The Council of State Governments Policy Webinar June 21st 2012

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2 The Council of State Governments Policy Webinar June 21st 2012

3 A little bit about us.

4 Medicaid Intelligence Ongoing surveillance and reporting of state Medicaid activity Comprehensive profiles of individual state market and regulatory dynamics: o o o Delivery system Pharmacy Budget and expenditures Assessments and assertive predictions on state Medicaid reform, e.g waivers Development of strategies to assist states respond PPACA implementation, including Medicaid expansion LEAVITT PARTNERS A health care intelligence business 2012 Leavitt Partners LeavittPartners.com

5 Insurance Exchange Intelligence In-depth analysis of state and market activity with a focus on: o o o Legislative activity Governance Exchange models Development of strategies to assist state policy makers: o Understand the implications of national rule-making o Plan and conduct stakeholder analysis o Develop planning documents Ongoing tracking of: o o Public and private exchange models Technical requirements of exchanges and capabilities of vendor community LEAVITT PARTNERS A health care intelligence business 2012 Leavitt Partners LeavittPartners.com

6 Uncertainty - not able to be relied on; not known or definite

7 TheSupremeCourt, Election and Fiscal Cliff cause an uncertain future for PPACA

8 Supreme Court

9 1) MandateOverturned 2) LawUpheld 3) Everything Else

10 June 28th.. Maybe?

11 Election 2012

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14 3 Possible Outcomes.. Democrat Gridlock

15 3 Possible Outcomes.. Democrat Gridlock Republican Gridlock

16 3 Possible Outcomes.. Democrat Gridlock Republican Gridlock Republican Sweep

17 $7.5 Trillion at stake in fiscal cliff

18 Bush Tax Cuts $3.3 Trillion Sequestration $1.2 Trillion Payroll Tax Cuts $804 Billion Alternative Minimum Tax Patch $505 Billion

19 Debt 90% Debt to GDP Recession Q1-Q Outcome $4.5-$5.5 Trillion in Cuts/Tax

20 16 Supreme Court Scenarios

21 8 Election Scenarios

22 64 Provision Scenarios

23 8,192 Unique Scenarios

24 Scenarios, Simplified.

25 About Bracketology: Health Reform Bracketology is a fun and instructive exercise that illustrates potential future scenarios in American health care. Based on a series of assumptions, each scenario paints a picture of what the future could be and then presents the implications in simple and easy to understand terms. The scenarios are developed by professional staff at Leavitt Partners, in consultation with the Leavitt Partners FuturePanel, a diverse, 14 member group of health care thought leaders. In addition, surveys are circulated among health industry thought leaders to gauge their perspective on potential outcomes through LP Health Watch. These groups are not unanimous in their opinion, demonstrating the diversity of thought surrounding the future of health reform. Scenarios depict alternative futures not necessarily desired futures and help senior executives navigate the significant uncertainty that currently exists in American health care.

26 Step 1: Choose a Supreme Court Decision Supreme Court Decision IM Upheld Remainder of Law Upheld 2012 Election Outcomes R White House Split Congress IM Overturned Remainder of Law Upheld D White House Split Congress IM Overturned Remainder of Law Overturned RWhite House R Congress Start Over 2012 Leavitt Partners, LLC HealthReformBracketology.com

27 Step 2: Choose a 2012 Election Outcome Supreme Court Decision 2012 Election Outcomes IM Upheld R White House Remainder of Law Upheld Law Upheld Split Congress IM Overturned Remainder of Law Upheld Mandate Overturned Law Upheld D White House Split Congress IM Overturned Remainder of Law Overturned Law Overturned RWhite House R Congress Back Start Over 2012 Leavitt Partners, LLC HealthReformBracketology.com

28 Step 3: Click The Future of Health Reform Supreme Court Decision 2012 Election Outcomes IM Upheld R White House Remainder of Law Upheld Law Upheld R Gridlock Split Congress IM Overturned Remainder of Law Upheld Mandate Overturned Law Upheld R Gridlock D Gridlock D White House Split Congress IM Overturned Remainder of Law Overturned Law Overturned Sweep RWhite House R Congress Back Start Over 2012 Leavitt Partners, LLC HealthReformBracketology.com

