1. HEALTH CARE REFORM 101
22 May 2012

2. WHAT IS THE ACA?
 The Patient Protection and Affordable Care Act (ACA) was signed into law
in March of 2010
 A governmental policy that changes the delivery of health care services in
a given place
 Major Changes:
 All Americans must have health insurance by 2014
 More emphasis on community-based services and less reliance on
institutional care
 Disease prevention and wellness are major themes

3. REFORMS IN THE ACA ATTEMPT TO:
 Broaden the population that receives health care coverage through
employment, or public sector insurance companies (e.g. DPW)
 Increase the number of health care providers people may choose from
 Improve the referral process and the right to be seen by a specialist
 Mandate health insurance by reducing the cost and making it affordable
for everyone

4. A NEW VOCABULARY
 Accountable care organization
(ACO)
 Basic health programs
 Carve-out
 Centers for Medicare and
Medicaid Services
 Community health centers
 Federally Qualified Health Center
 Electronic Health Record (EHR)
 Health care homes
 Health information technology
(HIT)
 Health information privacy and
security
 Health Insurance Portability and
Accountability Act (HIPAA)
 Home and Community-Based
Services
 Information transparency
 Meaningful User
 Medicaid
 Medical home
 Patient Protection and Affordable
Care Act

5. KEY COMPONENTS
Insurance Reform (Jan 2014)
Coverage Reform (Sept 2010)
Quality Reform (Jan 2011 – Dec 2013)
Payment Reform (Mar 2010 – Mar 2020)
HIT Reform (Jan 2011 – Dec 2013)

6. INSURANCE REFORM
Core feature of the ACA
Includes:
 Individual Mandate provision
 Expanding Medicaid eligibility
 Establishing Health Insurance Exchanges
 Establishing the Essential Health Benefits package
 Providing tax incentives to purchase insurance
An estimated 32 million individuals will become
insured by 2019

7. INDIVIDUAL MANDATE
Most controversial provision of the ACA
Requires individuals to obtain health insurance or
pay a penalty
Penalties increase each year
 Exemptions include:
 Religious
 Incarceration
 Undocumented status

8. MEDICAID EXPANSION
Individuals and families with incomes up to 133% of
the Federal Poverty Level (FPL) will be eligible
 Appx. $14,850 for an individual
 Appx. $30,650 for a family of four
Expected to enroll 11.6 million people in 2014

9. HEALTH INSURANCE EXCHANGE
States must establish by January 2014 or default to the
Federal government
Several requirements:
 User Friendly
 Must screen and enroll public & private coverage
 Must establish “navigators”
 Transparency
 Self-financing by 2015

11. ESSENTIAL HEALTH BENEFITS
WHAT IS ESSENTIAL?
Ambulatory patient
services
 Emergency services
Hospitalization
 Maternity and
newborn care
 Mental health and
substance use disorder
services, including
behavioral health
treatment
Rehabilitative and
habilitative services and
devices
Laboratory services
Preventive and wellness
services and chronic
disease management
Pediatric services,
including oral and vision
care
Prescription drugs

12. COVERAGE REFORM
Many provisions are already in effect:
 Pre-Existing Condition Coverage to age 19
 Family Coverage to age 26
 No Annual or Lifetime Limits
 Closing the Medicare Donut Hole
 No co-pays/deductibles for prevention/ promotion
interventions
 Medical loss ratios now at 85 and 80 %

13. QUALITY REFORM
Patient Centered Medical
Homes (PCMH) and Health
Homes
Accountable Care
Organizations
Establishment of National
Quality Measures

14. ACCOUNTABLE CARE ORGANIZATIONS
(ACO)
 Providers collectively take responsibility
for the quality and costs of
treatment
 If providers can reduce costs while
providing high quality care they receive
a share of the cost savings
 Can be operated by health systems,
health plans, hospitals, large physician
practices or other medical service
organizations
 Population health approach = not just
taking care of the sick but keeping
people healthy

15. PAYMENT REFORM
Payment reform involves moving whole
sectors of the health care field from encounter
payment systems to case and capitation
systems
Lead work in this area will be done by the
Center for Medicare & Medicaid Innovation:
 Medicare ACO Pioneer project
 CMMI Innovation Challenge
 Medicaid Emergency Psychiatric Demonstration
This is a 10 year undertaking

16. HEALTH INFORMATION TECHNOLOGY
REFORM
HIT is the use of computers as a means of exchanging
medical information from doctor to doctor, or provider to
provider
Currently, behavioral healthcare is not receiving financial
incentives to implement needed EHRs for the field
The Behavioral Health Information Technology Act of 2011,
S.B.39, is currently in Congress
 Would expand Federal incentives to implement HIT in
physical health care to behavioral health care

17. HEALTH EQUITY PROVISIONS
§10334: Elevates
Office of Minority Health
(OMH) to HHS and
requires six HHS
agencies to establish
offices of minority health
§4302: Mandates
federal health care
programs to collect and
report data on sex, race,
ethnicity, language and
disability status
§5306: Behavioral
health workforce
development grants
§5313: Community
health workforce grants
to promote culturally and
linguistically appropriate
services
§3509: Establishes an
Office of Women’s Health

18. CONSTITUTIONAL CHALLENGES
Kaiser Family Foundation. Available at: http://www.kaiserhealthnews.org/Supreme-Court-DecidesHealth-Law.aspx

19. ACA BENEFITS TO PENNSYLVANIANS
Insurance Reform
 7.7 million residents are without lifetime limits on coverage
 32,100 young adults received coverage through parent’s plans
 657,000 children can not be denied coverage due to preexisting conditions
Medicare Provisions
 2.3 million Medicare beneficiaries receiving primary care services with no
copay
 Currently, Medicare beneficiaries receiving 50% discount on brand name
drugs in donut hole
 By 2020 donut hole will be closed

20. ADVOCACY OPPORTUNITIES
 Essential Health Benefits inclusion of behavioral health services
 HHS has given States the discretion to craft the EHB Package
 While Mental Health/Substance Use is defined as an essential health
benefit, state determines at what level
 Health Insurance Exchange Design & Implementation
 Transparency & Governance
 Use of Navigators
 Other State Legislation
 S.B. 10: Amending the PA Constitution
 Maintenance of Effort (MOE) Waiver Request

21. QUESTIONS?