The ACA and Cancer Control

Presentation for the Cancer Control Coalition

Program Directors by

Health Policy Alternatives, Inc.September 27, 2011

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Overview of ACA

The Patient Protection and Affordable Care Act, enacted in March 2010 and known as the ACA, includes a wide range of provisions affecting health insurance, health care service delivery, and public health programs.

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Prevention of Cancer and Other Chronic Illnesses

• Recurring theme in debate leading to development/enactment of ACA– Prevention as a pathway to improving health

outcomes, slow growth in health care spending – Secondary but significant focus on reducing

disparities in insurance coverage, health services and health outcomes

• ACA’s focus is both on public and private sector programs through new federal:– Requirements (public and private insurance)– Incentives for employers, insurers, providers – Investments in research and delivery initiatives

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The ACA and National Comprehensive Cancer Control Program Priorities

Emphasize primary prevention of cancerSupport early detection and treatment activitiesAddress public health needs of cancer survivors Implement policy, systems, and environmental

changes to guide sustainable cancer controlPromote health equity as it relates to cancer

control Demonstrate outcomes through evaluation

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Topics for WebinarsToday• Private and public coverage expansions

– Insurance reforms – now and in 2014– Exchanges– Essential health benefits– Medicaid

September 20:• Medicare and Medicaid prevention benefits • Public health prevention and wellness• Health disparities• Other relevant provisions

– Quality, workforce, comparative effectiveness, delivery system changes 5

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Context for Presentation

• Today’s focus is on the law, regulatory developments and next steps

• Caveats– Ongoing repeal/defunding efforts in the

Congress– State adoption/implementation has varied – Budget/Super Committee– Lawsuits proceeding

• Final resolution expected at U.S. Supreme Court as early as 2012

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Coverage Expansions: Setting the Stage

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Coverage Among the Nonelderly Pre- and Post-health Reform

Number of Uninsured Reduced by 34 Million: Half will Gain Private Coverage

Medicaid/CHIP

Employer

Nongroupand other

Uninsured

Exchanges

Source: Congressional Budget Office, March 2011.

2011 2020

57% 57%

20%

9%14% 8%

18%

8%9%

Note: Nongroup and “other” includes Medicare

n=269 million n=284 million

55 million uninsured

22 million uninsured

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Framework for Coverage Reform (for Population under Age 65)

• Build on (or don’t erode) current base of coverage

• Address priority problems– Affordability and adequacy of coverage and care for

uninsured in short-term and long-term (2014 and thereafter)

– Problems in insurance market (especially individual and small group markets)

– Costs: for insured, uninsured, public programs

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Overall Approach• Financial support for coverage

• Medicaid (<133% of federal poverty level (FPL))• Premium tax credits, cost sharing subsidies (133-

400% FPL)

• Regulatory, purchasing changes• Increased regulation of insurers – short-run and for

2014 and beyond• State Exchanges created for individuals, small groups

• “Shared responsibility”• Individual mandate• Large employer penalties if employee gets subsidy

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States Play Critical Role • Responsible for implementing Exchanges

– Federal fallback if a state fails to establish Exchange

• Responsible for conforming state insurance laws– ACA provides for minimum standards– State laws that do not prevent application of ACA standards may still

apply (with important exceptions)

• Changes to Medicaid/coordination with Exchanges

• Regulations have emphasized state flexibility– ACA outcomes will vary across the states

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Private Insurance Coverage

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Improving Access to and Adequacy of Existing Coverage

(Beginning 2010 or 2011)

• No pre-x exclusion for kids under 19– Grandfathered individual coverage exempt

• Dependent coverage to age 26 • No lifetime limits• Restrictions on use of annual limits

– Grandfathered individual coverage exempt

• Improved appeals rights; other consumer protections– Grandfathered group and individual coverage exempt

• Minimum medical loss ratios & rebates– Applicable only to insured plans

• Small business tax credits 13

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Pre-Existing Condition Insurance Plan Program (PCIP)

• Insurance for uninsured individuals with cancer and other pre-existing medical conditions– Enrollment began in summer of 2010– Has to be uninsured for 6 months prior to

enrollment– Coverage begins upon enrollment, including

for pre-existing condition– Program ends in 2014 when major reforms

and Exchanges begin14

PCIPs-Cont’d

• 27 states running own qualified PCIP; 23 states & D.C. elected HHS-run PCIP

• Coverage of preventive benefits but without requirement for 100% coverage– Same benefit for all enrollees in HHS-run

