This document provides an overview of the impact of the Patient Protection and Affordable Care Act (PPACA) on rural health in the United States. It discusses key provisions of the health reform law including the individual mandate requiring health insurance, the establishment of health insurance exchanges, subsidies for low-income individuals to purchase insurance, and the expansion of Medicaid eligibility. It also notes challenges in implementing the law such as state capacity and resistance, building up the primary care workforce, and uncertainty around funding levels. In conclusion, it questions whether sufficient money will be available to address the specific health issues facing rural Americans and help rural hospitals and physicians.

1. Health Reform under
The Patient Protection and Affordable Care Act
What Does it Mean for Rural Health?
Carolyn L. Engelhard, MPA
Director, Health Policy Program
Department of Public Health Sciences, UVASOM
December 7, 2011

2. Health Reform
An overview of the impact of the
Patient Protection and Affordable Care
Act (PPACA) in the United States, signed
into law March 23, 2010

3. Q1: Will the health reform law require nearly all
Americans to have health insurance by 2014
of else pay a fine?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

4. Q1: Will the health reform law require nearly all Americans
to have health insurance by 2014 of else pay a fine?
Yes. Starting in 2014, most U.S. citizens and legal
residents will be required to obtain health
coverage or pay a penalty. Some exemptions
will be granted, for example, for those with
religious objections of where insurance would
cost more than 8% of their income.
http://www.kff.org/healthreform/upload/8148.pdf

5. Q2: Will the health reform law allow a
government panel to make decisions about
end-of-life care for people on Medicare?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

6. Q2: Will the health reform law allow a government panel to
make decisions about end-of-life care for people on
Medicare?
No. No such panels exist. While early versions of the
law did contain provisions that would allow
Medicare to reimburse physicians for voluntary
discussion with patient about end-of-life
planning, these provisions were dropped from
the final legislation.
http://www.kff.org/healthreform/upload/8148.pdf

7. Q3: Will the health reform law cut benefits that
were previously provided to all people on
Medicare?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

8. Q3: Will the health reform law cut benefits that were
previously provided to all people on Medicare?
No. The law reduces payments to the privately
administered Medicare Advantage plans, but
they will still be required to provide all benefits
that are covered by traditional Medicare.
http://www.kff.org/healthreform/upload/8148.pdf

9. Q4: Will the health reform law expand the
existing Medicaid program to cover low-
income, uninsured adults regardless of
whether they have children?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

10. Q4: Will the health reform law expand the existing Medicaid
program to cover low-income, uninsured adults
regardless of whether they have children?
Yes. Medicaid will be expanded to cover nearly all
individuals under age 65 with incomes up to
133% of the federal poverty level ($14,484 for an
individual or $29,726 for a family of four in 2011).
http://www.kff.org/healthreform/upload/8148.pdf

11. Q5: Will the health reform law provide financial
help to low and moderate income
Americans who don’t get insurance through
their jobs to help them purchase coverage?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

12. Q5: Will the health reform law provide financial help to low
and moderate income Americans who don’t get
insurance through their jobs to help them purchase
coverage?
Yes. Individuals without access to affordable coverage
who purchase coverage through the new
insurance Exchanges and have incomes up to
400% of the federal poverty level will be eligible
for premium tax credits based on their income.
http://www.kff.org/healthreform/upload/8148.pdf

13. Q6: Will the health reform law prohibit insurance
companies from denying coverage because of
a person’s medical history or health
condition?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

14. Q6: Will the health reform law prohibit insurance companies
from denying coverage because of a person’s medical
history or health condition?
Yes. Starting in 2014, all health insurers will be
required to sell coverage to everyone who
applies, regardless of their medical history or
health status.
http://www.kff.org/healthreform/upload/8148.pdf

15. Q7: Will the health reform law require all
businesses, even the smallest ones, to provide
health insurance for their employees?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

16. Q7: Will the health reform law require all businesses, even
the smallest ones, to provide health insurance for their
employees?
No. The law does not require employers to provide
health benefits. However, it does impose
penalties. In some cases, on larger employers
(those with 50 or more workers) that do not
provide insurance to their workers or that
provide coverage that is unaffordable.
http://www.kff.org/healthreform/upload/8148.pdf

17. Q8: Will the health reform law provide tax
credits to small businesses that offer
coverage to their employees?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

