1. Return to KaiserEDU Tutorials
Figure 1
Health Care Reform and The NM Health Insurance Exchange
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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Meeting Purpose
Figure 1
Present a brief Introduction into Health Care Reform and Health Exchanges
Sangre de Cristo will be meeting with as many of the local behavioral health collaboratives across the state as possible in order to gather information for the Health Exchange.
Information will be gathered by a combination of focus group discussions and a structured questionnaire.
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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3. Health Reform: An Overview
Figure 1
The Patient Protection and Affordable Care Act (PPACA) of 2010 (Health Care Reform) authorized State Planning and Establishment Grants to help each individual state like NM to establish a “Health Insurance Exchange”
By 2014, most people will be required to have health insurance
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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Goals for Health Reform
Figure 2
Expand health insurance coverage
Improve coverage for those with health insurance
Improve access to and quality of care
Control rising health care costs
Before we get into specific provisions of the law, it is helpful to understand what the law sought to achieve. Most people can agree on the underlying problems with our system. Many people (50 million in 2009) lack health insurance and even those with coverage face increasing premiums and plans that may not cover the services they need. Fragmentation in the health care system leads to duplication and inefficient care and means that people do not always receive the best care. Health care costs continue to skyrocket, outpacing increases in inflation as well as workers wages. And, while we don’t all agree on the solutions, the overarching goals for health reform were to address these fundamental problems. The goals spanned four key areas: expanding coverage to the millions of Americans who lack it today; improving the affordability and quality of the coverage for those who are currently insured; improving access to and the overall quality of care that individuals receive; and constraining the growth in health care costs. The law includes numerous provisions designed to address each of these goals. This tutorial will focus on some of the more significant provisions in each area.
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5. Promoting Health Coverage
Figure 3
Universal Coverage
Medicaid Coverage
(up to 133% FPL)
Exchanges
(subsidies % FPL)
Individual
Mandate
Health Insurance Market Reforms
The health reform law seeks to expand health coverage by building on the existing public-private system for providing health insurance and filling in the gaps in the current system. It expands eligibility for the Medicaid program, the current safety net health insurance program for the poor. It creates new exchanges, or marketplaces, where people can purchase coverage and, depending on their income, receive premium subsidies to help them afford the coverage. It includes new penalties for employers that don’t offer coverage to their employees and provides tax credits to small employers that do to bolster the availability of employer-sponsored coverage.
Supporting these enhanced coverage mechanisms are a new requirement that individuals, with some exceptions, have health insurance (referred to as the individual mandate) and new rules for insurers requiring them to provide coverage to everyone regardless of health status and limiting the variations in premiums they charge people.
Together, these strategies are designed to increase significantly the number of people with health insurance.
Employer-Sponsored Coverage
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6. Expanding Health Insurance Coverage— Early Actions
Figure 4
Create temporary Pre-existing Condition Insurance Plan for people with medical conditions who are uninsured
To qualify, individuals must be uninsured for six months
Federally funded
Available in each state until 2014
Allow adult children to remain on their parents’ health insurance policy until age 26
Children do not have to live with parents, nor be students
May be married, but spouses and children not eligible
To begin to fill the gaps in coverage, the health reform law makes some small changes to our system this year. To provide immediate coverage to individuals with medical conditions, the law creates the Pre-existing Condition Insurance Plan. Essentially a high risk pool available in each state, individuals are eligible if they have a pre-existing medical condition and have been uninsured for at least six months. To make the coverage in this plan more affordable, the premiums will be set as if the enrolled population was not sick. In some cases, however, the premiums will still be unaffordable for people who need the coverage. This program is federally funded and will be available until the new health insurance exchanges are up and running in 2014.
Targeting the young adult population, which has the highest risk of any age group of being uninsured, the law allows adult children to remain on their parents’ insurance policy until age 26. Adult children do not have to live with their parents or be claimed as a dependent on their parents’ taxes to be eligible. Nor do they have to be students. They may also be married, though their spouses and children are not eligible.
