the affordable care act and its effect on american healthcare (3)

Excellence Through Innovative Research

The Affordable Care Act And Its Effect On American Healthcare

Apurva A MandeGraduate Student

Systems Science and Industrial Engineering State University of New York at Binghamton

April 10, 2015

2Binghamton University | March 2015wise.binghamton.eduwise.binghamton.edu

Agenda Background of US Healthcare The Affordable Care Act

• Aims• Aspects

Impact of ACA on• Nursing• Medicare and Medicaid• Employer based insurance• Health insurance marketplace and private insurance• Pharmacy• Mental health services• Dental and vision benefits• Economy

Conclusion Future work

http://www.wise.binghamton.edu/



US Healthcare Background

Healthcare industry comprises of 18% of Gross Domestic Product (GDP) of the country and expected to rise up to 18.4% till 2016

Till 2022, healthcare expected to comprise of 19.9% of GDP

Fiscal Year Expected healthcare growth rate (%)

2013 4.1

2014 6.1

2015 6.2

[Blahous, 2013; CMS, 2013]




US Healthcare Background (Cont’d)

Fragmented in natureLack of universal access to quality and affordable health

servicesHigh spending on healthcare

Percent of spending population Amount spent per person on healthcare

30 12000

10 27000

1 90000

[Shi, 2014; Hoffman, 2014]




Implications Of Absence Of Coverage

Providers have a right to deny health services to the uninsured (except ER)

Missed diagnosis and preventable hospitalization in case of critical health conditions

Low chances of receiving follow-up treatments resulting in further deterioration of health

Forgoing and postponing of essential care due to high costs

High medical bills leading to financial insecurity, medical debts and bankruptcy

[KFF, 2014]




Need For ACA

Significant number of uninsured individuals (41 million) Healthcare spending very high20% projected share of healthcare in GDP by 2020 Increased rate of loss of insurance under 2008-2010

recession Emphasis on curative treatment instead of preventive

[APHA, 2012]




The Affordable Care Act




1. The Affordable Care Act (ACA)Popularly known as the Affordable Care Act, the Patient

Protection and Affordable Care Act (PPACA) (Public Law 111-148) is a federal decree, signed by the President of the United States on 23rd March 2010

Primarily consists of 2 pieces of legislation• Patient Care and Affordable Care Act• Health Care and Education Reconciliation Act

Serves with the aim to • Provide health insurance to every American citizen• Easy access to affordable and quality heath services

[Gruber, 2011]




2. Aims Of Affordable Care Act

Significant expansion of health insurance coverageMandatory health insurance to residentsExpanding eligibility criteria under insurance schemesEase of access [Ease Of Access]

• Coverage• Services• Timeliness• Clinical staff

[Shi, 2014; DPHP, 2014; CMS, 2012]




2. Aims Of Affordable Care Act (Cont’d)

Equality in insurance coverage• No discrimination on the basis of pre existing conditions • Insurance coverage to all individuals regardless of

• Healthcare costs• Severity of injuries• Access to employer• Limit on out of the pocket expenditure

Individual FamilyOut-of-pocket expenditure limit per year

$6350 $12,700

[Matheson, et al., 2012; Hoffman, 2014]




Subsidies for people with low income• Low costs for insurance premium • Particularly for individuals uninsured by government or

employerMandating individual insurance

• Any individual must be insured either by• Employer• Public health insurance• Individual market

• Fee payable in absence of insurance Individual Family

Amount charged 2% of annual income or

$325

$975

2. Aims Of Affordable Care Act (Cont’d)

[Matheson, et al., 2012; Healthcare.gov, 2015]




3. Aspects Of ACA

Allows young adults up to the age of 26 to be covered under parents insurance

Prohibits insurance companies from• Rejecting insurance to Americans with pre-existing

conditions • Spending more than 20% on administrative costs

rather than patient care

• Differentiating for mental healthcare• Charging women more than men

[Sommers, 2012; HHS, 2014]




Impacts Of Affordable Care Act




1. Nursing

Estimated increase in primary care providers owing to Minimum Essential Coverage (MEC) under ACA

ACA focused on providing routine check ups in outpatient settings

$900 million granted to primary care workers for improving access to health services for the less fortunate all over the country

Allotment of $30 million to ‘Advanced Nursing Education Expansion Program’ through ACA

1.2 million job openings for licensed and registered nurses estimated by 2020

[American Nurses Association, 2014; Lathrop, et al., 2014]




1. Nursing (Cont’d)

10% bonus payment from fiscal year 2011 to 2016 to• Nurse Practitioners• Clinical Nurse Specialist• Physician Assistant

$338 million distributed among the following categories in nursing• Advanced education• Practice• Quality• Retention grants

[American Nurses Association, 2014]




1. Nursing (Cont’d)

Increase in health care jobs [Roles under nursing]

• 30% projected increase in the number of registered nurses from year 2012-2022

• 432,000 registered nursing job availability over the next decade

[HHS, 2013; Paranzino, et al., 2014]




Summary

Owing to ACA, focus on primary care has increased Impact on nursing significant due this reasonIncrement in incentives for expansion of nursing

programs (education, retention grants etc.)




2. Medicare

Federal law insuring people over the age of 65 and permanently disabled individuals under 65

Prior to ACA, Medicare beneficiaries required to pay 20% of the costs of services covered

Since implementation, entire cost of annual health checkup funded under Medicare

No personal funds for preventive checkupsPrograms regarding health awareness for beneficiaries to

prevent costs for expensive treatments

[Davis, et al., 2010; Krasner, 2012]




2. Medicare (Cont’d)

Estimated reduction of $390 billion from fiscal year 2010 to 2019 in Medicare spending

Beneficiaries entitled for independent care at home• Physician and Nurse practitioner provide required primary

care at home • Intention of reducing expenditure and increasing health

outcomeGuaranteed protection of Medicare

• Medicare life estimated to extend till 2029Narrowing of the coverage gap

• Out-of-pocket funds estimated to be dropped to 25% by year 2020

[Davis, et al., 2010; American Nurses Association, 2014; Medicare.gov, 2014; AARP, 2014]




2.1 Projected Savings In Medicare Under ACA

[Blahous, 2012]

In absence of ACA, Medicare Hospital Insurance Trust Fund estimated to be depleted by 2016 resulting in decreased Medicare spending

