for kids, loss ratios/ rate review Delivery System Reform: Center for Medicare and Medicaid Innovation Delivery System Reform: ACOs, hospital value-based purchasing Delivery System Reform: Hospital readmissions, payment bundling Delivery System Reform: Physician quality reporting penalties New Revenue: Tax on prescription drug manufacturers New Revenue: Excise tax on medical device makers, Medicare tax on high earners New Revenue: Tax on health insurers New Revenue: Tax on high-cost health plans Medicare/Medicaid Savings: Medicare provider updates, Medicaid prescription drug rebates Timeline of Key Health Reform Provisions Coverage: Medicaid expansion, major insurance reforms (eg, guaranteed issue, rating rules, no pre-ex for adults) insurance exchanges, premium / cost sharing subsidies, individual / employer responsibility requirements

3. What Is In the Patient Protection and Affordable Care Act? The Basic Structure of Health Care Reform Expanding Coverage Private insurance Medicaid Medicare Enhancing Prevention Improving Quality of Life

4. Early Implementation: 2010-2013

5. Early Implementation Expanding Coverage: Private Insurance Within 90 days: Creates a temporary high-risk pool for those uninsured because of a pre-existing condition New “plan year” beginning 6 months after enactment: Dependent coverage extended until age 26 No pre-ex for children Eliminates rescissions No lifetime limits on coverage Regulates annual limits on coverage No cost for preventive care in “new plans”

6. Early Implementation Expanding Coverage: Medicaid CY 2010 New optional category for parents and childless adults under 133% FPL States under Maintenance of Effort (MOE) until 2014 –May not reduce B&C treatment eligibility during this time CY 2011 Optional state coverage of preventive services –Increases FMAP for states that cover prevention (Jan 1, 2013) Mandatory coverage of tobacco cessation services for pregnant women –Tobacco cessation coverage for pregnant women (Oct 1, 2010) CY 2013 Increases reimbursement to primary care doctors

7. Early Implementation Expanding Coverage: Medicare CY 2010 $250 rebate for those in the Part D “doughnut hole” CY 2011 Eliminates co-payments for preventive services Free wellness visit and personalized prevention plan 50% discount on brand-name drugs while in the doughnut hole

8. Early Implementation Enhancing Prevention CY 2010 New Interagency Prevention Council at HHS to expand and coordinate prevention and public health programs and strategies. Establishes a National Strategy on Prevention and Wellness –First report July 1, 2010 Creates a Prevention and Public Health fund –$500 million for fiscal years 2010 and increased to $2 billion in 2015 and subsequent years Temporary credit to small businesses to encourage investment in new therapies for the prevention of chronic diseases.

9. Early Implementation Menu Labeling Requires regulations on menu labeling for restaurant chains by 2011 States and localities are preempted on enactment from having a policy that applies to restaurants with 20 or more chains that is not identical to the federal law. We are currently working with outside experts to determine what "identical" means for states and localities that currently have or are considering a policy.

10. Early Implementation Addressing Disparities CY 2010 Increases funding for Community Health Centers Requires enhanced collection and reporting of data on race, ethnicity, sex, primary language, disability status, and for underserved rural and frontier populations Expands funding for scholarship and loan repayment for physicians working in underserved areas Reauthorizes Patient Navigator Act Reauthorizes the Indian Health Care and Improvement Act

11. Early Implementation Improving Quality of Life Pain Management –Institute of Medicine Conference and report on pain –New Interagency Pain Research Coordinating Committee at HHS to expand NIH pain research –Health professional education and training grants Comparative Effectiveness Research –Establishes a private, non-profit corporation to undertake comparative effectiveness research and information dissemination Quality Care Measures Development –National strategy and action plan to develop quality measures –New Interagency Working Group on Health Care Quality

12. Implementation: 2014 and Beyond

13. Implementation Expanding Coverage: Private Insurance Availability –Establishes health exchanges in 2014 for those without employer-sponsored health insurance –Allows inter-state compacts to sell insurance across state lines –Requires the federal Office of Personnel Management to establish nationwide, non-profit plans –No pre-existing condition restrictions –Requires guaranteed issue of health insurance regardless of health status –Waiting periods not longer than 90 days –Allows non-profit coops to be formed to provide insurance

