obama & biden's health reform: accessible health coverage for all

BARACK OBAMA AND JOE BIDEN’S PLAN TO LOWER HEALTH CARE COSTS AND ENSURE

AFFORDABLE, ACCESSIBLE HEALTH COVERAGE FOR ALL

電子病歷期末報告描述美國全民健保法條與未來實施狀況

P97843012 魏文一1

(1) INVEST IN ELECTRONIC HEALTH INFORMATION TECHNOLOGY SYSTEMS.

(2) IMPROVE ACCESS TO PREVENTION AND PROVEN DISEASE MANAGEMENT PROGRAMS.

(3) LOWER COSTS BY TAKING ON ANTICOMPETITIVE ACTIONS IN THE DRUG AND INSURANCE COMPANIES.

(4) REDUCE COSTS OF CATASTROPHIC ILLNESSES FOR EMPLOYERS AND THEIR EMPLOYEES.

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(1) GUARANTEED ELIGIBILITY.

(2) NEW AFFORDABLE, ACCESSIBLE HEALTH INSURANCE OPTIONS.

(3) TAX CREDITS FOR FAMILIES AND SMALL BUSINESSES.

(4) EMPLOYER CONTRIBUTION.

(5) REQUIRE COVERAGE OF CHILDREN.

(6) EXPANSION OF MEDICAID AND SCHIP.

(7) FLEXIBILITY FOR STATE PLANS.3

(1) EMPLOYERS.

(2) SCHOOL SYSTEMS.

(3) WORKFORCE.

(4) INDIVIDUALS AND FAMILIES.

(5) FEDERAL, STATE, AND LOCAL GOVERNMENTS.

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描述美國全民健保法條與未來實施狀況

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美國醫療現況

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美國醫療系統三大特色• 全世界醫療費用最貴的國家

(GDP 16.3%(2.2trillion, $7,421 per person) in 2007)

• 唯一沒有全民健保的已開發國家(無保險人數達總人口 15%)

• 醫療市場資本化，藥價由保險公司與藥廠協商

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現有醫療保險體系（ 7 成私人、 3 成公立）

• 聯邦政府• 州政府• 私人保險（ 9 成雇主、 1 成私人購買）• 無保險者：地區安全網

（ local safety net ）收費依個人收入而定

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主管機關 -DHHS

• 食品藥品監督管理局（ FDA ）• 疾病控制及預防中心（ CDC ）• 健康照護與品質研究機構（ AHRQ ）• 國家衛生研究院（ NIH ）• 醫療保險及醫療計畫補助中心（ CMS ）

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聯邦政府• 老人（ 65 歲以上）健康保險制度

（ MediCare ）– Part A 住院保險

•可免費享有– Part B 門診保險– Part C 額外保險– Part D 藥費保險 (2006 年實施 )

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州政府• 低收入戶健康保險制度（ MedicAid ）• 兒童（ 14 歲以下）醫療保險制度

（ SCHIP ）• 北方福利較南方好

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私人保險（ 9 成雇主、 1 成私人購買）

• 管理式照護 (managed care)1973 HMO act– 健康維護組織（ HMO ）

•主動管理，保費較低•PCP 家庭醫師制度（ Primary care physician）

– 優先醫療機構計畫（ PPO ）•特約制、自付費用低

– 獨立醫療執業組織（ IPA ）• 醫療儲蓄帳戶（ health saving account ）

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無保險者：地區安全網（ local safety net ）

• 收費依個人收入而定• 社區健康中心• 公立醫院• 社區醫院• 慈善門診

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衛生及公共服務部（ DHHS ）• 食品藥品監督管理局（ FDA ）• 醫療保險及醫療計畫補助中心（ CMS ）• 國家衛生研究院（ NIH ）• 健康照護與品質研究機構（ AHRQ ）• 疾病控制及預防中心（ CDC ）

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公共衛生概況• 平均餘命（ 2008 ）

– 男： 78.14 歲– 女： 83.13 歲

• 成人慢性病盛行（ 20 年變化）– 肥胖與體重過重（ 22% to 32% ）– 糖尿病 (成長 20%)– 高血壓 (成長 7%)

• 死亡– 心臟病與惡性腫瘤佔 50%– 黑人死亡率 > 白人死亡率

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美國民眾費用支付習慣

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各年齡層就醫次數

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為何執行 Health Reform?

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美國醫療三大問題• 醫療費用昂貴• 無醫藥保險比例過高• 低效率，高管理費

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經濟危機• 2018 年時總醫療費用可能佔 GDP 的

20.3%

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MediCare 與 MedicAid 的支出龐大

• Medicaid 佔州預算 32%• Medicare 較不顯著

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美國無保險人口

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OBAMA 的全民健保

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HEARA: The Healthcare and Education Affordability

Reconciliation Act of 2010

• contained tax and budget related changes to the PPACA

• passed through reconciliation process

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• Health insurance market reform

• Health insurance market exchanges

• MEDICAID and CHIP

• Medicare

• Workforce and other provisions

PPACA: Patient Protect and Affordable Care Act(1)

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• Health insurance market reform ： (1)– High-Risk Health Insurance Pool Program– Health insurance for young adults– Pre-existing medical conditions– Lifetime and annual limits on benefits– Community living assistance services and

support program (CLASS act)


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• Health insurance market reform: (2)– Individual responsibility– Employer responsibility– Excise tax on health insurers