Expected solvency of the Medicare Hospital Insurance Trust Fund till 2024 since implementation of ACA

Projected savings under ACA

$(in

bill

ions

)




2.2 Decrease In Medicare Spending Under ACA

14% fall in the projected Medicare spending for FY 2020

Medicare spending projections

Am

ount

in b

illio

n $

[Rudowitz, 2014]




Summary

Over $1600 saved per person under Medicare since ACAIncrease in life of Medicare trust fund by 13 yearsIncreased drug coverage under MedicareEligible for insurance even with pre-existing conditions




3. Medicaid

Medicaid – Health care reform for citizens with limited resources and income

Jointly ventured by federal and state governmentThe PPACA upgraded primarily the following aspects of

Medicaid• Eligibility criteria• Increase in federal funding • Improved accessibility to health services

Applicable since January 1st 201412 million enrollees predicted by 2016 Estimated reduction of uninsured individuals by 26 million

by 2024

[NCSL, 2011; Artiga, et al., 2014]




3. Medicaid (Cont’d)

Improved eligibility• Adults (below 65 years of age) with income increased from

100% to 138% below the Federal Poverty Line

Complete federal financing for 3 years for new enrollees through 2014 to 2016 in states adopting Medicaid expansion• Decrease in funding by 10% till year 2020

25% budget increase in Children's Health Insurance Program (CHIP)

Individual FamilyIncome $14,484 $29,726

[NCSL, 2011; Artiga, et al., 2014]




3. Medicaid (Cont’d)

Increase in Medicaid and CHIP enrollment• Data till 3 quarters for FY 2014

[Haislmaier, 2015]




3.1 Medicaid Eligibility For Children Under ACA(State Of New York)

Age category

1 2 3 4 5 6 7 8 Additional cost per person

Children under

1year & Pregnant Women

$2,169 $2,924 $3,678 $4,433 $5,187 $5,942 $6,696 $7,451 $755

1 to 18 years of

age

$1,498 $2,019 $2,540 $3,061 $3,582 $4,103 $4,624 $5,145 $522

[DOH, 2014]

Monthly income according to the size of the family




Summary

Medicaid expanded state wise Increased eligibility for coverage from 100% to 138%

below FPL, since implementation of ACAIndividual eligible for insurance even with pre-existing

conditionsIncrease in the number of enrollees




4. Employer Based Insurance 3 to 5 million fewer people estimated to obtain employer

based insuranceIncreased schemes under individual health insurance

marketplace• People can invest in their own start up

Young adults covered under parents insurance, hence not mandatory to be employed for it

Increase in the number of young adults

CB

O e

stim

ates

in m

illio

n

[CBO, 2012; Furman, 2014; Blahous, 2014]




4. Employer Based Insurance (Cont’d)

Coverage for employers with less than 25 employees• Small business health options program (SHOP)

• Available to businesses with 50 or fewer employees• High quality health and dental coverage

• Small business health care tax credit• Eligible for coverage if average annual income of employees

is $50,000 or less• Number of full time equivalent employees 25 or less

• Health contingent wellness programs• Rewarding employees for adopting healthier habits e.g.

reduction in use of tobacco• Rewards in form of increase in coverage

[Healthcare.gov; SBA, 2015]




Summary

Around 3% decrease in employer based insurance since ACA

Young adults till the age of 26 can be covered under parents insurance

Individuals no longer dependent solely on employers for insurance

Various coverage plans under SHOP for businesses having• Up to 25 employees• Between 25 to 50 employees• Between 50 to 100 employees• More than 100 employees




5. Health Insurance Marketplace

A place for the uninsured to compare and purchase health insurance

Facilitated federally and state wiseCost assistance for families earning 400% below FPLInsurance plans based on

• Age• Income• State• Family size

[IRS, 2015; Healthcare.gov, 2013]




5.1 Individual Health Insurance Self employed, freelancer, independent contractor can

get insurance through ‘Health Insurance Marketplace’ known as ‘Simple Cafeteria Plan’

According to the cost coverage offered, based on income and property

Catastrophic only coverage also available which includes free of cost primary care visits

Type of plan Costs covered (in %)

Bronze 60

Silver 70

Gold 80

Platinum 90

[Olafson, 2013]




5.1 Individual Health Insurance (Cont’d)

Coverage for the self-employed• Individual mandate• Additional Medicare tax

• 0.9% tax if income exceeds threshold of • $200,000 if single• $250,000 if married

• Net investment tax• 3.8% tax on net investment income exceeding threshold

of• $200,000 if single• $250,000 if married and filing jointly

[SBA, 2015; IRS, 2014]




5.2 Selecting Insurance In Marketplace

Search for desired plan

[nystateofhealth.ny.gov, 2015]




5.2 Selecting Insurance In Marketplace (Cont’d)

Selecting and comparing plans

[nystateofhealth.ny.gov, 2015]




Summary

Individual can choose from a variety of plans suitableIndividual able to examine and compare each plan

thoroughly and then choose according to budget in mind4 plans available, each with a specific range of insurance

coverageAvailability of coverage for the self-employed




6. Private Insurance

3 out of every 4 individuals covered by employer or government program

ACA impacts individuals opting for private insurance in 6 major ways• Liberty to choose from various policies• Less out of the pocket funds• Increased comprehensive benefits• No discrimination with respect to income or pre-existing

conditions• Increased enrollment • Increased eligibility for subsidies




6.1 Impacts On Private Insurance

Liberty to choose from various policies• Individual can choose any plan suitable• Plans include essential health benefits (EBH)• 80% of the premium allotted for medical expenses (82%

for the state of NY)• 20% of premium allotted for administrative purposes (18%

for the state of NY)

[nyhpa.org, 2013]




6.1 Impacts On Private Insurance (Cont’d)

Significant costs covered in the insurance• Limit on out of pocket funds • Division of deductibles depending on type of plan

[nyhpa.org, 2013]





Increased comprehensive benefits• Ambulatory patient services• Emergency services• Hospitalization• Maternity and newborn care• Mental health and substance abuse• Prescription drugs• Laboratory services• Pediatric dental services and vision care• Disease management and wellness service• Rehabilitation services

[nyhpa.org, 2013]