29 Scenario: Law Upheld / R Gridlock We believe that Republicans will seek to administratively disrupt and congressionally defund core provisions of PPACA, as well as seek to increase flexibility for other provisions The Breakdown by Republicans will continue to press for wholesale repeal, though some elements of the law that have already gone into effect will be preserved. Repeal will happen through reconciliation. Major provisions of PPACA will remain in force, but the Secretary will use his/her discretion to implement innovative changes in the Medicaid program that center on state flexibility (e.g., repealing the MOE, Duals initiatives, etc.). In this scenario, what tactic will Republicans use to disrupt PPACA? 70% Republicans will try to reform Medicare, likely through a Medicare exchange and increasing the eligibility age, but will be met with opposition from Democrats. IPAB will remain a target for repeal. Delivery reform will continue at the current pace with some provisions being shelved due to budgetary constraints and HHS capacity. Exchanges will be implemented as prescribed with additional administrative flexibility granted to states unable to meet the statutory deadline. The Federally Facilitated Exchange will be scaled back. 15% 10% Minor modifications will be made to select insurance reform provisions while reforms like guaranteed issue and community rating will stay in effect. Work w/ D's Admin Tactics to Slow Imp Modify Current Regs The premium subsidy will likely be reduced to 250% 300% of the FPL. Back Start Over 2012 Leavitt Partners, LLC HealthReformBracketology.com

30 Mandate Overturned High Degree of Change Medicaid Expansion Medicaid MOE Medicaid Demonstrations Premium Subsidies Exchanges Republican Sweep Payment Reform Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

31 Mandate Overturned High Degree of Change Medicaid Expansion Medicaid Expansion Medicaid MOE Medicaid Demonstrations Premium Subsidies Exchanges Republican Sweep Republican Gridlock Payment Reform Medicaid MOE Medicaid Demonstrations Premium Subsidies Exchanges Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

32 Mandate Overturned High Degree of Change Medicaid Expansion Republican Gridlock Payment Reform Medicaid MOE Medicaid Demonstrations Premium Subsidies Exchanges Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

33 Mandate Overturned High Degree of Change Medicaid Expansion Republican Gridlock Democrat Gridlock Payment Reform Medicaid Expansion Medicaid MOE Medicaid Demonstrations Exchanges Medicaid MOE Medicaid Demonstrations Premium Subsidies Exchanges Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

34 Mandate Overturned High Degree of Change Democrat Gridlock Payment Reform Medicaid Expansion Medicaid MOE Medicaid Demonstrations Exchanges Premium Subsidies Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

35 Law Upheld High Degree of Change Medicaid Expansion Medicaid MOE Medicaid Demonstrations Individual Mandate Premium Subsidies Republican Sweep Payment Reform Exchanges Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

36 Law Upheld High Degree of Change Medicaid Expansion Individual Mandate Medicaid Expansion Medicaid MOE Medicaid Demonstrations Individual Mandate Premium Subsidies Republican Sweep Republican Gridlock Payment Reform Exchanges Medicaid ExchangesMOE Medicaid Demonstrations Premium Subsidies Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

37 Law Upheld High Degree of Change Medicaid Expansion Individual Mandate Republican Gridlock Payment Reform Exchanges Medicaid MOE Medicaid Demonstrations Premium Subsidies Low Degree of Change Low Likelihood of Disruption High Likelihood of Disruption

38 Law Upheld High Degree of Change Medicaid Expansion Individual Mandate Republican Gridlock Democrat Gridlock Low Degree of Change Payment Reform Exchanges Medicaid Expansion Individual Mandate Medicaid MOE Medicaid Demonstrations Premium Subsidies Medicaid MOE Medicaid Demonstrations Premium Subsidies Low Likelihood of Disruption High Likelihood of Disruption

39 Law Upheld High Degree of Change Democrat Gridlock Low Degree of Change Payment Reform Exchanges Medicaid Expansion Individual Mandate Medicaid MOE Medicaid Demonstrations Premium Subsidies Low Likelihood of Disruption High Likelihood of Disruption

40 So what do we do? Anything. Something. So long as we just don t sit there. If we screw it up, start over. Try something else. If we wait until we ve satisfied all the uncertainties, it may be too late Lee Iacocca

41 A health care intelligence business 299 South Main, Suite 2300 Salt Lake City, Utah LeavittPartners.com