PCIP• HHS PCIP : 100% coverage of adult preventive care

obtained in-network (40% out-of-network) (includes “routine mammograms and cancer screenings”)

– State PCIPs: vary significantly from state to state

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PCIP Program: HHS-run and State-run Plans 2010-2011

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PCIPs - Continued• PCIP viewed as bridge until 2014 when most

people will be able to obtain insurance• Original forecast: as many as 350,000 “medically

uninsurables” might become insured between 2010 and 2014 without exclusions for their illnesses– Many likely to be cancer patients or survivors– As of July 31, 2011 = 30,395 enrolled in PCIPs

• Increased access to cancer-prevention screening and other preventive services– But specific preventive services and cost-sharing

requirements vary for state-run PCIPs18

PCIP Enrollment Enrollees steadily increasing but still under 35,000

798612437

2145424712

30,395

0

5000

10000

15000

20000

25000

30000

35000

Enrollment

Source: CCIIO website

PCIP – Growth in Enrollment for Top 10 States

State Nov 2010 July 2011

Cal 513 2,979

Colorado 368 863

Florida 293 1,454

Georgia 161 914

Illinois 664 1,568

New York 201 1,828

N. Carolina 513 1,897

Ohio 634 1,511

Oregon 340 993

Penn. 1,657 3,762

10 State Tot 5,344 17,769

NAT TOTAL 7,956 30,395

Top 10 as % 67% 59%

PCIP - Recent Changes

Federally administered (23 States plus DC)•Premiums reduced, cost sharing changes•Child-only policy•Simplification of proof of pre-existing condition:

– Agent attestation

– MD letter

•Agent/broker compensation•Notification

Premium reductions effective July 1: 2% - 40% reduction – not reflected in enrollment data

States (27 States): Some similar changes (but also premium increases)

Preliminary Analysis of Early PCIP enrollees:10 State Study

Commonwealth Fund, June 2011; 10 State Study; Data as of December, 2010

*Note: not shown on chart is 0.1% eligible due to premiums (limited number of States)

Preliminary Analysis of Early PCIP enrollees:

10 State StudyTop comorbidities

Arthropathies (joint diseases) 18.7%

Cardiovascular disorders 15.4%

Endocrine 16.8%

Diabetes (14.7%)

Psychiatric 14.7%

Dorsopathies (diseases of back/spine) 14.7%

Cancer 13.3%

Commonwealth Fund, June 2011; 10 State Study; Data as of December, 2010

PCIPs: Common Coverage Limits

24GAO, Pre-Existing Condition Insurance Plan Program, July 2011, http://www.gao.gov/new.items/d11662.pdf

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PCIP Challenges Ahead• Eligibility requirements, premiums, and benefit

levels and/or cost-sharing may discourage enrollment

• Despite stepped-up outreach, appears to be limited awareness of program among health providers, community groups and public at large

• Some states may exhaust allocations due to exceptionally high-cost claims experience– HHS intends to reallocate allotments after period of

not more than 2 years based on state enrollment and expenditures

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PCIPs and Cancer Control Opportunities and Challenges:

2011-2013

• Expand public awareness of new coverage options for young adults and individuals with pre-existing conditions– Group and individual insurance

• For individuals and families not connected to large employers, coverage may continue to be unaffordable, even if it is available

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2014: Insurance Reforms and Exchanges

• New requirements on insurers (in and out of the exchanges) – Continuation of 2010 reforms – Guaranteed issue and renewability– Prohibition on pre-existing condition exclusions for all enrollees– No lifetime limits; no annual limits on “essential health benefits”– Adjusted community rating for establishing premiums

• State-based exchanges designed to encourage competition on price and quality and reduce admin costs

• Federal subsidies to help pay for coverage• Goals: to make insurance more available, affordable,

and of greater value27

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2014 -- Premium Surcharge for Use of Tobacco

• Insurers of non-grandfathered small group and individual policies cannot use health status in determining premiums

• However, they can vary premiums on the basis of: – Age: An individual in most expensive age group can

be charged no more than 3 times as much as individual in least expensive age group (e.g., young adults)