No discrimination• Under ACA, insurance to be issued to any individual who

asks for it• Known as ‘Guaranteed Issue’• Individuals cannot be denied coverage based on the following

conditions• Low income• Pre-existing conditions• Sex

• Individuals with poor health status cannot be charged with higher premium

[nyhpa.org, 2013]





Increased enrollment• Mandatory enrollment for insurance • Estimated increase in the aging population (above 65)• Increased average age of the insured due to baby

boomers • Increment in total private market FY-2014

[Haislmaier, 2015]





[kff.org, 2013]

Increased eligibility for subsidies• Premiums to decline by 84% for individuals with low

income

Annual income

in $

% FPL Unsubsidized premium

in $

Potential government

tax credit subsidy in $

Premium after subsidy

in $

Individual

17000 148 5400 4742 65828000 234 5400 2565 2158

40000 348 5400 954 3800

Family of 4

35300 148 13500 12231 1269

58000 243 13500 8968 4532

83000 348 13500 5605 7895




Summary

Compulsory enrollment for insurance Increase in the number of covered benefitsDecrement in premiums for low income individuals No discrimination on the basis of income, pre-existing

conditions and sex of an individual while providing insurance

Decline in premiums for individuals




7. Pharmacists

Pharmacy comprises of 10.1% of total healthcare expenditure

Increase in expenditure of pharmaceutical industry by 33% in next 5 years

Projected increase in drug expenditure from $359 in 2012 to $483 in 2021

Year [CMS, 2012]




7. Pharmacists

Pharmacists play critical role in patient careGrowth in pharmaceutical sales since implementation of

ACAACA affected pharmacy in following primary areas

• Care delivery system• 340B drug pricing program

[Forman, 2014]




7.1 Impacts On Pharmacists

Care delivery system• Under ACA, pharmacists can participate in delivering care

to individuals with chronic conditions through• Medical homes

• Medicaid patients funded through state• Funded under U.S. Department of Health and Human

Services• Home-based care

• Pharmacists included as integral part of the patient care team along with physicians and nurses

• Medication therapy management (MTM)• Grants provided to pharmacists to provide MTM services to

patients with chronic conditions

[ASHP, 2010]




7.1 Impacts On Pharmacists (Cont’d)

340 B drug pricing program• Offering discounts to hospitals for reducing out patient

drug costs• Accurately calculates the drug costs to avoid overpricing • Extending participation to

• Children's hospital• Cancer centers• Rural referral centers• Community hospitals

[Smith, et al., 2014]





Reduced drug expenditure• Decreased costs for medicines, both branded and generic• Increase in Medicare drug coverage

Year Amount deductible for brand name

drugs (%)

Amount deductible for prescription

drugs (%)2015 45 65

2016 45 58

2017 40 51

2018 35 44

2019 30 37

2020 25 25

[CMS, 2015]





• Increase in Medicaid prescriptions

Year

Per

cent

Incr

ease

[healthcare.gov, 2014]





• Decline in out of the pocket funds for drugs• E.g. Contraceptives

Year

Pre

scrip

tions

dis

pens

ed





Summary

Growing pharmaceutical sales Increase in pharmaceutical expenditureIncrease in the roles (involvement) of pharmacists right

from nursing homes to home based careDecrease in out of the pocket cost for medicines specially

for MedicareExtended participation of the 340 B drug pricing program




8. Mental Healthcare

Present scenario of mental healthcare in U.S.Significant disorders

• Schizophrenia• Bipolar disorder• Depression• Post-traumatic stress

45.6 million adults suffer from either mental health or substance use conditions in the United States

24% of adults suffering from mental illness uninsuredNearly 1/3rd insured under marketplace have no coverage

for substance use disorder

[Collins, 2015; DHHS, 2013]




8. Mental Healthcare (Cont’d)

ACA along with the Mental Health Parity and Addiction Equity Act (MHPAEA) extends protection to nearly 62 million individuals

Ensures that, coverage for mental health and substance use, should be comparable with coverage for medical and surgical care

Three primary ways for expanding coverage• Including Essential Health Benefit (EHB)• Parity in individual and small market• Access to quality healthcare

[DHHS, 2013]





Essential health benefits• Starting 01/01/14, treatment for mental health and

substance use to be covered under EBH• 3.9 million insured under individual marketplace will gain

access to stated services• 1.2 million insured under small group market to gain

access to the sameEquality in individual marketplace and small group market

[DHHS, 2013]





Improved access to health services

[DHHS, 2013]




Summary

Before ACA, individuals though insured, lacked coverage for mental disorders and substance abuse

Improved access to mental health servicesMental health and recovery service for substance abuse

covered under essential health benefits included under coverage

Equality of benefits offered in both market place and small group market




9. Dental And Vision Benefits

Pediatric dental care included under the Essential Health Benefits (EHB) since January 1,2014

Adult dental care not covered in all health plansDental benefits classified primarily as follows

• Based on health plans• Embedded dental plan (included in health plan)• Stand alone dental plans

• Based on age groups• Dental plans for adults (above 19 years of age)• Pediatric dental plans

• Based on coverage• High coverage, low deductibles• Low coverage, high deductibles





9.1 Dental Plans

Stand alone dental plan• Not included in any medical policy• Can be coupled with health insurance plan• Maximum out of the pocket funds of $350• $65 deductible• Actuarial value of 70 to 85%

[deltadental, 2014]Year

Am

ount

in $




9.1 Dental Plans (Cont’d)

Embedded dental plan• Medical and dental benefits combined in a health plan• Deductible of around $2000• Maximum out of the pocket limit of $6600• Actuarial value of 50%

[deltadental, 2014]

Year

Am

ount

in $




9.2 Pediatric Dental Benefits

Pediatric dental coverage more of a preventive natureOral assessments, cleanings, fluoride treatment etc.

includedRegular dental coverage through age 19Owing to implementation of ACA, around 8.7 million

children to gain dental insurance by 2018• 3.2 million via Medicaid• 3.0 million via health exchanges• 2.5 million via employer sponsored insurance

Increase in the number of children covered by 15% since 2010

Reduction in the number of uninsured by 55%[American Dental Association, 2013]




9.3 Adult Dental Benefits

Since implementation of ACA, around 17.7 million adults expected to gain dental benefits

