Is a Healthcare Tsunami Really Here?

Cancer Center Administrators ForumHarry Holmes, Ph.D.

In Health Care, it was HR 3590

Patient Protection and Affordable Care Act 

Sponsor: Rep. Charles B. Rangel [NY-15] Cosponsors (40) 

9/17/2009 Introduced in House10/8/2009 Passed/agreed to in House: Agreed to by the yes and Nays: (2/3 required): 416 - 0 12/24/2009 Passed/agreed to in Senate: Passed Senate with an amendment and an amendment to the Title by Yea-Nay Vote. 60 - 39. 3/21/2010 Resolving differences -- House actions: On motion that the House agree to the Senate amendments Agreed to by vote: 219 – 212.

HR 3590 (cont.)

3/21/2010 Cleared for White House3/22/2010 Presented to President3/23/2010 Signed by President3/23/2010 Became Public Law No: 111-148

HR 3590 and HR 4872 when merged became the Accountable Care Act (ACA)

Health Reform Law (2) – H.R. 4872

• Health Care and Education Reconciliation Act of 2010 by Rep. John M. Spratt, Jr. [SC-5].

• Introduced 3/17/2010    Became Public Law No: 111-152 

• Made a number of health-related financing and revenue changes to the Patient Protection and Affordable Care Act (H.R.3590) and modified higher education assistance provisions

H.R. 4872 (cont.)

• Passed Senate w amendments by vote: 56 – 43,  3/25/2010

• Resolving differences --House agreed to the amendments vote: 220 – 207, 3/25/2010

• Signed by President, 3/30/10

• Together, H.R. 3590 and 4872 are called the

“Accountable Care Act” (ACA)

ACA in 2010

● Review of Health Plan Premium Increases● Changes in Medicare Provider Rates● Medicaid and CHIP Payment Advisory

Commission● Comparative Effectiveness Research● Prevention and Public Health Fund● Medicare Beneficiary Drug Rebate● Small Business Tax Credits● Medicaid Drug Rebate

HR in 2010, cont.• Coordinating Care for Dual Eligibles• Generic Biologic Drugs• New Requirements on Non-profit Hospitals• Medicaid Coverage for Childless Adults• Reinsurance Program for Retiree

Coverage• Pre-existing Condition Insurance Plan• New Prevention Council• Consumer Website• Tax on Indoor Tanning Services,

Medicaid Coverage of Smoking Cessation

HR – Year 1, cont.

• Expansion of Drug Discount Program• Adult Dependent Coverage to Age 26• Consumer Protections in Insurance• Insurance Plan Appeals Process• Coverage of Preventive Benefits• Health Centers, National Health Service

Corps• Coverage of costs of clinical trials• Health Care Workforce Commission• Medicaid Community-Based Services

HR – Year 1, cont.

• Minimum Medical Loss Ratio for Insurers• Closing the Medicare Drug Coverage Gap• Medicare Payments for Primary Care• Medicare Prevention Benefits• Center for Medicare and Medicaid

Innovation• Medicare Premiums for Higher-Income

Beneficiaries• Medicare Advantage Payment Changes• Medicaid Health Homes

HR – Year 1, cont.

• Chronic Disease Prevention in Medicaid• CLASS Program• National Quality Strategy • Changes to Tax-Free Savings Accounts• Breast Cancer Education, Research

and Prevention• Creates Cures Acceleration Network

(CAN)in NIH for translational research

Health Reform – Year OneHighlights

• March 23, 2010 - President signs reform law

• Same day, governors and attorneys general in 19 states challenge individual mandate in Florida federal court

• Virginia AG Ken Cuccinelli files his own lawsuit in Virginia.

• June 10 - "early deliverable“ for seniors: $250 Medicare prescription drug rebate checks mailed

• 4 million beneficiaries expected to receive checks to fill prescription drug "doughnut hole"

 

HR – Year 1, cont.

• June 22 - Three-month anniversary of ACA

• ACA Patient's Bill of Rights - new patient protection released

• New regulations cover annual, lifetime limits on benefits, rescissions, pre-existing conditions for children, consumers' choice of MD and access to out-of-network emergency care

•  September - New regs prohibit health plans from denying coverage to sick children

• Benefits suffer setback when plans stop issuing new children-only policies in 29 states

HR – Year 1, cont.

• October - OCIIO grants 30 temporary waivers from the law's $750,000 floor on annual benefits. It has granted more than 1,000 waivers covering 2.6 million people to date

• Nov. 2 - Democrats suffer major losses at the polls, losing 63 seats in the House and six in the Senate. Repealing healthcare reform is a key platform for Republicans.

