An introduction to USA's health reform, with a overview for the provisions and schedule.

1. BARACK OBAMA AND JOE BIDEN’S
PLAN TO LOWER HEALTH CARE COSTS
AND ENSURE AFFORDABLE,
ACCESSIBLE HEALTH COVERAGE FOR
ALL
電子病 期末報告歷
描述美國全民健保法
條與未來實施狀況
P97843012 魏文一
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2. (1) INVEST IN ELECTRONIC HEALTH INFORMATION
TECHNOLOGY SYSTEMS.
(2) IMPROVE ACCESS TO PREVENTION AND
PROVEN DISEASE MANAGEMENT PROGRAMS.
(3) LOWER COSTS BY TAKING ON ANTICOMPETITIVE
ACTIONS IN THE DRUG AND INSURANCE
COMPANIES.
(4) REDUCE COSTS OF CATASTROPHIC ILLNESSES
FOR EMPLOYERS AND THEIR EMPLOYEES.
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3. (1) GUARANTEED ELIGIBILITY.
(2) NEW AFFORDABLE, ACCESSIBLE HEALTH
INSURANCE OPTIONS.
(3) TAX CREDITS FOR FAMILIES AND SMALL
BUSINESSES.
(4) EMPLOYER CONTRIBUTION.
(5) REQUIRE COVERAGE OF CHILDREN.
(6) EXPANSION OF MEDICAID AND SCHIP.
(7) FLEXIBILITY FOR STATE PLANS.
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4. (1) EMPLOYERS.
(2) SCHOOL SYSTEMS.
(3) WORKFORCE.
(4) INDIVIDUALS AND
FAMILIES.
(5) FEDERAL, STATE,
AND LOCAL
GOVERNMENTS.
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5. 描述美國全民健保法條
與未來實施狀況
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6. 美國醫療現況
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7. 美國醫療系統三大特色
• 全世界醫療費用最貴的國家
(GDP 16.3%(2.2trillion, $7,421 per
person) in 2007)
• 唯一沒有全民健保的已開發國家
( 無保險人數達總人口 15%)
• 醫療市場資本化，藥價由保險公司與藥廠
協商
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8. 現有醫療保險體系
（ 7 成私人、 3 成公立）
• 聯邦政府
• 州政府
• 私人保險（ 9 成雇主、 1 成私人購買）
• 無保險者：地區安全網
（ local safety net ）
收費依個人收入而定
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9. 主管機關 -DHHS
• 食品藥品監督管理局（ FDA ）
• 疾病控制及預防中心（ CDC ）
• 健康照護與品質研究機構（ AHRQ ）
• 國家衛生研究院（ NIH ）
• 醫療保險及醫療計畫補助中心（ CMS ）
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10. 聯邦政府
• 老人（ 65 歲以上）健康保險制度
（ MediCare ）
– Part A 住院保險
• 可免費享有
– Part B 門診保險
– Part C 額外保險
– Part D 藥費保險 (2006 年實施 )
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11. 州政府
• 低收入戶健康保險制度（ MedicAid ）
• 兒童（ 14 歲以下）醫療保險制度
（ SCHIP ）
• 北方福利較南方好
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12. 私人保險
（ 9 成雇主、 1 成私人購買）
• 管理式照護 (managed care)
1973 HMO act
– 健康維護組織（ HMO ）
• 主動管理，保費較低
• PCP 家庭醫師制度（ Primary care physician ）
– 優先醫療機構計畫（ PPO ）
• 特約制、自付費用低
– 獨立醫療執業組織（ IPA ）
• 醫療儲蓄帳戶（ health saving account ）
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13. 無保險者：地區安全網
（ local safety net ）
• 收費依個人收入而定
• 社區健康中心
• 公立醫院
• 社區醫院
• 慈善門診
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14. 衛生及公共服務部（ DHHS ）
• 食品藥品監督管理局（ FDA ）
• 醫療保險及醫療計畫補助中心（ CMS ）
• 國家衛生研究院（ NIH ）
• 健康照護與品質研究機構（ AHRQ ）
• 疾病控制及預防中心（ CDC ）
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15. 公共衛生概況
• 平均餘命（ 2008 ）
– 男： 78.14 歲
– 女： 83.13 歲
• 成人慢性病盛行（ 20 年變化）
– 肥胖與體重過重（ 22% to 32% ）
– 糖尿病 ( 成長 20%)
– 高血壓 ( 成長 7%)
• 死亡
– 心臟病與惡性腫瘤佔 50%
– 黑人死亡率 > 白人死亡率
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16. 美國民 費用支付習慣眾
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17. 各年齡層就醫次數
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18. 為何執行 Health Reform?