Most benefits covered under Medicaid hence differ from state to state

4.5 million adults to gain dental coverage through Medicaid

800,000 adults to gain dental coverage through health exchanges

Overall decrease in number of adults not having dental coverage by 5%

Generation of 7.5 million adult dental visits

[American Dental Association, 2013]




9.4 Overall Effect

Effect on economyIncrease in dental expenditures by $4 billion4% of national expenditure$2.4 billion growth in Medicaid dental expenditure

[American Dental Association, 2013]




9.5 Vision Benefits

Vision benefits included in EHBMandatory to be included in any health plan unlike dentalPreventive serviceTimely vision screening for early problem detectionExpansion in every state compulsoryBenefits provided by state include

• Vision screenings and primary examinations in the medical facilities

• Extensive annual eye check up along with necessary treatments

• Corrective remedies like contact lenses and spectacles in case of refractive error

[AAPOS, 2013]




9.6 Vision Benefits For Pediatrics

Benefits for pediatrics according to age limits

[AAPOS, 2013]

Age limit Preventive testsNewborn – 3 years Red reflex test

Corneal light reflectionOcular motilityPupil examinationVision assessment

3 years – 5 years Vision screening Visual acuity test

5 years and above Regular vision screening




Summary

Dental and vision benefits included in essential health benefits

Dental not mandatory to be included in the health insurance plans as opposed to vision benefits

Stand alone dental plans more economic than embedded dental plans

Excessive focus on preventive dental and vision benefits for pediatrics

Increment in number of individuals getting coverage for dental benefits• 8.7 million children• 17.7 million adults




10. Free Clinics

Health care organizations providing variety of medical services to the economically challenged• Dental• Vision• Pharmacy

Services limited to individuals who are• Uninsured• Underinsured• Insured but lack access to necessary medical services

Employees are usually volunteersFree clinics are usually charitable hospitals

[NAFC, 2015]




10. Free Clinics (Cont’d)

Even though number of insured is increasing, focus on free clinics persistent due to increased importance of primary care

However, small free clinics anticipated to go out of business or estimated to turn towards advocacy

Free clinics willing to transform to adapt to the ACA regulations

Willingness to start accepting Medicare and Medicaid insurance patients

Need for the free clinics and charitable trusts to expand their policies according to ACA

[Cohen, 2013]




10. Free Clinics (Cont’d)

Process flow of a free clinic in Michigan after implementation of ACA

[FCOM, n.d.]




10.1 Impact Of King v. Burwell On Free Clinics

Free clinics and charitable organizations to be majorly impacted if ruling in favor of King v. Burwell litigation

King V. Burwell claim in the opposition of expansion of tax credits to federal marketplaces

As a result, significant portion of individuals to become uninsured

Thus opportunity for the free clinics to flourishWith no insurance and increased premiums, preference

of individuals towards free clinics

[NPR.org, 2013 ; NAFC, 2015]




10.1 Impact Of King v. Burwell On Free Clinics (Cont’d)Free clinics are suggested to implement the following if

court favors the King v. Burwell claim• Reconciling with former patients who are covered under

FFM• Promote the clinic with the help of media and other social

means of communication• Creating awareness and imparting knowledge regarding

effect of loss of subsidies

[NAFC, 2015]




Summary

Free clinics facing the need to change under ACAThreat to small free clinics in view of decreasing number

of uninsuredFree clinics to expand services to Medicare and Medicaid If results in favor of King v. Burwell, free clinics to have

booming business




11. EMS Billing

Billing for emergency medical services basically includes costs for emergency transportation (ambulance)

[Plaintownship, 2013]




12. Uncompensated Care (UCC)

Uncompensated care• Providing health services to the uninsured, publicly insured

and underinsured • Patients treated free of charge • Service costs incurred by the health care organization • Comprises of ‘bad debt’ and ‘charity care’

Introduction of ACA led to• Significant decrease in the number of uninsured

• Decrease of 10.3 million in the number of uninsured • Increase in number of Medicaid patients

Projected decrease of $5.7 billion (16% decrease from the spending baseline of UCC)

[DeLeire, et al., 2014]




13. Economy

Reduction in deficit• Probable decrease in the deficit by $109 billion through

fiscal years 2013-2022• Projected reduction in 0.5% of GDP over the decade 2023-

2032 totaling to a reduction of $1.6 trillion• Change in deficit

[Furman, 2014]

$(in

billi

on)




13. Economy (Cont’d)

Reduction in job lock

[Finegold, 2013]





• Significant proportion of population employer-insured• Fear of increase in premiums or cancellation of

insurance resulted in continuation of existing jobs• Led to condition known as ‘job lock’, an obstacle to

labor mobility• Employees eligible for insurance even with pre-existing

conditions through ACA• Reduction in job locks resulting in entrepreneurship

ultimately contributing to economic growth of the country

[Furman, 2014]





Improvement in the health of employees • Implementation of ACA resulted in increased access to

primary health care• Preventive health services accessible easily• Resulting in increased productivity of employees• Healthy employees able to contribute more, hence

incrementing the economyEnhanced financial security

• Ban on insurance companies to sell policies with lifetime or annual limits

• Reduction in out of the pocket catastrophic costs Decrease in catastrophic costs

[Furman, 2014; Hoffman, 2014]




Summary

Increased access to primary careReduction in growth rate of healthcare expenditure by

0.5%Reduction in job locks because of health insurance

marketplacesNo lifetime constraints on insurances




Challenges To Affordable Care Act




1. King v. Burwell

Issue raised• IRS (internal revenue service) willing to permissibly

expand tax credit subsidies to health insurances purchased under federally funded health exchanges (‘Marketplace’)

Challenge (claim under King v. Burwell litigation)• ACA allows expansion of tax subsidies to individuals

enrolled in health plans only funded through states i.e. Qualified Health Plans and not through Federally Facilitated Marketplace (FFM)

As a result, IRS facing opposition regarding the extension of subsidies

Decision of IRS termed to be ‘unlawful’ by opposition[Teitelbaum, 2015]




1.1 BackgroundACA allows formation of health exchange under every

stateEvery State at the liberty to whether or not adopt this

policy As a result, two types of health exchanges created

• State funded (for states setting up their own exchanges) known as Qualified Health Plans (QHP) – adopted by 17 states

• Federally funded (for states opting out of setting own exchanges) know as Federally Felicitated Marketplace (FFM) – adopted by 34 states

