H & S 450 9/24/13

Health Care Part IIAffordable Care Act

Agenda

• Test Thursday - a little bit of every kind of question on it

• Probably not getting to community building as topic today – later in the course

• Flu and meningitis clinics together• 10/9, 10/15, 10/28, 10/29

Ongoing news this week

• Liking Your Neighbors Could Help Prevent You From Having a Stroke (Atlantic – posted on BB Learn)

• 4 million more people would be poor if it weren’t for food stamps (The Washington Post)

• Many states with few insured citizens aren’t expanding Medicaid under Obamacare (Washington Post)

• Analysis: Nearly a Million Fewer Uninsured Children Are Eligible for Public Coverage (RWJF.org)

• Smoking and Diabetes: Does the Increased Risk Ever Go Away? (Amer. J of Epidemiology)

• Plague in the US (NY Times)

Recent US Census snapshot –SNAP issues

• Great deal of discussion in the news about funding SNAP in Congress

Prescription cost issues• http://projects.propublica.org/checkup/. • Medicare Part D in 2010• 28M Beneficiary Claims • 1.1B Prescriptions (Including Refills) • $78B Retail Price of All Prescriptions• 1.7M Number of Prescribers• 40 Average Prescriptions per Beneficiary• $70 Average Retail Price of a Prescription• 3% HC Prescribers That Wrote Half of All Prescriptions

• Note: Include initial prescriptions and refills . • Retail price inc. patients' out-of-pocket costs but not drug maker

rebates. 

Health coverage current Medicaid (first in 1965)

• Each state sets its own program standards. • In Idaho –

Criteria for eligibility:• Child <19, pregnant, aged, blind, or disabled

and need nursing home care- limited adults• Income- 133-185% of poverty; • Pass asset test• Need US Citizenship/legal status• Exceptions: i.e. Women diagnosed with

breast or cervical cancer or pre-cancer

Medicare (1965)

• 65 and older• OR severe chronic disabilities- e.g., unemployed

and before age 65• Contributions lifelong through US wages• Consists of:• Part A- mandatory hospital insurance• Part B- Health Care Services-automatically

enrolled, can decline. Deductible and co-pay• Part D- Prescription drug coverage-optional,

monthly premium

State Children’s Health Insurance Plan (SCHIP)• Administered by the states• Started in 1997• Eligible income limit for Idaho SCHIP is

185% of the FPG. = $41,347.50 (family of 4)• Idaho is one of only seven states that have

income limits set below 200% of the FPG.• 1/3 of Idaho children are in SCHIP or

Medicaid – 1/3 more qualify and should not be kept on parent insurance or go uninsured

Medicaid/CHIP Participation Rates Among Children: An Update

Put all the pieces together

• Estimated 2/3 of Idaho children qualify for SCHIP • Only 1/3 eligible enrolled• Highest family of 4 income to qualify is

$41,347.50• Last lecture average income in Latah County is

approx. $30,000.• Overall picture of struggle

with health care access

Regardless of the politics…

• 48.6 million in US with no health insurance

• How to advocate health prevention and promotion if you cannot get screened ? • NO coverage to get

screened• How do you rein in

costs ?• Is health care a

human right ?

Income Below Specified Ratio of Poverty Thresholds 1967 to 2011

• Poverty for household of 4 = • $ 22,350 in 2011• 15.7 percent of the

country under poverty line• Very important for

the Affordable Care Act proposals

Affordable Care Act – one attempt

• http://kff.org/health-reform/video/youtoons-obamacare-video/.

• Health Reform video

• Legislation passed by Congress in 2010• Large part takes effect on January 1, 2014• Lots of provisions are phased in over several years

(to 2020)

Key Features of ACA Health Reform

Individual Mandate- “Acceptable health coverage” required of all eligible citizens in 2014• Annual penalties if not covered- varying by

income (phased in)• Exceptions- religious objections, financial

hardship, American Indians, those without coverage < 3 months.• Bottom line – should get better quality

coverage at less cost

Employer/Business requirements

• Employers required to offer insurance if over 50 employees (< 50 exempt)• Business assessed fees of $2000/employee if

not providing insurance.• If >200 employees, employee must enroll in

insurance or use exchange• Premium subsidies to small employers- tax

credits and reinsurance for employees over 55• Walgreens last week will pay employees a

stipend to shop for exchange insurance

Required benefits of ACA health policies• Prescription drug

coverage• Emergency and

hospital care coverage• Doctor visits • Remember the

hallmark of the new care plan is strengthening primary care and access to it

• Kaiserhealthnews.org

• Maternity services• Mental health services• Rehabilitation services• Lab services• Preventive services

must be covered without any out of pocket cost to consumer

• (Routine screening tests)

Expanded public programs

• Expand Medicaid to all individuals under 65 to 133% FPL – 2012 Supreme Court decision• Idaho refuses to do this• All recipients receive “benchmark” benefits

policy- essential services• Increase Medicaid payments to providers to

Medicare rates• CHIP- Increase federal funds to states to cover

increased numbers of children.• Funds from Feds States. Not all state burden

Individual citizen premiums

• Provide policy premium credits and cost sharing subsidies for individuals and families for those between 135-400% FPL• Lowers out of pocket spending limits• Federal subsidies and tax credits will be

offered to individual and families up to 400% FPL

Create state insurance marketplaces

• If earn more than 133% of FPL and no employer provided insurance, states will have insurance exchanges to provide coverage starting 10/1/13• Must be 4 levels of plans – all with the specified

essential health services

• Helps the currently uninsured

https://www.healthcare.gov/

Changes for Insurance Companies

• No more lifetime coverage limits on policies• No more waiting periods of > 90 days for coverage• No higher rate for females or poor health• Cannot deny coverage due to health history• Extends dependent coverage to age 26• No cost sharing for preventive services, limits out of

pocket cost to consumer• Consumer has rights before a company now

Higher quality care the goal (Boxes 13.7, 13.10 13.11 in text )

• All policies must :• Cover vaccinations and screenings with no co-pay or

deductible• Hospitals pay a penalty if patient readmitted in a certain

time with common diseases(2012) Cut health care administrative costs (2012) Doctors paid based on quality and not quantity (2015)

• Require chain restaurants and vending machines to disclose nutritional content.• Appropriate funds for prevention research & outreach• In short, higher quality care, prevention and

wellness are emphasized

Adult Female wellness services covered

• Routine wellness and screening services (Pap test, mammogram, etc.)• Gestational diabetes screening• HPV DNA testing• STI counseling• HIV screening and counseling• Breastfeeding support, supplies, and

counseling• Interpersonal and domestic violence screening

and counseling

How to buy health insurance under ACA

• Go to The Henry J. Kaiser Family Foundation home page• http://kff.org/• Click on the Health Reform box at the bottom• Scroll down to the Interactive Health

Insurance Subsidy calculator• Click on the calculator and estimate buying

insurance for the people on the following scenarios in the handout.