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19. 美國醫療三大問題
• 醫療費用昂貴
• 無醫藥保險比例過高
• 低效率，高管理費
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20. 經濟危機
• 2018 年時總醫療費用可能佔 GDP 的 20.3%
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21. MediCare 與 MedicAid 的支出龐
大
• Medicaid 佔州預算 32%
• Medicare 較不顯著
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22. 美國無保險人口
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23. OBAMA 的全民健保
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24. HEARA: The Healt hcare and
Educat ion Af f ordabilit y
Reconciliat ion Act of 2010
• contained tax and budget related changes
to the PPACA
• passed through reconciliation process
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25. • Health insurance market reform
• Health insurance market exchanges
• MEDICAID and CHIP
• Medicare
• Workforce and other provisions
PPACA: Pat ient Prot ect and
Af f ordable Care Act (1)
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26. • Health insurance market reform ： (1)
– High-Risk Health Insurance Pool Program
– Health insurance for young adults
– Pre-existing medical conditions
– Lifetime and annual limits on benefits
– Community living assistance services and
support program (CLASS act)
PPACA: Pat ient Prot ect and
Af f ordable Care Act (2)
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27. • Health insurance market reform: (2)
– Individual responsibility
– Employer responsibility
– Excise tax on health insurers
PPACA: Pat ient Prot ect and
Af f ordable Care Act (3)
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28. • Health insurance market exchanges:
– Health insurance exchanges
– Premium assistance credits, caps on out-of-
pocket costs for health plans
– Health care choice compacts
PPACA: Pat ient Prot ect and
Af f ordable Care Act (4)
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29. • MEDICAID and CHIP:
– Medicaid expansion
– CHIP
– Medicaid medical home pilot
– Medicaid emergency psychiatric
demonstration
– Medicaid community-based services
– Medicaid accountable care organization pilot
program
PPACA: Pat ient Prot ect and
Af f ordable Care Act (5)
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30. PPACA: Pat ient Prot ect and
Af f ordable Care Act (6)
• Medicare:
– Specialized Medicare advantage plans for
special needs individuals
– Medicare Part D
– Medicare medical home pilot program
– Medicare accountable care organization
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31. PPACA: Pat ient Prot ect and
Af f ordable Care Act (7)
• Workforce and other provisions: (1)
– Co-location of primary and specialty care in
community-based behavioral health settings
– National health service corps
– Training for behavioral health professionals
– Loan repayment for pediatric behavioral
health specialists in underserved areas
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32. PPACA: Pat ient Prot ect and
Af f ordable Care Act (8)
• Workforce and other provisions: (2)
– Educating primary care providers about
behavioral health
– Community transformation grants
– Community health workforce grants
– National health care workforce commission
– Federal definition of community mental health
centers
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33. The Promise
• All Americans guaranteed affordable,
high quality healthcare
• The freedom to choose whatever doctor
or health plan you want
• all that a savings of some $2,500 per
family
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34. Feat ures
• individual mandate
• sufficient coverage
• elimination of
underwriting
• tax equity, subsidy
(indiv vs group)
• public plan to
compete
• emphasis on
prevention and
wellness
• elimination of waste
• electronic data
keeping
• comparative
effectiveness
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35. I mpact on st akeholders-1
• Employer
– Eliminate and reduce the favored tax of healthcare
expense ($194.2B a year)
– less control over plan designs offered to employees
• Carriers
– Competition from ''public plan''
– inability to underwrite
– increased regulation
– shift to individual policies
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36. I mpact on st akeholders-2
• TPAs (Third party administration)
– potential loss of FSA( 財務監管局 )/HRA(Health
reimbursement account) admin
– potential gain of FSA substitution
– shift from groups to individuals
• Broker and agents
– Competition from connectors
– shift to individual market
– relief from underwriting
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37. I mpact on st akeholders-3
• individuals
– requirement to purchase insurance
– Tax credits and subsidy
– Reduced the tax advantage of HSAs, FSAs and
itemized deduction of medical expense
– New ''sin taxes'' on products such as alcohol and
sugary soft drinks
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38. I mpact on st akeholders-4
• providers
– Reduced Medicare spending on home healthcare,
durable medical equipment, medical imaging and
prescription drugs
– increased demand for services, especially primary
care
– 5% bonus payment for office visits and other ''primary
care services''
– Medicare
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39. Medicare policies
• increase payments to doctors who
regularly exceed ''national benchmarks''
for the quality of care
• Bonuses to hospitals that provide superior
care for heart attack, pneumonia and
selected other conditions
• Doctors could receive extra payments if
they hire nurses to manage follow-up care
for chronic cases
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40. Medicare policies
• Government set national standards for
the appropriate use of CT scans, MRI and
other diagnostic imaging techniques
• Make single bundled payment for all
services provided to a hospital patient.