[Teitelbaum, 2015]




1.2 IRS Regulation And Opposition

As stated under ACA, individuals covered under QHP’s that is State exchanges, eligible for financial assistance (tax credits)

Regulation stating the expansion of tax credit benefits to individuals covered under either exchanges (State or Federal) issued by IRS

Under this regulation, around 90% individuals among the 5 million insured under FFM received the benefit of credit

This regulation of IRS contradictory to claim under ACA, termed inappropriate

[Teitelbaum, 2015]




1.3 Effects

Appeals by • Fourth Circuit Court of Appeals – subsidy applicable for

both• D.C. Circuit Court of Appeals – subsidy limited to FFM

If ruling in favor of King v. Burwell claim,• 8 to 10 million people will lose insurance• Imbalance in the insurance markets due to removal of

such high percentage of population from insurance pool• Federally funded states will have to make a decision

whether to implement marketplace or not• States may implement 1332 waiver which gives privileges

to waive certain conditions under ACA

[NACC, 2015; Teitelbaum, 2015]




Summary

IRS to extend tax credit benefits to individuals covered under federally funded exchanges

King v. Burwell law suit filed against this regulation stating that expansion of subsidies applicable only for state funded or Qualified Health Plans

If decision in favor of litigation filed, and subsidies for FFM suspended, approximately 8-10 million individuals to lose insurance

This may result in rise in premium costs all over the country




2. Triple Aim

Benefits of the ACA combined together to create the ‘triple aim’

2 major aspects of the ACA• Change in the delivery of care• Expansion of insurance coverage

Improvements made till date• Increased number of accountable care organizations

(more than 600)• Increase in hospitals implementing bundled payments

contracts • Increase in number of certified medical practices (more

than 5700)

[Berwick, et al., 2015]




2. Triple Aim (Cont’d)

Better care for individuals

Better health for population

Decrease in health care

costs





2. Triple Aim (Cont’d)

4 major steps required to be taken to successfully realize the triple aim• Incorporating technical adaptations like telemedicine for

improved access to care • Innovations in delivery of care like community paramedics

and community health workers• Building strong relationship between patient and health

care provider• Alliance of healthcare providers and social leaders

(Leadership Alliance)





2.1 Care Design Principles For Triple Aim

In order for the triple aim to make progress following design principles for care should be followed• Investing in care systems showing potential for continuous

improvement • Reducing waste and non-value added activities in

healthcare settings• Increasing communication and co-operation between

workforce• Complete utilization of resources• Lowering the rate of healthcare expenditures to 15% of

GDP• Equal power to patients, families and communities for co-

producing health and well being [Berwick, et al., 2015]




Summary

Combination of benefits from ACA combined to form the ‘Triple Aim’

The triple aim intends to• Reduce healthcare costs• Improve quality of healthcare for individuals• Improve healthcare for population

Measures taken to successfully implement triple aimDesigning of care principles for the same




3. Challenges To Insurers

Since implementation of ACA, insurers face certain restrictions

Under ACA, the insurers are required to • Propose plans covering all the essential health benefits • Removal of prohibitions on annual and lifetime limits • No discrimination on the basis of preexisting condition or

on basis of health status• Guarantee the issuance of insurance • Maintain the insurers’ medical loss ratio to 80% or above




3. Challenges To Insurers (Cont’d)

Owing to this situation, insurers unaware of the medical conditions of applicants and thus uncertain about setting premiums

In order to prevent insurers from facing this situation, 3 premium stabilization programs issued under ACA • Reinsurance • Risk Corridors• Risk Adjustment




3.1 Reinsurance

Implemented though the ACA to help individuals with unexpected high medical costs that is, ‘high risk’ patients

Effective for FY 2014 to 2016Reinsurance payments include the following plans

• All ACA compliant plans• Non-grandfathered plans (both outside and inside of the

health exchanges)Program funded through fees charged on all available

insurance plansReinsurance fee limit totals amounts for, fixed limit for

reinsurance payment and U.S. treasury and varying limit for administrative costs

[Boothe, et al., 2015]




3.1 Eligibility For Reinsurance

In order for the enrollee to be eligible for the reinsurance payment plan, following financial limits are set

Reinsurance fee limit in $

Year Annual medical cost limit reached by enrollee in $

2014 45000

2015 70000

2014 2015 2016

Reinsurance payment

10 billion 6 billion 4 billion

U.S. Treasury 2 billion 2 billion 1 billion

Per person cost

63 44 27

[Boothe, et al., 2015]




Summary

Reinsurance necessary for stabilizing the insurance marketplace during 1st year of its operation

States at the liberty of expanding reinsurance even in the absence of health exchanges

In absence of State participation, Department of Health and Human Services (HHS) runs the reinsurance program in that State

Prevents the high risk individuals from incurring high medical costs




3.2 Risk Corridor

Intends to promote accurate premium values Plan to be implemented on a trail basis from fiscal years

2014 through 2016Encourages the insurers to eliminate uncertainty about

premium costs in health insurance exchanges Administered by federal governmentExpects the insurers participating through exchanges to

allocate 80% of premiums to developing health care and improving its quality

This plan compares the allowable premium costs with a particular target amount (target amount = premium cost – administrative costs)

[healthaffairs.org, 2015; kff.org, 2014]




3.2 Risk Corridor (Cont’d)

Plan deemed to be eliminated by the federal government in the case if insurers remain underpriced

This might be possible as a major amount of losses suffered by insurers are not reimbursed by the program

In FY 2014, 80% insurers made payments to Medicare whereas only 20% received money back

This resulted in contradiction of the aim of risk corridor of equality among insurers regarding making and receiving equal payments to and from the government, in order to avoid net budgetary effect

[healthaffairs.org, 2015]




3.2 Risk Corridor Law Under ACA

Law states different responsibilities for insurers having the range of, ratio of allowable costs to target costs, within 3% points in both directions

Actual cost limit Responsibility of the insurer

Insurers with actual spending below 92%

To refund 80% of the profit earned to the federal

governmentInsurers with actual spending

between 92 and 97%To pay department of health and

human services (HHS), an amount half of their gains

Insurers with actual spending between 97 and 103%

To keep the profits to themselves and bear their own losses

Insurers with actual spending between 103 and 108%

Half of the losses reimbursed

Insurers with actual spending above 108%

80% of losses reimbursed by the federal government

[healthaffairs.org, 2015]