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• Health insurance market exchanges:– Health insurance exchanges– Premium assistance credits, caps on out-of-

pocket costs for health plans– Health care choice compacts


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• MEDICAID and CHIP:– Medicaid expansion– CHIP– Medicaid medical home pilot– Medicaid emergency psychiatric

demonstration– Medicaid community-based services– Medicaid accountable care organization pilot

program


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• Medicare:– Specialized Medicare advantage plans for

special needs individuals– Medicare Part D– Medicare medical home pilot program– Medicare accountable care organization

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• Workforce and other provisions: (1)– Co-location of primary and specialty care in

community-based behavioral health settings– National health service corps– Training for behavioral health professionals– Loan repayment for pediatric behavioral

health specialists in underserved areas

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• Workforce and other provisions: (2)– Educating primary care providers about

behavioral health– Community transformation grants– Community health workforce grants– National health care workforce commission– Federal definition of community mental health

centers

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The Promise

• All Americans guaranteed affordable, high quality healthcare

• The freedom to choose whatever doctor or health plan you want

• all that a savings of some $2,500 per family

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Features

• individual mandate• sufficient coverage• elimination of

underwriting• tax equity, subsidy

(indiv vs group)• public plan to

compete

• emphasis on prevention and wellness

• elimination of waste

• electronic data keeping

• comparative effectiveness

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Impact on stakeholders-1

• Employer– Eliminate and reduce the favored tax of

healthcare expense ($194.2B a year)– less control over plan designs offered to

employees• Carriers

– Competition from ''public plan''– inability to underwrite– increased regulation– shift to individual policies

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• TPAs (Third party administration)– potential loss of FSA(財務監管局 )/HRA(Health

reimbursement account) admin– potential gain of FSA substitution– shift from groups to individuals

• Broker and agents– Competition from connectors– shift to individual market– relief from underwriting

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• individuals– requirement to purchase insurance– Tax credits and subsidy– Reduced the tax advantage of HSAs, FSAs and

itemized deduction of medical expense – New ''sin taxes'' on products such as alcohol

and sugary soft drinks

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• providers– Reduced Medicare spending on home

healthcare, durable medical equipment, medical imaging and prescription drugs

– increased demand for services, especially primary care

– 5% bonus payment for office visits and other ''primary care services''

– Medicare

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Medicare policies

• increase payments to doctors who regularly exceed ''national benchmarks'' for the quality of care

• Bonuses to hospitals that provide superior care for heart attack, pneumonia and selected other conditions

• Doctors could receive extra payments if they hire nurses to manage follow-up care for chronic cases

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Medicare policies

• Government set national standards for the appropriate use of CT scans, MRI and other diagnostic imaging techniques

• Make single bundled payment for all services provided to a hospital patient. (Bad for nursing homes, home care, hospice, etc.)

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• Pharmaceuticals– Reduce government spending on

prescription drugs– Re-importation of drugs from other

countries to lower costs– Shift insurance coverage toward

prevention, could increase sales for heart, diabetes and other drugs that patients take long-term

– Increased Rx spend by $15~$18B41


• Wellness– Tax credits or other subsidies it

employers who offer wellness programs that meet federal criteria

– Make it easier for employers to use financial rewards or penalties to promote healthy behavior among employees

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• Health IT providers– $20B in Stimulus money– Electronic Health Records

• Marketing communications– Need to communicate new programs

• Benefits attorneys– Need to interpret new regulations

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期待• additional information and guidance from

the DHHS, Congress, IRS, insurance industry

• Repeal and replace• Reduce costs• Will employers eliminate coverage when

the Exchanges are implemented?• What happens in 2018 when the Cadillac

Tax become effective?

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未來實施時程規劃

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Early implementation

• Small business tax credits• Temporary retiree medical reinsurance pool

to help employers lower costs for early retirees (2010~2014)

• insurance market reforms• 10% excise tax on indoor tanning services

(July1)• Health & Human Services (HHS) to develop

informational website portal (July1)• Relief begins for retirees in the Medicare Part

D coverage gap ''donut hole'' 46

Six months after enactment

• eliminate lifetime limits and annual limit restrictions• eliminate pre-existing condition limitations for

children• expand dependent coverage• cover preventive care• require nondiscrimination testing • New coverage appeals processes• emergency services must be covered as in-network

services• designate any in-network doctor as a primary care

physician

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2011

• spending account restrictions• new W-2 reporting requirements• CLASS Act (Community Living Assistance

Services and Supports Act)

• Uniform standards developed by HHS for communicating benefit provisions

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2012 & 2013

• implement uniform standards for communicating benefit information with $1000 fine for each failure

• Salary reduction to FSAs are limited to $2,500, with annual index (2013)

• Employers must notify employees plan benefits and Exchanges

• Annual comparative effectiveness research fee of $2 per member assessed on fully insured plans

• Individuals with earnings greater than $200,000 and households with earnings greater than $250,000 subject to additional taxes

• eliminate the tax reduction for employers who receive Medicare D retiree drug subsidy payments

• New taxes on the industry providers and manufactures49

2014• Requires U.S. citizens and legal residents to have

insurance or pay penalty• State based Exchanges established for individuals and

small groups to purchase coverage with required benefit plans being offered

• Employers with 50+ employees are required to coverage or pay a penalty

• minimum essential benefits must be offered to individuals and small groups outside the exchange- Grandfathered and large employers plans are exempt

• Premium and cost sharing credits for low-income individuals (up to 400% of FPL)

• Employers with 200+ employees must automatically enroll employees (out-put)

• Maximum waiting period limited to 90 days 50

Beyond 2014

• Insurance industry taxes begin which impact fully insured plans

• eliminate pre-existing condition limitations and annual limits

• Cadillac Tax becomes effective in 2018

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待釐清問題

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Thank youThank you

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obama & biden's health reform: accessible health coverage for all

Health & Medicine