H al e t al h P oli ol c i y c ve ve s r u s s H al e t al h Poli ol t i ic i s The e A ff f or or able l e Care ar H a e lth Po P licy c : y

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1 Health Policy versus Health Politics The ffordable Care ct: It s Impact on Women s Health Care Michael S Policar, MD, MPH policarm@obgyn.ucsf.edu Health Policy: What policies, structures, and financing lead to optimal clinical and economic health outcomes The Clinton Health Care Plan Health Politics: What is possible, who wins, and who loses The Obama Health Care Plan Why Health Reform Now? ccess is worsening 46 million mericans lack health insurance 38 million 10 years ago Health outcomes are inferior US: 31 st life expectancy, 37 th infant mortality Costs continue to escalate 1993: $1 trillion, 2012: $3 trillion National spending/ person»1960:$1, : $7, : $13,100 1

2 Why Health Reform Now: Cost of Care arak Obama, March 2009 The greatest threat to merica s health is not Social Security. It s not the investments we ve made to rescue the economy during this crisis y a wide margin, the biggest threat to our nation s balance sheet is the skyrocketing cost of healthcare.it s not even close Patient Protection and ffordable Care ct (C) March 23, 2010 First step: Second step: Third step: Patient Protection and ffordable Care ct Expand access to health insurance Everyone has Fairer insurance practices Expand to 32 million by 2019 Improve quality of care Change the practice of medicine Stabilize cost of health care Reduce waste and fraud Improve efficiency The C is just the beginning of health reform Patient Protection and ffordable Care ct (C) ccess: Three Part Formula Insurers must offer to everyone Subsidies to help people to afford Everyone must have health insurance roadens risk pool to healthy + less healthy makes premiums more affordable Only way to cover those with pre-existing existing conditions 2

3 The Individual Mandate ll citizens, legal immigrants must have Tax penalty if no (phased in by 2016) Exemptions granted for Undocumented persons No for less than 3 months Lowest cost plan > 8% personal income Financial hardship Religious objection Insurers Must Offer Coverage to Everyone What changes will occur to those currently covered by insurance and to the uninsured? How will the C be phased in? What impact will the C have on Women s health care? Reproductive health care providers? Little or no change Military Veterans dmin Minor changes Medicare Major changes Uninsured Insured through employer Medicaid Self employed Undocumented individuals Small business Major Changes 5 0 % Medicaid Uninsured Self employed Small business (50-100) 5 0 % % State Health Insurance Exchanges California Health enefit Exchange?? Employer based Small usiness Health Options Program 3

4 What re State Health Insurance Exchanges? Health Insurance Exchanges State regulated insurance marketplaces Consumers will compare plans by quality and cost ll will offer the same essential benefits Optional participation by health insurance plans Subsidies for families % FPL ($88K family of 4) Premium credit (toward purchase of insurance), and Cost-sharing sharing credit (rebate on OOP costs) Limited to citizens, legal immigrants Level Platinum 90% Gold 80% Silver 70% Plan covers ronze 60% Catastrophic < 30 years old Premiums are higher at each level Subsidy based on average Silver plan cost Out of pocket max= Health Savings ccount limit $6,000 individual $11,900 family Lower limits if subsidized When will these changes occur? Coverage on parents plan until age million newly covered in 2011 No limitation of lifetime benefits Insurance cannot be revoked during episode of illness unless fraud proven No limitation of annual benefits PCIPs for uninsurables (until 2014) 29 state plans; 21 use federal plan Specified preventive services covered without deductible or co-payment Help with drug benefit for seniors Collins SR, Commonwealth Fund, 2010 Collins SR, Commonwealth Fund,

5 Full of uninsured citizens Expand Medicaid eligibility 8.2 million women < age 65 State insurance exchanges 7 million women < age 65 Minimum essential benefit package defined for all plans sold in exchanges Insurance Market Reforms Individual and Small Group Problem Example Solution When Recission If costly disease, insurance revoked retroactively Prohibited 9/2010 ll citizens must have health insurance or pay a fine Collins SR, Commonwealth Fund, 2010 Insurance Market Reforms Individual and Small Group Problem Example Solution When Recission Gender rating If costly disease, insurance revoked retroactively Women charged more than men for the same Prohibited 9/2010 Prohibited 1/2014 Insurance Market Reforms Individual and Small Group Problem Example Solution When Recission Gender rating Exclusion of pregnancy If costly disease, insurance revoked retroactively Women charged more than men for the same Only 13% of individual plans now include pregnancy Prohibited 9/2010 Prohibited 1/2014 Guaranteed maternity 1/2014 5