18. Q8: Will the health reform law provide tax credits to small
businesses that offer coverage to their employees?
Yes. Beginning in 2010, businesses with fewer than
25 full time equivalent employees and average
annual wages of less than $50,000 that pay at
least half of the cost of health insurance for their
employees are eligible for a tax credit.
http://www.kff.org/healthreform/upload/8148.pdf

19. Q9: Will the health reform law create a new
government run insurance plan to be
offered along with private plans?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

20. Q9: Will the health reform law create a new government run
insurance plan to be offered along with private plans?
No. The law does not create a new government-run
health insurance plan. The existing Medicaid
program will be expanded to cover more low-
income people, government regulation of the
health insurance industry will be increased, and
tax credits will be provided to make private
health insurance more affordable for people.
http://www.kff.org/healthreform/upload/8148.pdf

21. Q10: Will the health reform law allow
undocumented immigrants to receive financial
help from the government to buy health
insurance?
1. No, the law will not do
this
2. Yes, the law will do this
3. Don’t know

22. Q10: Will the health reform law allow undocumented
immigrants to receive financial help from the
government to buy health insurance?
No. Undocumented immigrants are not eligible to
receive financial help from the government to
buy health insurance, nor are they eligible for
Medicaid or to purchase insurance with their
own money in the new Exchanges.
http://www.kff.org/healthreform/upload/8148.pdf

23. Less than 1 percent of surveyed Americans* responded to all 10 questions correctly
* Nationally representative random sample of 1207 adults ages 18 and up http://www.kff.org/healthreform/upload/8148.pdf

24. Estimated changes in health
coverage after health reform Individual mandate would
require most people to
purchase coverage
MILLIONS
Establishes insurance
“exchanges” with standardized
benefits to compare and buy
plans and prohibits insurance
companies from excluding
anyone based on health status
Provides subsidies for low- to
moderate-income to purchase
insurance*
Expands Medicaid coverage to
cover some people who don’t
quality now (e.g. poor childless
adults)
Reduce number of uninsured by
* 9 million currently uninsured would be ineligible for subsidies; illegal immigrants not
eligible for subsidies or the expanded Medicaid program 32 million by 2019
Source: Adamy and Weisman WSJ October 8, 2009, http://online.wsj.com/article/SB125494356104171425.html?mod=djem_jiewr_HC

25. Health Reform: Perils, challenges, and wild cards
 Gap period < 2014 – Republican
Congress may slow down
implementation
 Payment and delivery system
pilots & demonstrations –
stakeholder concerns
 State capacity and resistance to
implement reforms – broke, mad,
and suing feds

26. Is the ACA Constitutional? Judicial scoreboard so far…
Nov. 8
FOR LAW
Court rules 2-
1 that
individual
mandate is
constitutional
FLORIDA + 25 STATES VIRGINIA
The Supreme Court is expected to issue ACA rulings by next June on 3 issues:
individual mandate, Medicaid expansion, and Anti-Injunction Act

27. Health Reform: Perils, challenges, and wild cards
 Gap period < 2014 – Republican Congress
may slow down implementation
 Payment and delivery system pilots &
demonstrations – stakeholder concerns
 State capacity and resistance to implement
reforms – broke, mad, and suing feds
 Building up primary care workforce –
coverage without access?
 Post “super-committee” failure and
possible cuts to GME, SGR “fix,” and
Medicare
 2012 elections and repealing/defunding

29. What’s Ahead for Rural Health under the ACA?
PROBLEM ACA
Rural Americans are uninsured at  Guaranteed issue and other regulation of
higher rates than urban Americans insurance companies
Rural Americans are sicker with  Prohibits lifetime limits on benefits and cost-
higher rates of chronic illness sharing for preventive services
Rural America is already  Investment in NHSC, rural physician training
experiencing a health care grants; reallocation of GME slots
workforce crisis
 Extension of many rural programs: Rural
Rural hospitals struggle financially Community Hospital Demonstration Program;
because of low reimbursement Medicare Dependent Hospital Program;
rates and low patient volume Payment Adjustment for Low-volume
hospitals; Medicare Rural Hospital Flexibility
Program; unclear if ACO demos will help/hurt
Q: WILL THE MONEY BE THERE ?????

30. What do Americans want? This?

31. Unlike citizens in many
other industrialized
countries, Americans
mistrust a strong
centralized authority
like the federal
government,
preferring pluralism
and individual rights

32. Or This?
AP Photo http://www.politico.com/news/stories/0910/42588.html

33. Questions?