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Implementing Insurance Reforms

in 2010 and Beyond

Len M. Nichols, Ph.D. Director, Center For Health Policy Research and Ethics

Professor of Health PolicyCollege of Health And Human Services

George Mason University

Alliance for Health Reform BriefingAugust 2, 2010

Washington, DC

Two Types of Health Reform

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FederalTakeover!!!

Federal-ist, as in, Federalism

A Federal Takeover…

• Is not 2000+ pages long

• Does not give states many options

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What is Reform REALLY About?

• Signaling that “Business As Usual” is over– We can’t afford it– The system is failing more of us each year

• Changing obsolete business models– Risk Selection helping all find value– FFS pay for volume pay for value

• Insurance and delivery reforms reinforce the incentive realignment strategy at the core of this bill

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Structure Of PPACA

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Choice States Have• Comment on draft regs, pre- and post-issuance

• Operate new high risk pool, fed money

• Perform new annual premium review process with federal money/help

• Apply for and accept federal money for:– Ombudsman, TA for exchanges, Medical

Reimbursement Data Centers

• Cooperate in enforcement of pre-2014 insurance reforms (e.g., MLR)

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Actions Pursuant to Exchanges

• State must create by 3/23/2012, operational by 1/1/2014– Feds must help, with money and TA, will step in by

1/1/2013 if states do not act– States choose, if they will, non-profit or state operated

• Exchanges could also sub-state, or multi-state

• GI, GR, no pre-ex, end of high risk pools, etc., modified CR (family, geog, age, smoking)

• Certifying qualified health plans– HHS regs, State DETERMINATIONS re: benefits, actual,

performance, conduct• How are they doing re: quality, safety, reduce readmits, cost,

patient satisfaction

• Risk adjustment

States must also:

• Expand Medicaid, to 133% of poverty• Streamline enrollment applications and income

definition, use new income definition and HHS to verify income and citizenship status

• Track and account for money flows• Keep HHS informed

• States MAY:– Propose alternative ways to cover people, starting in 2017– Enter into compacts with other states for ASL– Change malpractice laws– Engage on delivery system reforms with HHS and local

employers

Final Thoughts

• Successful Health Reform is a participation sport

• PPACA is structured to engender participation and feedback loops of modifications

• What does “failure” mean?

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