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7. Expanding Health Insurance Coverage— in 2014
Figure 5
Expand Medicaid to all individuals under age 65 with incomes up to 133% of the poverty level ($14,400/individual or $29,300/family of 4)
Create new Health Insurance Exchanges where individuals and small employers can purchase coverage
Provide premium subsidies to eligible individuals and families with incomes up to 400% of the poverty level ($43,300/individual or $88,200/family of 4) through the Exchanges
Much more significant coverage expansions occur in In 2014, the law expands the Medicaid program to cover nearly all individuals with income up to 133% of the federal poverty level, which is $14,400 for an individual or $29,300 for a family in This expansion will create a uniform eligibility threshold for Medicaid across the states. Currently, states set eligibility levels for Medicaid and in most states, adults without dependent children regardless of their income are not eligible.
Also in 2014, the law creates new state-based health insurance exchanges or marketplaces, where individuals and small employers can purchase coverage. These exchanges will allow individuals to compare plans and select the one that best meets their needs.
To ensure that coverage in the exchanges is affordable to most consumers, beginning in 2014, premium subsidies will be available to those with incomes up to 400% of the federal poverty level or $43,300 for an individual and $88,200 for a family of four in 2010.
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8. Improving Health Insurance
Figure 7
Reform the health insurance market
Prohibit insurers from denying coverage or charging people more because they are sick
Prohibit insurers from rescinding coverage or placing annual or lifetime limits on coverage
Improve benefits for those with insurance
Ensure coverage of preventive services with no cost- sharing
Establish minimum benefit standards
Limit out-of-pocket spending for consumers
In addition to expanding coverage, the law seeks to improve the adequacy and the affordability of the coverage that people have. New insurance market rules will prohibit insurers from denying coverage or charging people more because they are sick. In addition, insurers will not be permitted to rescind coverage, except in cases of fraud, nor will they be able to place lifetime or annual limits on the coverage.
Other changes will require plans to provide coverage for certain preventive services, such as mammograms, colonoscopies, and diabetes screenings, with no cost-sharing for the individual. Many plans will be required to offer a minimum set of benefits and to limit what people have to pay out-of-pocket for their care.
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9. Employer Requirements and Incentives
Figure 8
Larger employers that don’t offer affordable coverage will face penalties of up to $2,000 per full-time worker per year beginning in 2014
Small employers with up to 50 employees will be exempt from penalties
Tax credits available for some small businesses that offer health benefits
The law includes new requirements and incentives for employers to offer health coverage to their workers. Beginning in 2014, employers with 50 or more employees that don’t offer affordable coverage will be subject to penalties of $2,000 per full-time worker per year, excluding the first 30 workers.
Recognizing the particular difficulty small employers face in providing health insurance, the law exempts employers with fewer than 50 employees from the penalties, and provides the smallest employers that offer coverage tax credits to offset some of the costs of that coverage.
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Individual Mandate
Figure 9
Individuals will be required to have health coverage that meets minimum standards in 2014
Individual mandate spreads costs among whole population
Mandate enforced through the tax system
Penalty for not having insurance: greater of $695 (up to $2085 for family) or 2.5% of family income
Exemptions for certain groups and if people cannot find affordable health insurance
One of the more controversial aspects of health reform is the requirement that individuals have health insurance. Beginning in 2014, most people will be required to have health insurance that meets minimum coverage standards. This mandates was included in the law to ensure that the requirement that insurers provide coverage to everyone could work. Without a mandate for coverage, some people might choose not to purchase insurance until they got sick. Doing that would drive up premiums for everyone else, making coverage unaffordable for many.
This new requirement will be enforced through the tax system and individuals will face monetary penalties if they don’t have coverage. Certain individuals will be exempt, including those who don’t have access to affordable coverage, those with incomes below a certain threshold, American Indians, immigrants who are not legal residents, and people in jail.
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11. Some Uninsured Will Remain
Figure 10
Congressional Budget Office (CBO) estimates 23 million uninsured in 2019
Who are they?