6 Insurance Market Reforms Individual and Small Group Problem Example Solution When Recission Gender rating Exclusion of pregnancy Pre-existing condition exclusions If costly disease, insurance revoked retroactively Women charged more than men for the same Only 13% of individual plans now include pregnancy 38% women denied Prior pregnancy Prior caesarean section Domestic violence Prohibited 9/2010 Prohibited 1/2014 Guaranteed maternity 1/2014 Prohibited 1/2014 The Impact of the C on Women s Health Care Providers Direct access to Ob-Gyns No referrals or pre-authorizations permitted No restriction on number of visits or types of services Increased support for CNMs: increased payment (65% 100% of MDs) Free standing birth centers (Medicaid) Tobacco cessation in pregnancy (Medicaid) Maternal Infant HomeVisiting Program The Impact of the C on Women s Health Care Preventive services bortion services Family Planning services Specified preventive services must be covered with no cost-sharing sharing (no out-of-pocket cost to patient) pplies to private and public programs (New) Private insurance policies 2010 Medicare, Medicaid 2011 State insurance exchanges 2014 Improves for preventive services in many individual and small group plans 6

7 Required Preventive Services Preventive services include all services categorized by USPSTF with a grade [] or [] recommendation Young women singled out for breast cancer screening research and provider and consumer education IOM will recommend to HRS additional women s prevention benefits; regulations due 8/11 The battle to include contraception has started!!! Pro: contraception is preventive by nature Con: Pregnancy is not a disease to be prevented Topic lood pressure screening Cervical cancer screening Cholesterol screening: women 45 and older Colorectal cancer screening Folate supplementation Healthy diet counseling HIV screening Tobacco use counseling and interventions Syphilis screening: non-pregnant persons Grade Required Preventive Services Federal Medicaid Funding of bortion Topic RC screening (counseling) reast cancer preventive medication reast cancer screening Chlamydial infection screening Depression screening: adolescents, adults Diabetes screening Gonorrhea screening Obesity screening and counseling: adults Osteoporosis screening: women STI counseling Grade 1973: Hyde mendment: no federal funding for abortion, unless the pregnancy is the result of rape or incest or would, as certified by a physician, place the woman in danger of death unless an abortion is performed Currently 17 states cover all or most medically necessary abortions under Medicaid 33 states provide no or minimal Medicaid of abortion beyond federal requirements 7

8 The Impact of the C on Elective bortion The Impact of the C on Elective bortion The Stupak-Obama Compromise Presidential Executive Order (3/24/10) enforcing Hyde pplies to exchanges, Medicaid, PCIPs, Community Health Center Fund No federal subsidies may be used to purchase for abortion beyond Hyde In state health insurance exchanges (starting in 2014) t least 1 plan that covers + 1 does not cover abortion No plans can be required to offer abortion State laws may ban abortion in exchange Plans in exchange that cover abortion Must notify enrollees of abortion benefit Must pay with separate check for abortion bortion premiums and pay-outs are kept in separate account, apart from taxpayer money No plan can discriminate against a provider or facility because of unwillingness to provide abortion services Does not apply to health plan products that have no members with federal support The Impact of the C on Elective bortion Extends the Hyde mendment to middle class individuals using state health insurance exchanges Sends the message that abortion is not health care Further institutionalizes the moral view of some members of Congress Unlikely that many women will write the separate check will not have when they need it So What Is SP?? Family Planning State Plan mendment authorized in Section 2303 of the C ased upon success of federal 1115 waivers in 27 states Contraceptive and FP-related services available to persons not eligible for Medicaid Optional for states to choose SP (or not); may convert existing 1115 Waiver to SP (or not) Programs operate side-by-side with Title X grants CMS released guidance (7/10) but not final regulations 8

9 Family PCT services averted 205,000* pregnancies that would have led to verted Pregnancy Outcomes 94,000 79,000 CY ,000 2,000 *due to the provision of contraceptive services to females only Unintended births bortions Miscarriages Ectopic Pregnancies The Family PCT Program is Cost-Saving Time Frame (CY 2002) Total Costs verted C/ Ratio 2 yrs following birth $1.1 billion $ yrs following birth $2.2 billion $5.33 Time Frame (CY 2007) Total Costs verted C/ Ratio 2 yrs following birth $1.9 billion $ yrs following birth $4.1 billion $9.25 Health Care Reform: Who Won? Who Lost? Criticisms of the C The Winners Most of the uninsured Women insured by indiv and small group plans Women s health services Children under 26 yrs old Primary care providers CNMs, NPs, Ps Insurance companies Pharma companies The Losers Undocumented persons Women needing abortions Most specialists Medicare recipients Too much government Too much taxpayer money (for subsidies, Medicaid) Too much focus on the uninsured The C changed the health insurance industry but not the inefficient manner in which care is delivered It hasn t addressed the hard stuff Health care quality and outcomes Health care costs 9

10 ending the Cost Curve: Issues Not ddressed Yet Reducing patient demand for unnecessary services Financial incentives in fee-for-service practice Inefficiencies in end-of-life care Duplication, inefficiency and waste Insurance fraud Restrictions on health policy and payment based on comparative outcomes research Health Reform Report Card Subject Grade ccess - Outcomes C Cost Control Incomplete n exercise of the possible with health insurance to get a start on comprehensive health reform The Cs ultimate success (or abject failure) will be dependent upon the final grade in cost control Concluding Thoughts Health reform will be a major issue in our lifetimes Tension: demand for care and ability to pay for it Poor health status not correctable by better care alone e open in your thinking Rejectionist No way!!! Pessimist etter than no change, but the C makes a broken system available to more people Optimist ased on the reality of health politics, covering >95% of mericans is a good first step 10