– Tobacco: A user of tobacco can be charged up to 150% more than a non-user of tobacco

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Implications/Concerns• Rationale for tobacco surcharge

– Smokers share in paying for their higher health care costs– Rating for tobacco use is already a common tool today in

individual and small group insurance markets• State laws vary in what they permit

– Higher premium acts as financial incentive to quit using tobacco and non-grandfathered plans will have to offer tobacco cessation counseling as a recommended preventive service

• Concerns– May be seen as penalizing people for unhealthy behaviors,

some that may not be controllable– May have adverse effects on lower income and minority

populations due to their higher rates of tobacco use• ACA premium subsidies will not be increased to pay for premium surcharge

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Functions of Exchanges

• Certify/decertify Qualified Health Plans (QHPs) for participation (consistent with federal requirements)

• Facilitate plan comparisons (website, call center; standardized comparative information; plan ratings)

• Determine eligibility (including subsidies) and enroll in plans– Certification for individual mandate penalty exemption– Establish Navigator program to do outreach/education re:

Qualified Health Plans, subsidies, etc.

Illustrative Exchange

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Illustrative Exchange: MA ConnectorShopping Experience)

Select High or Low and With or Without prescription drug coverage

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EXCHANGES/QHPs: Proposed RulesNPRM July 15, 2011; Comments by October 31

•“Codifies” statute; significant discretion given to States• Overall timeline:

– Initial open enrollment: October 1, 2013– Statutory deadline for approval: Jan. 1, 2013; could be “conditional”– “Federally-facilitated” Exchange in absence of approved State Exchange

•Three broad approaches: (1) statutory state (2) Federal and (3) proposed new “hybrid” model with split functions • Includes preliminary proposals re: Qualified Health Plans• Separate rules on risk mitigation provisions

– Transitional State (or HHS) reinsurance program– Transitional federal risk corridors– Permanent state (or HHS) risk adjustment program

Exchanges and Essential Community Providers (ECPs)

• Each QHP participating in Exchange must ensure that its provider network includes ECPs where available– §340B(a)(4) of the PHS Act and §1927(c)(1)(D)(i)(IV) of the

Social Security Act

• QHP must demonstrate to Exchange that it has a sufficient number and distribution of ECPs to ensure timely access for low-income, medically underserved individuals in the service area– Not an “any willing provider” requirement– Not requiring a QHP to cover any specific medical procedure

provided by an ECP

• States can impose more stringent requirements

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Proposed Exchange Enrollment Periods for Individuals

• Initial open enrollment period October 1, 2013-February 28, 2014– Future years annual open enrollment Oct 1- Dec 7 (or Nov 1-

Dec 15)• Other open enrollment limited to special enrollment

periods (also 60 days)– Triggered by loss of other coverage, changes in dependency

due to birth, marriage, adoption, etc. – Outreach for open enrollment periods even more important than

outreach for Medicaid, which has continuous open enrollment• Special enrollment period proposed for individuals newly

eligible (or newly ineligible) for premium tax credit or cost sharing subsidy regardless of whether they are enrolled in an Exchange qualified health plan– Provides for extended initial open enrollment for subsidy-eligible

individuals

State Exchanges: Grant Activity

• Planning grants: All States except Alaska have received Exchange planning grants.

• Early innovator grants, IT infrastructure: Six States and one consortium (Kansas, Maryland, New York, Oklahoma, Oregon, Wisconsin, and Massachusetts consortium (for Massachusetts, Maine, New Hampshire, Vermont, Rhode Island and Connecticut) have received early innovator grants.

• Establishment grants: 16 states have received establishment grants

State Exchanges: State Action

A total of 25 States are proceeding with some level of implementation

•15 States have enacted legislation related to Exchanges, with 4 pending

•Four have initiated action by Executive Order

•Two have existing exchanges

Source: Kaiser Family Foundation, www.statehealthfacts.org

State Exchanges: Selected Information on

“Type of Exchange” The Kaiser Family Foundation summary characterizes two approaches that Exchanges can take in contracting with qualified health plans (QHPs):•“Clearinghouse”: Exchange can contract with all qualified health plans; or•“Active purchaser”: Exchange can contract with selected plans and/or negotiate premium prices.