(Bad for nursing homes, home care,
hospice, etc.)
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41. I mpact on st akeholders-5
• Pharmaceuticals
– Reduce government spending on prescription
drugs
– Re-importation of drugs from other countries
to lower costs
– Shift insurance coverage toward prevention,
could increase sales for heart, diabetes and
other drugs that patients take long-term
– Increased Rx spend by $15~$18B
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42. I mpact on st akeholders-6
• Wellness
– Tax credits or other subsidies it employers
who offer wellness programs that meet
federal criteria
– Make it easier for employers to use financial
rewards or penalties to promote healthy
behavior among employees
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43. I mpact on st akeholders-7
• Health IT providers
– $20B in Stimulus money
– Electronic Health Records
• Marketing communications
– Need to communicate new programs
• Benefits attorneys
– Need to interpret new regulations
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44. 期待
• additional information and guidance from the
DHHS, Congress, IRS, insurance industry
• Repeal and replace
• Reduce costs
• Will employers eliminate coverage when the
Exchanges are implemented?
• What happens in 2018 when the Cadillac Tax
become effective?
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45. 未來實施時程規劃
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46. Early implement at ion
• Small business tax credits
• Temporary retiree medical reinsurance pool to
help employers lower costs for early retirees
(2010~2014)
• insurance market reforms
• 10% excise tax on indoor tanning services
(July1)
• Health & Human Services (HHS) to develop
informational website portal (July1)
• Relief begins for retirees in the Medicare Part D
coverage gap ''donut hole''
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47. Six mont hs af t er enact ment
• eliminate lifetime limits and annual limit restrictions
• eliminate pre-existing condition limitations for children
• expand dependent coverage
• cover preventive care
• require nondiscrimination testing
• New coverage appeals processes
• emergency services must be covered as in-network
services
• designate any in-network doctor as a primary care
physician
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48. 2011
• spending account restrictions
• new W-2 reporting requirements
• CLASS Act (Community Living Assistance
Services and Supports Act)
• Uniform standards developed by HHS for
communicating benefit provisions
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49. 2012 & 2013
• implement uniform standards for communicating benefit
information with $1000 fine for each failure
• Salary reduction to FSAs are limited to $2,500, with annual
index (2013)
• Employers must notify employees plan benefits and Exchanges
• Annual comparative effectiveness research fee of $2 per
member assessed on fully insured plans
• Individuals with earnings greater than $200,000 and households
with earnings greater than $250,000 subject to additional taxes
• eliminate the tax reduction for employers who receive
Medicare D retiree drug subsidy payments
• New taxes on the industry providers and manufactures
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50. 2014
• Requires U.S. citizens and legal residents to have insurance or
pay penalty
• State based Exchanges established for individuals and small
groups to purchase coverage with required benefit plans being
offered
• Employers with 50+ employees are required to coverage or pay
a penalty
• minimum essential benefits must be offered to individuals and
small groups outside the exchange- Grandfathered and large
employers plans are exempt
• Premium and cost sharing credits for low-income individuals
(up to 400% of FPL)
• Employers with 200+ employees must automatically enroll
employees (out-put)
• Maximum waiting period limited to 90 days 50

51. Beyond 2014
• Insurance industry taxes begin which
impact fully insured plans
• eliminate pre-existing condition
limitations and annual limits
• Cadillac Tax becomes effective in 2018
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52. 待釐清問題
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55. Thank youThank you
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