Immigrants who are not legal residents
Eligible for Medicaid but unenrolled
Exempt from the mandate (most because can’t find affordable coverage)
Choose to pay penalty in lieu of getting coverage
Many remaining uninsured will be low-income
Despite efforts to expand coverage, some uninsured will remain. The Congressional Budget Office estimates that 23 million people will be uninsured in The remaining uninsured include immigrants who are not legal residents and therefore not eligible for Medicaid or for federal premium subsidies in the exchanges, people who are eligible for Medicaid but are unenrolled, those who are exempt from the individual mandates in most cases because they do not have access to affordable insurance and those who choose to pay the penalty instead of purchasing health coverage. It is expected that many of the remaining uninsured will be low-income so that the need for a strong network of safety net providers to care for these uninsured will continue.
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12. Health Reform and Delivery System Changes
Figure 11
Health Reform and Delivery System Changes
Promoting primary care and prevention
Improving provider supply
Developing new models for coordinating and delivering care
Making use of information technology
Reforming provider payments to promote quality
In addition to the provisions focusing on health coverage, the law makes important changes to the health care delivery system. These delivery system changes are aimed at improving access to care and overall quality and to reign in rising health care costs. They cover a number of areas including promoting primary care and prevention, improving the supply of providers, particularly primary care providers, creating new models for delivering health care that promote quality and efficiency, using health information technology to streamline the delivery of care, and creating incentives for quality care through provider payments.
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13. Promoting Primary and Preventive Care
Figure 12
Increased Medicare and Medicaid payments for primary care providers
Incentives for new doctors and other health professionals to practice primary care
No cost-sharing in Medicare and new private plans for certain preventive services and incentives for states to do same in Medicaid
Funding for population-based prevention activities
The health reform law places a strong emphasis on primary and preventive care. To improve access to primary care, the law increases Medicare and Medicaid payments for primary care providers. Through loan repayment programs, scholarships and other mechanisms, the law also creates incentives for new doctors and nurses to practice in primary care.
The law also seeks to increase access to preventive services by requiring Medicare and new private health plans to provide coverage for certain preventive services, including mammograms, colonoscopies, and diabetes screenings, at no cost to the consumer. It provides incentives in the form of enhanced federal payments for states to offer the same coverage through their Medicaid programs. To improve the health of the population, the law creates the Prevention and Public Health Fund to support initiatives to prevent obesity and diseases such as HIV, promote tobacco cessation, and strengthen the public heath infrastructure.
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14. Improving Health Care Quality
Figure 13
Development of a national quality strategy
Coordinated care through medical homes and other models
Quality-based payments for health care providers and improved information on provider quality
Comparative effectiveness research to identify most effective treatments and interventions
Enhanced data collection to address health care disparities
As one of the overarching goals for health reform, the law contains numerous provisions to improve health care quality. While it’s not possible to describe all of the quality improvement provisions, here are a few of the more significant ones. First, the law requires the development of a national quality strategy to coordinate federal activities to improve the nation’s health. It promotes more coordinated health care through the creation of medical homes and other arrangements that hold providers accountable for the care they provide. Paying providers based on the quality of care they provide and making information on provider quality available to consumers is a central tenet of the law. The law also invests in research to identify and disseminate findings on the most effective treatments. Finally, enhanced data collection will enable a renewed focus on reducing health care disparities.
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15. Containing Health Care Costs
Figure 14
Greater oversight of health insurance premiums and insurer practices
Increased competition and price transparency through Exchanges
Provider payment reforms in Medicare
Testing of new, more efficient delivery system models in Medicare and Medicaid
Another key area addressed by the Health Reform Law is containment of health reform costs. Some of the provisions in the health reform law targeting health care costs focus on health care prices, primarily the premiums insurers charge, while other provisions address provider payment methodologies and the ways in which the health care system is organized that may be contributing to overutilization and inefficient delivery of care.