3.2 Risk Corridor Example

Example of risk corridor for a target amount of $500

[kff.org, 2014]




Summary

Plan originally introduced to bring stability to premiums for insurers introducing plans in marketplaces

Risk corridor plan to be run on a trial basis for years 2014 to 2016

Plan intends to have equal quantity of money going out and coming in into the federal government via insurers

Primary intention to nullify net budgetary effect




3.3 Risk Adjustment

Under risk adjustment under ACA, payment received by the insurer based on the predicted medical cost of the enrollee

Medical costs estimated on the basis of risk factors All the non-grandfathered plans whether individual or

small group market, whether included in the marketplace, benefitted by the risk adjustment plan

Payments made to the insurers depend upon the actuarial risk

Plans with higher than average actuarial risk to receive payments from plans having lower than average actuarial risk

[acadeathspiral.org, 2014; Pope, et. al., 2014]




3.3 Risk Adjustment (Cont’d)

In absence of risk adjustment, plans having high risk enrollees, will have to charge higher average premiums to the enrollees

States have an option to participate and if not, allow federally exercised plan (by HHS) to run in the State

States not wanting to run the federally governed plan can run their own risk adjustment plan, after getting a federal approval

In the plan, insurers compared on the basis of financial risk of their applicants

[acadeathspiral.org, 2014; kff.org, 2014]




3.3 Risk Adjustment Calculation

Each applicant (enrollee) assigned an individual risk score based on gender, age and diagnosis

The diagnosis are assigned a numerical value and listed under ‘Hierarchical Condition Category’, which determine the price the plan is likely to cost for that particular diagnoses

Risk score values vary depending upon the diagnoses of a person• An individual having multiple unrelated diagnoses, all the

corresponding HCC values are used while calculating risk score

• An interaction factor is added to an individuals risk score, suffering from multiple illnesses

[kff.org, 2014]




3.3 Risk Adjustment Calculation (Cont’d)

The risk score values are then averaged (weighted average)

This weighted average value represents the predicted expense of the plan

A scope for adjustment is kept for • Actuarial value• Geographic cost variation • Rating variation

From these values, enrollees having higher and lower risk values are calculated

[kff.org, 2014]




3.3 Risk Adjustment Calculation (Cont’d)

The risk adjustment costs calculated have the following benefits for the enrollee and the plan • Predicts the risk of healthcare cost (high or low) for an

enrollee• Calculates the actuarial risk for every plan for all of its

enrollees• Calculation determines the cost owed by each plan along

with the costs due to the same

[kff.org, 2014]




Summary

Risk adjustment plan aims to distribute funds from plans covering low-risk enrollees to those covering high-risk enrollees

[kff.org, 2014]




4. Maintenance Of Marketplaces

Marketplaces under ACA funded by two sources• Federally funded marketplaces (federally facilitated

exchanges)• State funded exchanges

Federally funded marketplaces are functional in the States who have chosen not to establish their own health exchanges




4.1 Issues Being Faced

Health exchanges even though provide a variety of health plans to choose from, are facing certain challenges themselves

Following are the challenges faced by health insurance exchanges • Availability of subsidies • Assistance of consumer• Funding of exchanges• Threat of adverse selection • Challenges due to States not expanding Medicaid • Federal and State rules

[Health Policy Brief, 2014; NCSL 2015]




Readiness Of Grants (Subsidies)

Debate over availability of subsidies under Federally Facilitated Exchanges for individuals with low income and small businesses

Benefit of tax credits only to people insured through state exchanges

However regulation stated by IRS suggests availability of credits regardless of the type of exchange

Funding of exchanges • State based exchanges to be financial sustainable till FY

2015• In order for the FFE (federally facilitated exchanges) to

sustain, a user fee of 3.5 percent on the premium of all plans sold only through exchanges is applicable

[Health Policy Brief, 2014; NCSL 2015]




Assistance to customers

Conflicts between customers regarding policies of exchanges

Guidelines for help known as ‘navigators’ to assist low income individuals and small businesses

The navigators expected to have thorough knowledge regarding the policies about local markets

Navigators expected to have experience of working with small firms and companies and also undergo training

However, number of navigators working depend on the funds available for training in the federal budget

[Health Policy Brief, 2014]




Threat of Adverse Selection

States have option of regulating health plans, either purchased through exchange or outside of exchanges, equally

However FFE can regulate health plans only through exchanges

This inequality may affect the stability of health insurance market

If health plans outside FFE offer cheaper coverage which is less comprehensive, there is a high possibility of healthy people opting for that coverage, while sick people will have to opt for broader coverage

This is adverse selection, leading to sick individuals incurring more claims

[Health Policy Brief, 2014, NCSL, 2015]




Challenges For Non-Medicaid States

Under the ACA, States have option of not expanding Medicaid

Along with Medicaid, many states (25) are reluctant for setting up State exchanges

As a result, individuals in such States are ensured through FFE

However the cost of private coverage is more than the coverage under Medicaid

Also if decision is made in favor of King v. Burwell, majority people insured under FFE will lose insurance and in these States individuals would suffer because of lack of Medicaid expansion





Federal And State Rules

Under ACA, both Federal and State exchanges and their regulations exist.





Summary

Even though health exchanges, either Federal or State, offer a variety of health plans to choose from, they face numerous challenges

The major challenges are faced by Federally Facilitated Exchanges mostly regarding their tax credits and subsidies

Challenges faced by State exchanges are related to Medicaid expansion




Operational Level Impacts Of Affordable Care Act




1. Workforce

Destabilization among the workforce and of the system due to increase number of the insured

Overload on the healthcare systemCatastrophic workforce shortages mainly in primary care

facilities Healthcare workforce has following effects on its

operations due to ACA• Improper distribution of workforce and unbalanced ratio• Aging workforce• Increased workload• Increasing dissatisfaction among physicians • Bottleneck in education pipeline

[Anderson, 2014]




1.1 Improper Distribution Of Workforce And RatioUrban locations have increased access to health services

than rural areas According to current distribution

• 10% of primary care physicians • 18% of nurse practitioners available in rural areas