The chart that follows characterizes the twelve States that have actually established Exchanges as follows:•Clearinghouse model: 3•Active purchaser model: 5•To be decided by the Board of the Exchange: 2•Not addressed in the legislation: 2

Kaiser Family Foundation, www.statehealth facts.org

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Benefits under Private Health Insurance

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Coverage of Preventive Services(2010)

• 100% coverage of recommended preventive services– Plan years beginning on or after 9-23-2010– Applies only to non-grandfathered (new)

health plans – Can use value-based insurance designs but

Secretary will have to develop guidelines – Implementing rules (7-19-2010)

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“Recommended” Preventive Services• Evidence-based items or services that have in effect a rating of A or

B in the current recommendations of the USPSTF with respect to the individual involved– Exception for breast cancer screening recommended issued on or

around November 2009

• Immunizations for routine use in children, adolescents and adults recommended by the Advisory Committee on Immunization Practices of the CDC

• With respect to infants, children, and adolescents, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA; and

• With respect to women, evidence-informed preventive care and screenings provided for in comprehensive guidelines supported by HRSA that are not otherwise addressed by the USPSTF

– August 2011- Secretary Sebelius announced new guidelines requiring non-grandfathered plans to cover certain women’s preventive services, including screening for HPA for women 30 years and older. Effective August 1, 2012. 41

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Cancer-Related Services Graded A or B by the USPSTF

• Referral for genetic counseling and evaluation for breast cancer susceptibility gene (BRAC) testing for women whose family history is associated with an increased risk for deleterious mutations in BRCA 1 or BRAC 2 genes

• Screening mammography, with or without clinical breast examination every 1-2 years for women aged 40 and older

• Screening for cervical cancer in women who have been sexually active and have a cervix.

• Screening for colorectal cancer using fecal occult blood testing, sigmoidoscopy, or colonoscopy, in adults, beginning at age 50 years and continuing until age 75

• Tobacco cessation interventions for non-pregnant adults who use tobacco products

• Augmented, pregnancy-tailored counseling for pregnant women who smoke

• Discussion of chemoprevention with women at high risk for breast cancer and at low risk for adverse effects of chemoprevention

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Implications for Cancer-Related Preventive Services

• About 31 million in group health plans (GHPs)* subject to prevention requirement in 2011; 78 million by 2013 as plans lose grandfathered status*– But most GHPs cover some recommended services without application

of deductible and many larger GHPs provide “free” coverage• Not clear is the scope of covered preventive services or extent to which they

are covered without any cost-sharing

• About 10 million or more in individual policies will newly gain preventive services without cost-sharing*

• May have limited impact on people covered under insured plans in many states – Many already require coverage of cancer-related preventive services– As of 2014, will depend on whether a state elects to pay for any

additional costs associated with non-recommended preventive services

• See Federal Register, 7-19-2010.43

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Essential Health Benefits Package (Beginning 2014)

• Must be offered by issuers of individual and small group coverage

• 4 actuarial levels: Bronze (60%) , silver (70%), gold (80%) and platinum (90%).

– Exception for catastrophic plan (individual market only)• May be offered by a plan to those under age 30 or who are exempt from the individual

mandate due to other coverage unaffordable or hardship exemption

• Scope of benefits = typical employer plan– Must include specified general categories of items and services

• Preventive and wellness as well as hospital, ambulatory, emergency, maternity, mental health, Rx drugs, lab, rehab, pediatric, chronic disease management

– Must comply with specified cost-sharing limitations– Include patient protections (e.g. prudent layperson standard; in-

network cost-sharing for emergency services)44

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Process for Defining Essential Benefits• HHS Secretary defines with input from stakeholders and

Department of Labor’s assessment of scope of typical employer plan– Reported April 15, 2011 (http://www.bls.gov/ncs/ebs/smb_health.htm)

• HHS Secretary must ensure that benefits—– Reflect appropriate balance and not unduly weighted toward any

category;

– Not make coverage decisions, determine reimbursement rates, establish incentive programs, or design benefits in ways that discriminate against individuals because of their age, disability, or expected length of life;

– Take into account health care needs of diverse segments of the population, including women, children, persons with disabilities, and other groups; and meet other objectives

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Essential Benefits: DoL Survey

• Some categories (hospital, surgery, MD visits) generally covered by all.