● US Senate ● Pre-election: 60-40 Democratic Caucus

Majority (with Lieberman and Sanders)● Post-election: 57-43 Democratic Caucus

● House ● Pre-election: 257-178 Democratic

Majority● Post-election: 242-193 Republican

Majority

Election 2010

Senate Leadership - 2011

 ● Sen. Harry Reid (D-Nev.), Majority Leader● Sen. Richard Durbin (D-Ill.), Majority Whip● Sen. Mitch McConnell (R-Ky.), Minority

Leader● Sen. Jon Kyl (R-Ariz.), Minority Whip

  

Senate Cmte Leadership - 2011

Appropriations Committee• Sen. Daniel K. Inouye (D-Hawaii), Chair• Sen. Thad Cochran (R-Miss.), Ranking Appropriations Labor-HHS Subcmte• Sen. Tom Harkin (D-Iowa), Chair• Sen. Richard Shelby (R-Ala.), Ranking Committee on Health, Education, Labor and

Pensions (HELP)• Sen. Tom Harkin (D-Iowa), Chair• Sen. Michael B. Enzi (R-Wy.), Ranking

House Leadership - 2011

• Rep. John Boehner (R-Ohio), Speaker• Rep. Eric Cantor (D-Va.), Majority Leader• Rep. Kevin McCarthy (R-Calif.), Majority

Whip• Rep. Nancy Pelosi (D-Calif.), Minority

Leader• Rep. Steny Hoyer (D-Md.), Minority Whip

 

House Cmte Leadership - 2011

 Appropriations Committee• Rep. Harold Rogers (R-Ky.), Chair• Rep. Norm Dicks (D-Wash.), Ranking Appropriations HHS Subcmte • Rep. Denny Rehberg (R-Mont.), Chair• Rep. Rosa DeLauro (D-Conn.), Ranking Energy and Commerce Committee• Rep. Fred Upton (R-Mich.), Chair• Rep. Henry Waxman (D-Calif.), Ranking

HR – Year 1, cont.

• Nov. 5 - HHS announces choice of high-risk pool plans for patients with pre-existing conditions

• About 12,000 enrolled in pools during the first six months, even though millions are eligible.

• Jan. 19 - House Republicans fulfill their electoral promise and repeal healthcare reform, 245-189

• Only three Democrats — Reps. Dan Boren (OK), Mike McIntyre (NC) and Mike Ross (AR) — join all GOP members to vote for repeal.

HR – Year 1, cont.

• Jan. 31, 2011 - Federal judge in Florida strikes down entire ACA

• Sets up Supreme Court showdown, possibly as early as this summer

• Judge in Virginia struck down the ACA individual mandate

• Three judges — in Michigan, Virginia and District of Columbia found ACA constitutional.

• Feb. 2 - Vote to repeal in the Senate fails on a 47-51 party-line vote.

ACA Legal Scorecard

Tracking the status of 25 cases:● Court overturned law or part of law:  2 cases ● Court ruled law constitutional and dismissed case: 6

cases ● Court dismissed for lack of standing or procedural

problems: 4 cases ● Court dismissed but gave plainiff right to refile: 1 case ● Court decision pending: 12 cases

 

OPT OUT – Be careful what you ask

for!

• Feb. 28, 2011 - President announces support for bipartisan legislation allowing states to apply as early as 2014 for a waiver from certain requirements of the law, including its individual mandate

http://facts.kff.org/chart.aspx?ch=1419

Opt Out (cont.)• In speech to NGA President supports legislation

allowing states waivers for alternatives to ACA• States could opt out, beginning in 2014, from

the requirement that individuals buy insurance• Polls show mandate is deeply unpopular with

the public• Opt out bill is S. 248 by Sens. Ron Wyden (D-

OR), Scott Brown (R-MA) and Mary Landrieu (D-LA)

• Would let states opt out of many of ACA mandates in 2014

Gotcha!

• Waiver provision comes with a catch• State’s waiver proposal must show that it

is capable of providing coverage that is at least as comprehensive and affordable as that offered through new state-run health insurance exchanges, which also open in 2014

• The state must also provide coverage to as many residents as the exchanges would have, and the proposal must not increase the federal deficit

HHS Opt Out

• March 12 - Department of Health and Human Services (HHS) issued rules for states that want to opt out of certain requirements under the ACA and instead implement their own insurance reform

• States can receive a "state innovation waiver" that allows them to opt out of some federal requirements in the ACA starting in 2017 if they successfully enact a state-specific plan to cover as many people as the ACA would cover, at a similar cost

HHS Opt Out, cont.

