Health Reform under The Patient Protection and Affordable Care Act

What Does it Mean for Rural Health?

Carolyn L. Engelhard, MPA Director, Health Policy Program

Department of Public Health Sciences, UVASOM

December 7, 2011

Health Reform

An overview of the impact of the Patient Protection and Affordable Care

Act (PPACA) in the United States, signed into law March 23, 2010

Q1: Will the health reform law require nearly all Americans to have health insurance by 2014 of else pay a fine?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q1: Will the health reform law require nearly all Americans to have health insurance by 2014 of else pay a fine?

Yes. Starting in 2014, most U.S. citizens and legal residents will be required to obtain health coverage or pay a penalty. Some exemptions will be granted, for example, for those with religious objections of where insurance would cost more than 8% of their income.

http://www.kff.org/healthreform/upload/8148.pdf

Q2: Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q2: Will the health reform law allow a government panel to make decisions about end-of-life care for people on Medicare?

No. No such panels exist. While early versions of the law did contain provisions that would allow Medicare to reimburse physicians for voluntary discussion with patient about end-of-life planning, these provisions were dropped from the final legislation.

http://www.kff.org/healthreform/upload/8148.pdf

Q3: Will the health reform law cut benefits that were previously provided to all people on Medicare?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q3: Will the health reform law cut benefits that were previously provided to all people on Medicare?

No. The law reduces payments to the privately administered Medicare Advantage plans, but they will still be required to provide all benefits that are covered by traditional Medicare.

http://www.kff.org/healthreform/upload/8148.pdf

Q4: Will the health reform law expand the existing Medicaid program to cover low-income, uninsured adults regardless of whether they have children?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q4: Will the health reform law expand the existing Medicaid program to cover low-income, uninsured adults regardless of whether they have children?

Yes. Medicaid will be expanded to cover nearly all individuals under age 65 with incomes up to 133% of the federal poverty level ($14,484 for an individual or $29,726 for a family of four in 2011).

http://www.kff.org/healthreform/upload/8148.pdf

Q5: Will the health reform law provide financial help to low and moderate income Americans who don’t get insurance through their jobs to help them purchase coverage?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q5: Will the health reform law provide financial help to low and moderate income Americans who don’t get insurance through their jobs to help them purchase coverage?

Yes. Individuals without access to affordable coverage who purchase coverage through the new insurance Exchanges and have incomes up to 400% of the federal poverty level will be eligible for premium tax credits based on their income.

http://www.kff.org/healthreform/upload/8148.pdf

Q6: Will the health reform law prohibit insurance companies from denying coverage because of a person’s medical history or health condition?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q6: Will the health reform law prohibit insurance companies from denying coverage because of a person’s medical history or health condition?

Yes. Starting in 2014, all health insurers will be required to sell coverage to everyone who applies, regardless of their medical history or health status.

http://www.kff.org/healthreform/upload/8148.pdf

Q7: Will the health reform law require all businesses, even the smallest ones, to provide health insurance for their employees?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q7: Will the health reform law require all businesses, even the smallest ones, to provide health insurance for their employees?

No. The law does not require employers to provide health benefits. However, it does impose penalties. In some cases, on larger employers (those with 50 or more workers) that do not provide insurance to their workers or that provide coverage that is unaffordable.

http://www.kff.org/healthreform/upload/8148.pdf

Q8: Will the health reform law provide tax credits to small businesses that offer coverage to their employees?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q8: Will the health reform law provide tax credits to small businesses that offer coverage to their employees?

Yes. Beginning in 2010, businesses with fewer than 25 full time equivalent employees and average annual wages of less than $50,000 that pay at least half of the cost of health insurance for their employees are eligible for a tax credit.

http://www.kff.org/healthreform/upload/8148.pdf

Q9: Will the health reform law create a new government run insurance plan to be offered along with private plans?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q9: Will the health reform law create a new government run insurance plan to be offered along with private plans?

No. The law does not create a new government-run health insurance plan. The existing Medicaid program will be expanded to cover more low-income people, government regulation of the health insurance industry will be increased, and tax credits will be provided to make private health insurance more affordable for people.

http://www.kff.org/healthreform/upload/8148.pdf

Q10: Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance?

1. No, the law will not do this

2. Yes, the law will do this

3. Don’t know

Q10: Will the health reform law allow undocumented immigrants to receive financial help from the government to buy health insurance?

No. Undocumented immigrants are not eligible to receive financial help from the government to buy health insurance, nor are they eligible for Medicaid or to purchase insurance with their own money in the new Exchanges.

http://www.kff.org/healthreform/upload/8148.pdf

http://www.kff.org/healthreform/upload/8148.pdf

Less than 1 percent of surveyed Americans* responded to all 10 questions correctly

* Nationally representative random sample of 1207 adults ages 18 and up

Source: Adamy and Weisman WSJ October 8, 2009, http://online.wsj.com/article/SB125494356104171425.html?mod=djem_jiewr_HC

Individual mandate would require most people to purchase coverage

Establishes insurance “exchanges” with standardized benefits to compare and buy plans and prohibits insurance companies from excluding anyone based on health status

Provides subsidies for low- to moderate-income to purchase insurance*

Expands Medicaid coverage to cover some people who don’t quality now (e.g. poor childless adults)

Reduce number of uninsured by 32 million by 2019 * 9 million currently uninsured would be ineligible for subsidies; illegal immigrants not

eligible for subsidies or the expanded Medicaid program

Estimated changes in health coverage after health reform

MILLIONS

Health Reform: Perils, challenges, and wild cards

Gap period < 2014 – Republican Congress may slow down implementation

Payment and delivery system pilots & demonstrations – stakeholder concerns

State capacity and resistance to implement reforms – broke, mad, and suing feds

Is the ACA Constitutional? Judicial scoreboard so far…

The Supreme Court is expected to issue ACA rulings by next June on 3 issues: individual mandate, Medicaid expansion, and Anti-Injunction Act

FLORIDA + 25 STATES VIRGINIA

Nov. 8

FOR LAW

Court rules 2-1 that

individual mandate is

constitutional

Health Reform: Perils, challenges, and wild cards

Gap period < 2014 – Republican Congress may slow down implementation

Payment and delivery system pilots & demonstrations – stakeholder concerns

State capacity and resistance to implement reforms – broke, mad, and suing feds

Building up primary care workforce –coverage without access?

Post “super-committee” failure and possible cuts to GME, SGR “fix,” and Medicare

2012 elections and repealing/defunding

What’s Ahead for Rural Health under the ACA?

PROBLEM

Rural Americans are uninsured at higher rates than urban Americans

Rural Americans are sicker with higher rates of chronic illness

Rural America is already experiencing a health care workforce crisis

Rural hospitals struggle financially because of low reimbursement rates and low patient volume

ACA

Guaranteed issue and other regulation of insurance companies

Prohibits lifetime limits on benefits and cost-sharing for preventive services

Investment in NHSC, rural physician training grants; reallocation of GME slots

Extension of many rural programs: Rural Community Hospital Demonstration Program; Medicare Dependent Hospital Program; Payment Adjustment for Low-volume hospitals; Medicare Rural Hospital Flexibility Program; unclear if ACO demos will help/hurt

Q: WILL THE MONEY BE THERE ?????

What do Americans want? This?

Unlike citizens in many

other industrialized

countries, Americans

mistrust a strong

centralized authority

like the federal

government,

preferring pluralism

and individual rights

AP Photo http://www.politico.com/news/stories/0910/42588.html

Or This?

Questions?