Rural areas have high potential of Medicaid patientsProjected need of 7987 primary care physicians for the

newly insured due to ACAShortage of 20000 to 45000 nurse practitioners and

physicians predictedDisastrous outcomes of shortage resulting in increased

mortality and morbidity

[Anderson, 2014]




1.2 Aging Workforce

Currently 2.8 million registered nurses and 985,375 physicians estimated to be serving in healthcare industry

Of the estimated workforce, about 33% expected to retire in the next 10 years

As a result, shortage of workforce is anticipated as follows

Shortage due to more number of insured individuals

Type of workforce Expected shortage

Physicians 95,000 to 130,000

Registered Nurses 300,000 to 1.2 million




1.3 Increased Workload

Due to increased regulations owing to ACA, increase in paperwork

As a result, time a physician or registered nurse spends with patient is compromised

Estimated increase of 190 million hours of paperwork due to mandatory regulations introduced under ACA

As a result, compromise in the quality of care providedDifficult to maintain the quality of care provided due to

increasing insured population




Summary

Healthcare workforce (nurses, physicians etc.) impacted severely by ACA

Increased workload for the existing workforce due to tremendous increase in the number of insured individuals

Owing to the same, projected shortage of the workforce for the coming decade

Ultimately, formation of a gloomy outlook of the workforce towards the industry because of ACA resulting in deteriorating quality of the care provided




2. Healthcare Delivery

Owing to the increased regulations, changes being brought about in the healthcare delivery system

Merger of hospitals, healthcare businesses, independent physicians in order to maintain position in marketplace

Merging results in • Acquiring higher market share• Increased negotiation power with insurers, government

agencies etc.• Creation of a united healthcare system

Done in order to ensure solvency in light of policies of ACA




2. Healthcare Delivery (Cont’d)

Following reasons are prompting healthcare institutions to make changes to their delivery models• Shortage in workforce• Increased regulations• Reduced interaction with patient (owing to increased

paperwork)Providers taking up the approach of ‘cash-only’ practicesAs a result elimination of third party insurers resulting in

less number of regulationsHence physicians able to practice medicine as deemed fit

by them, keeping it patient centered Such models claimed to be ‘direct’ models




Summary

Delivery in healthcare is affected to the health reformsHospitals, physicians practicing independently are

merging in order to survive in the healthcare marketplaceHealthcare institutions adopting ‘pay for performance’

and ‘cash only’ policies Effort to keep third party insurers out of the delivery

scenario in order to provide quality health services




Conclusion

Reduction in the healthcare spending by 0.6% ($22 billion 800 million) in the year 2013

Historic decrease in the number of uninsured

Per

cent

age

Year

[Furman, et al., 2014]




Conclusion (Cont’d)

Increase in public and private insurance FY-2014

[Haislmaier, 2015]




Future Work

Operational level impacts of ACA on hospital operations

Effect of ACA • Trauma and Emergency care• Safety net providers

Timeline for ACA




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Health Care”, http://www.nursingworld.org/FunctionalMenuCategories/MediaResources/MediaBackgrounders/APRN-A-New-Age-in-Health-Care.pdf, 2011, Accessed February 2015

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References (Cont’d) Artiga, S. and Rudowitz, R., “Medicaid Enrollment Under the Affordable Care

Act: Understanding the Numbers”, http://kff.org/health-reform/issue-brief/medicaid-enrollment-under-the-affordable-care-act-understanding-the-numbers/, 2014, Accessed January 2015

Blahous, C., “The Fiscal Consequences of the Affordable Care Act”, http://www.economics21.org/commentary/fiscal-consequences-affordable-care-act, 2012, Accessed January 2015

Blahous, C., “Losing Employer-Provided Coverage: Another ACA Prediction Comes True”, http://www.economics21.org/commentary/losing-employer-provided-coverage-another-aca-prediction-comes-true, 2014, Accessed February 2015

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http://kff.org/health-reform/issue-brief/medicaid-enrollment-under-the-affordable-care-act-understanding-the-numbers/

http://kff.org/health-reform/issue-brief/medicaid-enrollment-under-the-affordable-care-act-understanding-the-numbers/

http://www.economics21.org/commentary/fiscal-consequences-affordable-care-act

http://www.economics21.org/commentary/fiscal-consequences-affordable-care-act

http://www.economics21.org/commentary/losing-employer-provided-coverage-another-aca-prediction-comes-true

http://www.economics21.org/commentary/losing-employer-provided-coverage-another-aca-prediction-comes-true

http://www.economics21.org/commentary/no-grounds-claim-obamacare-lowers-healthcare-costs

http://www.economics21.org/commentary/no-grounds-claim-obamacare-lowers-healthcare-costs

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2012.pdf

http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/downloads/proj2012.pdf


References (Cont’d) Closing the Coverage Gap - Medicare Prescription Drugs Are Becoming

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http://www.medicare.gov/Pubs/pdf/11493.pdf

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http://thinkprogress.org/health/2015/03/13/3633203/obama-mental-health-care-legacy/

https://www.cbo.gov/publication/43090


References (Cont’d) DeLeire, T., Joynt, K., and McDonald, R., “Impact Of Insurance Expansion

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http://aspe.hhs.gov/health/reports/2014/uncompensatedcare/ib_uncompensatedcare.pdf

http://aspe.hhs.gov/health/reports/2014/uncompensatedcare/ib_uncompensatedcare.pdf

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References (Cont’d) Haislmaier, E. F., Gonshorowski, D., “Q3 2014 Health Insurance Enrollment:

Employer Coverage Continues to Decline, Medicaid Keeps Growing”, The Heritage Foundation, http://www.heritage.org/research/reports/2015/01/q3-2014-health-insurance-enrollment-employer-coverage-continues-to-decline-medicaid-keeps-growing, 2015, Accessed March 2015

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Lathrop, B., Hodnicki, D., "The Affordable Care Act: Primary Care and the Doctor of Nursing Practice Nurse“, OJIN: The Online Journal of Issues in Nursing Vol. 19 No. 2., 2014