• Variation in others: 80% coverage of physicals, 56% adult immunizations

• Outpatient Rx drugs:– generally covered; 79% coverage of maintenance/mail order

drugs– key design elements not featured (definitions, cost

sharing/formularies, in/out of network prescribers and pharmacies, specific categories of drugs, benefit management features.)

• Issues: data limitations; applicability to smaller employers

DoL: “Selected Medical Benefits: A Report from the DoL to DHHS” April, 2011 – recap of 2008/2009 survey

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Essential Health Benefits and IOM

• IOM commissioned by Secretary of HHS to do “consensus study” and recommend criteria/methods for determining essential benefits package – 18 member committee– Looking at how insurers determine covered benefits and medical

necessity– Provide guidance on criteria to account for appropriate balance

among categories of care; needs of diverse segments, and nondiscrimination

– Report expected early October 2011• www.iom.edu/Activities/HealthServices/EssentialHealthBenefits

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Essential Health Benefits: Upcoming Regulations

• HHS will issue proposed regulation – timing unclear (late 2011 or sometime in 2012)– Take into consider IOM recommendations and

Department of Labor data

• All indications from HHS in implementing the ACA is that substantial discretion will be given States, Exchanges, and qualified health plans in defining essential benefits

Essential Health Benefits/QHP Policy

Tradeoffs:•Affordable premiums v. affordable care once insured: coverage, cost sharing, utilization management•Implement new policy v. minimal disruption of market•Federal v. State v. Exchange v. plan discretion – a lot of discretion likely

How to think about future policy:•What must be covered – goal is to be here•What cannot be covered – goal is to avoid this•The likely huge and undefined “middle” – where most of action will be – requires focus on

– Anti-discrimination language/constraint – key tool

– Evidence-base, medical necessity, network, management protocols

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Employer Wellness Programsand Non-Discrimination (2014 or Earlier)

• ACA provides “safe harbors” from non-discrimination requirements for employer plans providing incentives for –

– Participation in qualified wellness programs– Achieving certain outcomes as a result of participation in qualified wellness

programs

• Incentives up to 30% discount from or rebate on plan premium (other forms of rewards also possible); Fed. Gov’t may raise to 50%

• Qualified programs are defined– E.g., Smoking cessation programs, waiving cost-sharing for preventive services,

attend health education seminars, fitness center membership, diagnostic testing

• Low income premium subsidies offered in Exchange are calculated without regard to wellness premium adjustments

– Example: a person earning $14,700 pays $300 (2% of income) if subsidized, but $1,860 (13% of income) with wellness penalty

• Authorizes demonstration project for individual insurance market in 10 states

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Wellness Programs: More Specifics

• Wellness programs that condition rewards based on satisfying a standard related to a health status factor must:– Be “reasonably designed” to promote health or prevent disease in

participating individuals and not be overly burdensome, a subterfuge for discriminating based on a health status factor, and not highly suspect in the method chosen to promote health or prevent disease

– Give eligible individuals the opportunity to qualify for the reward at least once each year

– Offer a reasonable alternative standard to those who cannot meet the program standard for medical reasons

– Make available the full reward to all similarly situated individuals

– Meet disclosure requirements

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Expansion of Medicaid Coverage

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Coverage Among the Nonelderly Pre- and Post-health Reform: Medicaid

Medicaid/CHIP

Employer

Nongroupand other

Uninsured

Exchanges

Source: Congressional Budget Office, March 2011.

2011 2020

57% 57%

20%

9%14%

8%18%

8%9%

Note: Nongroup and “other” includes Medicare

n=269 million n=284 million

55 million uninsured

22 million uninsured

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Medicaid Eligibility Prior to 2014• States must maintain Medicaid eligibility

levels in effect as of 3/23/2010– Limited exceptions

• States have option to expand coverage to adults <65 with incomes at or below 133% of the federal poverty level at regular matching rates – Excludes Medicare-eligible individuals – May be phased in – CT, DC, MN are using this option

Note: 2011 FPL = $10,890 individual/$22,350 family of 4

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2014 Expansion of Medicaid Eligibility• Mandates eligibility up to 133% of federal poverty

level – 138% including 5% income disregard – Based on “Modified Adjusted Gross Income”

• Expected to add 16 million Medicaid beneficiaries nationally (currently ~48 million) – Impact will vary among the states

• Newly covered will be adults– About 13% of uninsured “childless adults” (no

dependent children) are age 55-64, higher risk of cancer due to age

• New eligibility category financed with 100% federal funds for 2014-2016, then phases down to 90% for 2020 and later

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235%

185%

75%64%

38%

0%

Children PregnantWomen

Elderly andIndividuals

withDisabilities

WorkingParents

Non-WorkingParents

ChildlessAdults

Note: Medicaid income eligibility for most elderly and individuals with disabilities is based on the income threshold of Supplemental Security Income (SSI).SOURCE: Based on a national survey conducted by the Center on Budget and Policy Priorities for Kaiser Commission on Medicaid and the Uninsured, 2009.

