Wellness and Prevention in Health

Reform

Concerns with wellness plans and examples of consumer-friendly prevention provisions

Claire McAndrew

Families USA

February 16, 2010

Wellness Plans Today Individual market wellness

plans are not federally regulated; some states have passed relevant laws

Group market (workplace) wellness plans are

regulated by HIPAA rules Rules divide employer wellness plans into two

groups:

Wellness Plans Today: Employer Plan Design

Plans based on participation goals: Example: Employees who participate in a

nutrition seminar will have a lower deductible for their health insurance

Incentive size restriction: none

Wellness Plans Today: Employer Plan Design

Plans based on health factors/ outcomes: Example: An employer charges a higher

deductible to workers who do not have a BMI under 35

Incentive size restriction: 20% of the value of total health insurance premium (including the employer’s and the worker’s share) Average worker premium for ESI in 2009: $4,824

(Kaiser/HRET 2009 Annual Health Benefits Survey) 20%= $965

Concerns with wellness plans today Access to coverage and care: Surcharges could

make health coverage unaffordable altogether Lack of evidence-base Lack of comprehensive supports in programs Inequities: may place a disproportionate burden on

individuals with low-incomes, racial and ethnic minorities, and individuals with chronic health problems or disabilities

Concerns with wellness plans today

Privacy issues Alternative standards Verifying compliance/ measuring achievement

Lack of appeal rights

Wellness Plans and Health Reform: Senate Bill

Increases allowable incentive from 20% of premium value to 30%, with the option to go up to 50% This would increase allowable surcharges from

$965 to $1,447 for an average worker, with the possibility of a $2,412 surcharge (using 2009 average values as an example)

Wellness Plans and Health Reform: Senate Bill

Provides incentives for 10 states to start incentive-based wellness plans in their individual markets/ exchanges Expands to more states in 2017 at the Secretary’s

discretion Major concern: Bill language appears to allow

wellness surcharges to be tacked-on after people receive premium credits, undermining affordability protections

Wellness Plans and Health Reform: Medicaid

Grants for states to do Medicaid wellness programs

Protections Evidence-based Take into account unique needs of Medicaid population Incentives cannot affect eligibility or benefits

Issue to watch

Wellness Plans and Health Reform: House Bill

No change to incentive limit (20% for outcome-based plans still stands)

Grant program for small businesses to start wellness plans, but only those that do NOT vary premiums or cost-sharing To receive grants, programs must also be comprehensive

and provide an array of supports Note: Final Senate bill adopted some of these

provisions— created a small business grant program with some standards, but doesn’t prohibit insurance-linked incentives.

Wellness Plans and Health Reform: Talking About It

House provisions reflect broader health reform goals: evidence-based, comprehensive supports for improving health

Senate provisions contradict broader goals of health reform, which seek to eliminate: Pre-existing condition and health status

discrimination Unaffordable health coverage and care

Concerns with today’s plans still stand

Wellness and Prevention that Works for Consumers: Senate Bill

Comprehensive coverage for and increased access to preventive and health promotion services Private Market: Essential

benefits package Medicare: wellness visit, no

preventive cost-sharing Medicaid: smoking cessation

for pregnant women Grant program for states to

increase adult vaccination rates; Medicare study of beneficiary vaccine access

Wellness and Prevention that Works for Consumers: Senate Bill

Targeted prevention and health promotion efforts based on where people spend their time: Grants for school-based health centers Grants to states, local governments, and

community organizations to implement evidence-based, community prevention activities

Specific grants for community health prevention and health promotion activities targeted to individuals ages 55-64, including screenings and referrals

Wellness and Prevention that Works for Consumers: Senate Bill

Support for a preventive and public health infrastructure Creates a preventive

medicine and public health training grant program

Establishes a Community Health Center fund to increase investments in centers

Wellness and Prevention that Works for Consumers: Senate Bill

Public awareness and education New fund for national prevention and health promotion

strategies New campaign to make Americans aware of new

access to preventive services Oral health prevention campaign Breast cancer awareness campaign targeted at young

women New national diabetes prevention campaign and CDC

National diabetes “report card”

Wellness and Prevention in Health Reform: Takeaway

Wellness and prevention= GOOD!

Underwriting and insurance discrimination disguised as wellness=

BAD!

Wellness and Prevention in Health Reform: ResourcesFamilies USA Talking Points: “Senate Amendment on Wellness

Program Surcharges Jeopardizes Access to Affordable Coverage and Care” http://www.familiesusa.org/assets/pdfs/wellness-amendment-in-senate-bill.pdf

Families USA Blog Post: “The Wellness Plan Discrimination Loophole” http://www.standupforhealthcare.org/blog/archives/the_wellness_plan_discrimination_loophole/

HIPAA Rules on Wellness Plans: “Nondiscrimination and Wellness Programs in Health Coverage in the Group Market; Final Rules,’ Federal Register 71, no. 239 (December 13, 2006): 75014-75055. http://www.dol.gov/ebsa/regs/fedreg/final/2006009557.htm