• States could create own system • Would receive federal money that would

have otherwise been spent there to provide insurance subsidies to residents who couldn't afford to buy insurance on their own.

• ACA bars insurance companies from imposing lifetime limits on plans. It also requires them to cover young adults on their parents' plans until their 26th birthday; cover preventive services with no cost-sharing; and have medical loss ratio of at least 80%

HHS Opt Out, cont.

• In 2014, more provisions, like expansion of pre-existing medical condition prohibition take effect

• States receiving a waiver would be required to keep those insurance company provisions in place

• Each application from a state seeking a waiver must explain state plan will meet goals of coverage expansion, affordability, coverage comprehensiveness, and lower costs

Opt Out, cont.

• State must also provide actuarial certification and economic analyses to prove plan will meet ACA requirements

• Analysis of what happens to a resident’s access to healthcare services when leaving state

• How plan will deter waste, fraud, and abuse

• Submit quarterly reports that track how state plan is performing

Another HHS ACA Waiver

• March 8 - Maine is first state to get a waiver from medical-loss ratio requirement

• Requires individual and small-group plans to spend at least 80 percent of premiums on healthcare benefits or give consumers a rebate

• Six other states — Georgia, Florida, Kentucky, Nevada, New Hampshire and North Dakota — have applications pending

An After Shock Hits NCI

• Feb. 8 - at National Cancer Advisory Board meeting, NCI Director Harold Varmus said cuts to NCI programs were coming

• Varmus indicated he was considering reductions to cancer center awards, contracts and inflationary increases for non-competitive awards

Varmus, cont.

• Varmus said top priorities will be:• Sustain the same number of new grant

awards in FY2011 as was awarded in each of the past two years,

• Ensure cancer genomics programs are supported

• Pay for the ongoing improvements to the clinical trials program.

President’s Budget

• Feb. 14 President submitted FY 2012 budget to Congress

• For NIH, the President's budget proposed $31.748 billion, an increase of $745 million (2.4 percent) over the FY 2010 funding level

• NIH projects the Biomedical Research and Development Price Index (BRDPI) will increase by 3.0 percent in FY 2011 and 2.9 percent in FY 2012

President’s NIH Budget, cont.

President’s budget emphasized four areas for NIH “investment:”

• Advancing translational sciences, including the creation of the National Center for Advancing Translational Sciences (NCATS)

• Accelerating discovery through technology

• Enhancing evidence base for health-care decisions

• Encouraging new investigators and new ideas.

House Budget - H.R. 1

• Feb. 19 House approved H.R. 1, an omnibus appropriations bill for remainder of FY 2011

• Would cut federal discretionary spending by more than $61 billion from FY 2010 levels

• $1.6 billion cut to NIH and substantial cuts for the Title VII and VIII health professions programs and the National Health Service Corps

• H.R. 1 fails to pass Senate on March 9 and alternative proposal by Senate Appropriations Chair Daniel Inouye (D-HI)

House Budget, cont.• NIH budget cut of $1.6 billion reduces

agency's total budget to $29.6 billion, a 2008 level

• Interestingly, cuts are not across the board - specific line items are cut:

• Global AIDS Transfer fund, Project Bioshield Special Reserve Fund Transfer

• Funds for buildings and facilities• Inflation adjustment for non-competing

grants and NIH Common Fund• $640 million is a general reduction to

2008 levels, and would directly impact the National Cancer Institute

Budget by Continuing Resolution (CR)

• March 17 - Senate voted, 87-13, to approve three week extension of funding until April 8

• This CR (H.J.R. 48) is sixth for fiscal year that began Oct. 1, 2010

• House passed this latest CR on March 16 by a vote of 271-158

 

HJR 48

• House Joint Resolution (HJR) 48 continues funding for most federal programs at FY 2010 levels

• Cuts $6 billion in spending by reducing or ending 25 programs and eliminating certain earmarks

• Latest CR does not affect funding for NIH or Health Resources and Services Administration (HRSA)’s Title VII and VIII health professions programs.

Budget End Game for FY 2011

• House and Senate leaders say they believe they can reach agreement on FY 2011 spending plan with cuts estimated at $33 billion

• Alternative is a government shutdown in April

• Frustration with piecemeal approach growing

• Conservative House members also are unhappy with the CRs because they do not include H.R. 1 funding cuts and policy riders to derail ACA

In Change There is Opportunity but

We’re Going to Need a Bigger Boat!