Matheson, V.A. and Congdon-Hohman, J. “Potential Effects of the Affordable Care Act on the Award of Life Care Expenses”, http://college.holycross.edu/RePEc/hcx/Matheson-Congdon_ACATortAwards.pdf, 2012, Accessed January 2015



http://www.heritage.org/research/reports/2015/01/q3-2014-health-insurance-enrollment-employer-coverage-continues-to-decline-medicaid-keeps-growing




http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/The-Health-Insurance-Marketplace

http://www.irs.gov/Affordable-Care-Act/Individuals-and-Families/The-Health-Insurance-Marketplace

http://college.holycross.edu/RePEc/hcx/Matheson-Congdon_ACATortAwards.pdf

http://college.holycross.edu/RePEc/hcx/Matheson-Congdon_ACATortAwards.pdf


References (Cont’d) Medical and Prescription Drug Deductibles for Plans Offered in Federally

Facilitated and Partnership Marketplaces for 2015, http://kff.org/health-reform/fact-sheet/medical-and-prescription-drug-deductibles-for-plans-offered-in-federally-facilitated-and-partnership-marketplaces-for-2015/, 2015, Accessed March 2015

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http://kff.org/health-reform/fact-sheet/medical-and-prescription-drug-deductibles-for-plans-offered-in-federally-facilitated-and-partnership-marketplaces-for-2015/



http://www.ncsl.org/documents/health/HRMedicaid.pdf

https://www.health.ny.gov/health_care/child_health_plus/eligibility_and_cost.htm

https://www.health.ny.gov/health_care/child_health_plus/eligibility_and_cost.htm

https://nystateofhealth.ny.gov/individual/searchAnonymousPlan/search

http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services

http://www.healthypeople.gov/2020/topics-objectives/topic/Access-to-Health-Services


References (Cont’d) Paranzino, G., Burnette, P., “ How nontraditional roles are reshaping nursing

careers”, Kelly Health Resources, http://www.slideshare.net/thetalentproject/a-new-era-for-nursing-how-nontraditional-roles-are-reshaping-nursing-careers, 2014, Accessed February 2015

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Six ways the affordable care act will affect individual insurance, http://www.nyhpa.org/PDFs/6-Ways-ACA-6.11-(4%20pages).pdf, 2013, Accessed March 2015

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https://www.healthcare.gov/small-businesses/provide-shop-coverage/small-business-tax-credits/

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References (Cont’d) Sommers, B., U.S. Department of Health and Human Services,

http://aspe.hhs.gov/aspe/gaininginsurance/rb.cfm, 2012, Accessed January 2015

Sonfield, A., “Affordable Care Act Survives Supreme Court Test, But Medicaid Expansion Placed in Peril”, Guttmacher Institute, http://www.guttmacher.org/pubs/gpr/15/3/gpr150302.html, 2012, Accessed January 2015

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http://aspe.hhs.gov/aspe/gaininginsurance/rb.cfm

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References (Cont’d) U.S. Small Business Administration, “Healthcare”, Managing a business,

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https://www.sba.gov/healthcare

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http://www.slideshare.net/deltadentalins/dental-benefits-and-the-affordable-care-act

http://www.slideshare.net/deltadentalins/dental-benefits-and-the-affordable-care-act

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References (Cont’d) Free Clinics of Michigan, “Resources for Free Clinics”, http://

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Gordon, E., “Healthcare Law Puts Free Clinics at a Cross Roads”, http://www.npr.org/2012/03/25/149350040/health-care-law-puts-free-clinics-at-a-crossroads, National Public Radio, 2013, Accessed April 2015

Cohen, R., “Future of Free Clinics under Obamacare”, https://nonprofitquarterly.org/policysocial-context/22721-the-future-of-free-health-clinics-under-obamacare.html, 2013, Accessed April 2015

The National Association of Free and Charitable Clinics [NAFC], https://nonprofitquarterly.org/policysocial-context/22721-the-future-of-free-health-clinics-under-obamacare.html, 2015, Accessed April 2015

Teitelbaum, J., King v. Burwell: A policy expert’s view (Part 1), Jones and Bartlett Learning, 2015

http://www.nafcclinics.org/about-us/what-is-free-charitable-clinic



http://www.fcomi.org/other-resources-for-free-clinics.html



http://www.npr.org/2012/03/25/149350040/health-care-law-puts-free-clinics-at-a-crossroads



https://nonprofitquarterly.org/policysocial-context/22721-the-future-of-free-health-clinics-under-obamacare.html









References (Cont’d) Boothe, A., Couture, B., “The ACA’s Risk Spreading Mechanisms: A Primer

on Reinsurance, Risk Corridors and Risk Adjustment”, http://americanactionforum.org/research/the-acas-risk-spreading-mechanisms-a-primer-on-reinsurance-risk-corridors-a, 2015, Accessed April 2015

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Centers for Medicare and Medicaid services, “Reinsurance, Risk Corridors, and Risk Adjustment Final Rule”, http://www.cms.gov/cciio/resources/files/downloads/3rs-final-rule.pdf, n.d., Accessed April 2015



http://americanactionforum.org/research/the-acas-risk-spreading-mechanisms-a-primer-on-reinsurance-risk-corridors-a




http://www.heritage.org/research/reports/2014/03/the-impact-of-the-affordable-care-act-on-the-health-care-workforce




http://www.cms.gov/cciio/resources/files/downloads/3rs-final-rule.pdf




References (Cont’d) ACA death spiral, “Continuing resolution jeopardizes risk corridors”,

http://acadeathspiral.org/category/risk-adjustment/, 2014, Accessed April 2015

Health policy briefs, “Risk Corridors”, http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=118, 2015, Accessed April 2015

The Henry J. Kaiser Family Foundation, “Explaining Health Care Reform: Risk Adjustment, Reinsurance, and Risk Corridors”, http://kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/, 2014, Accessed April 2015

Pope, G. C., Kautter, J., Keenan, P., “Affordable Care Act Risk Adjustment: Overview, Context, and Challenges”, Medicare and Medicaid Research Review, 2014

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_84.pdf http://www.ncsl.org/research/health/state-laws-and-actions-challenging-

ppaca.aspx



http://acadeathspiral.org/category/risk-adjustment/

http://acadeathspiral.org/category/risk-adjustment/

http://www.healthaffairs.org/healthpolicybriefs/brief.php?brief_id=118



http://kff.org/health-reform/issue-brief/explaining-health-care-reform-risk-adjustment-reinsurance-and-risk-corridors/




http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_84.pdf

http://healthaffairs.org/healthpolicybriefs/brief_pdfs/healthpolicybrief_84.pdf

the affordable care act and its effect on american healthcare (3)

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