With respect to prices, the law requires states to review premium rate requests by insurers to identify excessive or unreasonable premium increases. Insurers will also be required starting in 2011 to spend a certain portion of premium dollars on patient care, as opposed to administrative costs or profits. The offering of standardized plans through the Exchange will make it easier for people to comparison shop, which should spur competition and possibly lower premiums.
In other areas, the law calls for reforming payment policies in Medicare, including reducing payments to Medicare managed care plans, known as Medicare Advantage plans, and slowing annual payment increases for other providers, as well as reducing payments to providers for avoidable complications, such as hospital-acquired infections and readmissions. It will test new delivery system models that will be designed to provide higher quality care more efficiently.
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16. Health Insurance Exchanges
Figure 1
What is a Health Insurance Exchange?
What is Health Insurance Exchange Supposed to Do?
How will the Health Insurance Exchange do this?
What about any behavioral health needs and concerns that I might have?
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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17. Health Insurance Exchanges
Figure 1
Offer a choice of health plans based on cost and quality of benefits
Provide information to help understand the options available
Provide “one-stop shopping” to compare, select, and enroll in health plans
Help eligible individuals receive premium discounts or enroll in other federal or state healthcare programs like Medicaid
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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18. Health Exchange Survey
Figure 1
What will make the New Mexico Health Insurance Exchange useful to you?
What other services would you like to see in the health insurance plans offered through the exchange beyond those that are required?
How can the exchange provide clear information that describes the benefits and limitations of the health insurance plans, allowing you to make an informed choice?
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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19. Health Exchange Survey
Figure 1
What would be the most important features you would look for when comparing health insurance plans?
What are the best ways to inform you about the role of the exchange and the services available (e.g., internet, toll-free call center, customer service center, etc.)?
Do you believe the exchange will benefit you? Why? Why not?
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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20. Future of Health Reform: Legislation Is Just the Beginning
Figure 17
Implementation will be challenging
Guidance and federal oversight needed
Resources for infrastructure and capacity building
Policy and political challenges
Health reform provides opportunities to improve our health care system
Reduce the number of people who are uninsured
Make the health insurance system work better for all consumers
Transform delivery and payment systems to get better value
Reorient health care to focus on prevention and primary care
The challenge of transforming our health care system, which represents 1/6 of our economy is daunting. It will require guidance from the federal government to explain how the law will be implemented as well as to provide oversight to ensure that implementation is proceeding as expected. Key stakeholders, including states, health plans, employers, and providers must commit to making the necessary changes. Resources to build infrastructure and to expand provider capacity will be needed. And, all of this will be done in the face of stiff political opposition.
Despite the challenges, if we can get it right, health reform provides an opportunity to really transform our health care system so that it works better for all of us.
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21. If you have any Questions Please let us know.
Let’s Complete the Survey
Please know that your answers will be kept strictly confidential
Figure 1
If you have any Questions
Please let us know.
If you know of someone interested in completing the survey please visit our
Web site at
sdcchp.org and click on health insurance exchange link
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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Special Thanks To
Figure 1
Jennifer Tolbert
Associate Director
Kaiser Commission on Medicaid and the Uninsured
for KaiserEDU.org
September 2010
Hello, I’m Jennifer Tolbert, an Associate Director with the Commission on Medicaid and the Uninsured at the Kaiser Family Foundation. Today, I will provide an overview of the Patient Protection and Affordable Care Act, which I will refer to simply as the health reform law. This comprehensive law was enacted on March 23, 2010 and will bring about significant changes to our health care system. This overview will focus on several key areas of the law: health insurance coverage, delivery system improvements and cost containment efforts.
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Resources
Figure 18
Kaiser Family Foundation:
New DHHS consumer website:
Alliance for Health Reform:
National Association of Insurance Commissioners:
National Governors Association:
Additional KaiserEDU tutorials:
Health Care Reform: A Retrospective:
Health Reform: How Will Medicaid Change?:
Health Reform and Medicare: reform/player.html
I’m glad you’ve taken the time to learn more about the new health reform law and I hope you’ve found this tutorial useful. If you would like more information on provisions of the law and its implementation, I would suggest these additional resources. Thank you.
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