14. Implementation Expanding Coverage: Private Insurance Affordability –Provides premium subsidies for middle income individuals and families (up to $88,000 for a family of four) –Bans annual limits on coverage in 2014 (ceiling on them before 2014 TBD by Secretary of HHS) –Limits out of pocket maximums –Limits deductibles –Premium rating can only be based on age (3:1), family status, and geography AND premium surcharge for tobacco use (1.5:1) –Allows employer wellness programs to provide insurance discounts up to 30%. Also demo projects in individual market in 5 states.

15. Implementation Expanding Coverage: Private Insurance Adequacy –Creates essential health benefits package –Coverage of preventive health services with no co-pays or deductibles

16. Implementation Expanding Coverage: Private Insurance Administrative simplicity -Exchanges can standardize and simplify forms -Plans will have ratings to reflect level of coverage (bronze, silver, gold, platinum) -Appeals and other administrative processes will be standardized -Internet portal will be established to facilitate comparison and enrollment

17. Implementation Responsibility Individual mandate –Fine or income tax for those w/o coverage –Exceptions for religious or affordability reasons Employer mandate –Employers w/ more than 50 employees have to contribute $2000 for each worker receiving subsidies in exchange

18. Implementation Expanding Coverage: Medicaid Expands coverage to all persons under 133% FPL (up to $29,327 for a family of four) Simplifies enrollment into Medicaid Incentive programs to encourage participation in chronic disease preventive programs Increases access to cessation drugs

19. Implementation Expanding Coverage: Medicare Closes prescription drug (Part D) “doughnut hole” Will change reimbursement to emphasize integration of delivery and better health outcomes

20. Implementation Enhancing Prevention Incentives to increase number of primary care providers –Loan repayment –Low interest loans –Graduate Medical Education training slots Permits employers to have wellness premium discounts

21. Implementation Addressing Disparities Qualified health plans must provide materials in appropriate languages Strategy for increases access to language translation services

22. Implementation Improving Quality of Life Clinical Trials Coverage –All group or individual commercial plans must cover routine patient care costs for trials participation –Includes FEHBP plans, but not self-insured plans (ERISA plans) –Preemption provision protects existing state laws & voluntary agreements

23. Assessment and Improvements State experiences HIAS patient stories and reports Consumer experiences Mandatory federal reports Legislative and Regulatory “Fixes”

24. Legal Challenges to HCR Lawsuits by Attorney Generals –Claims that imposing the individual mandate is unconstitutional –Asserts that the expansion of Medicaid is an enormous unfunded mandate that the states cannot bear financially –Other legal issues The law will be defended by U.S. Attorney General Judicial Advocacy Initiative (JAI) will continue to monitor challenges, but ACS CAN is not a party to any lawsuit

25. Health Care Reform Implementation ACS CAN’s Primary Focus New High Risk Pool Plan --important transitional program for currently uninsured, high risk people --will establish tone and precedent for future HCR implementation issues, and therefore, we want to be very visible Exchanges—critical to making the 4As real for cancer patients and survivors Prevention—an opportunity to truly enhance its role in our nation’s health system Medicaid expansion—issues around state costs, benefits for new enrollees, and maintenance of B&C program

26. YOUR ROLE

27. Implementation: State activity Contracting of high-risk pools Creation of the exchanges Creation of state-based ombudsman programs Protecting mandates and B&C program until at least 2014

28. The Federal Regulatory Process The federal regulatory process is highly structured and formal –Strict rules about comment periods and external contacts –Very reliant on concrete information HHS will be primary agency, but Labor and Treasury have important roles, too

29. Implementation: To do list Learn what’s in the bill Identify state publications where call for regulatory comments will appear Develop a relationship with your state Insurance Commissioner and Medicaid Director Refer questions to State and Local Campaigns team

30. Implementation: Resources ACS CAN HCR Web page Refer questions to State and Local Campaigns team

31. Thank You! www.acscan.org