Median Medicaid/CHIP Income Eligibility Thresholds, 2009

Medicaid Eligibility underHealth Reform = 133%FPL

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Benefits for Newly Eligible

• Expansion population receives at least the essential benefits– May differ from benefits for other Medicaid

eligible population

• Essential benefits include recommended cancer screenings with no cost sharing

• State variation should be expected 57

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Eligibility and Enrollment for Exchange Subsidies and Medicaid

• ACA Envisions “No Wrong Door” Approach– If individual applies to Exchange and is Medicaid

eligible, no further application required– Reverse holds true as well – Enhanced funding through 2015 for states to build IT

infrastructure to coordinate eligibility systems with Exchange

– August 17 proposed regulations detail Medicaid eligibility and coordination requirements for states

Potential Shifting between Medicaid and Exchange Coverage

• Estimates that within 1 year, 50% of population under 200% of poverty will shift between Medicaid and Exchange eligibility (Sommers and Rosenbaum, Health Affairs, Feb. 2011)

• Shifting complicates benefits, cost sharing and provider continuity

• August 17 proposed rule includes state flexibility to avoid some shifting and potential gaps in coverage but concerns remain

Other Changes to Medicaid Eligibility

• In addition to expansion, ACA affects existing Medicaid populations

• MAGI will be used for some, but not all, existing Medicaid eligibility categories

• Some people who would be Medicaid eligible under current income definitions will not qualify in 2014; others who are not eligible now may qualify

• Once maintenance of eligibility requirement expires in January 2014, some states may reduce optional coverage– Shift to Exchange for subsidies

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Medicaid Breast and Cervical Cancer Treatment Option

• ACA made no changes to NBCCEDP or Medicaid Breast and Cervical Cancer Treatment Option

• In general, states must maintain pre-ACA eligibility rules until Exchanges are up and running in 2014

• But, program participation will be affected by ACA coverage expansions beginning in 2014

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Effects of 2014 Coverage Changes on Medicaid Breast and Cervical Cancer Option

• As Medicaid expansion, private coverage subsidies and individual mandate take effect, fewer women <250% of FPL should qualify as uninsured

• But eligibility for the Medicaid treatment option is not likely to shrink to zero – Some uninsured women may remain unaware of

Medicaid/subsidy eligibility or may choose to go without coverage

– Exchange enrollment limited to designated open enrollment periods, so private coverage may not be available when cancer diagnosis is made

• Out of pocket costs for women with private coverage in the Exchange will likely be greater than under the Medicaid option, which requires only nominal cost sharing

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Coverage among the nonelderly pre- and post-health reform: Uninsured

Medicaid/CHIP

Employer

Nongroupand other

Uninsured

Exchanges

Source: Congressional Budget Office, March 2011.

2011 2020

57% 57%

20%

9%14%

8%18%

8%9%

Note: Nongroup and “other” includes Medicare

n=269 million n=284 million

55 million uninsured

22 million uninsured

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Uninsured Population >2014

• Undocumented individuals– Ineligible for Medicaid or Exchange coverage

• Individuals eligible for Medicaid, but not enrolled– Continuous open enrollment opportunities

• Individuals eligible for subsidized coverage in the Exchange, but not enrolled– Annual and special open enrollment periods

• Other individuals who choose not to purchase insurance

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Coverage Expansions and Cancer Control

• States play important role in operationalizing ACA reforms• Opportunities for input on exchanges – governance,

structure, role• Opportunities to help inform lawmakers on importance of

affordable accessible coverage for individuals with pre-existing conditions

• Consider options for cancer control to participate in Medicaid outreach activities

• Importance of maintaining Medicaid option for breast and cervical cancer treatment

• Ongoing challenges of non-financial barriers to accessing services

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