The Affordable Care Act: Its Impact on Cancer Care in Maine

Trish Riley, Senior FellowMuskie School of Public Service, USM

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Goal?

Access to Affordable, Quality health care for everyone in the United States

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The Long National Debate

• Everybody was self pay–INDIVIDUAL CHOICE

• 1912–Teddy Roosevelt and the Bull Moose Party –Universal coverage for all–GOVERNMENT

• 1929–Baylor Hospital pre-paid health plan for teachers–(.50/mo for 21 hospital days)–PRIVATE SECTOR

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Mixed Model–Private and Public

Government–Wage and price controls–WWIIEmployers–Offer health insurance instead

– Tax deductibility post-war

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The Debate Continues for the Next 60 Years…

Truman (1940’s-post war)–Universal coverageFAILED

Johnson (1965)–Medicare and Medicaid Incremental

Nixon (1970s)–Employer mandateFAILED

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The Debate Continues…

Clinton: Universal coverage plan/managed competition–Republican alternative–Individual mandate–Congress rejects; big players (AMA, HIAA) oppose

Congress: State Children’s Health Insurance

Bush: Medicare Pt D., but with a donut hole

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After 100 Years of Trying…

Where did our pre-ACA system get us?

◦ Patchwork quilt

◦ Pay twice what other developed nations do

◦ We don’t get better health

◦ We leave 47 million uninsured

The Commonwealth Fund 8

Health Spending per capita, 2009adjusted for differences in cost of living

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TX

FL

NMGA

AZ

CA

WY

NV

AK

OK

MSLA

MTWA

OR ID SD

ND

MNWI

MI

AR

OH

AL

PA

NY

ME

MA

NHVT

HI

UTCO

KS

NEIA

MO

IL IN

KY

WVVA

NC

SC

DCMD

DE

NJ

CTRI

Source: KFF, Income, Poverty, and Health Insurance Coverage in the United States: 2010. United States Census Bureau, Sept. 2011. Percentages are two-year averages, 2009–2010; national average is 16.2% over the two-year period.

5%–<11% uninsured

11%–<16% uninsured

16%–<20% uninsured

20%–25% uninsured

TN

Rates of Uninsured

•

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Health Insurance Coverage ofthe Nonelderly Population, 2010

266.0 Million

SOURCE: KCMU/Urban Institute analysis of 2011 ASEC Supplement to the CPS.

Private Non-group

5.5%

Over $750 Billion Wasted Annually

$340

$190

$105

$75

$55

Unnecessary/Inefficient CareExcessive Administrative CostsPrice too highFraudMissed Prevention

In Billions of U.S. Dollars, Source: IoM The Healthcare Imperative: Lowering Costs and Improving Outcomes (2011) Riley, USM

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US Spends More than Peer Nations

• More hospital care• Higher administrative costs/complexity• Higher prices• Higher staff ratios• More surgery/procedures–no better outcomes

(more MRIs, CT)

McKinsey Global Institute, 2011

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IOM: “Shorter Lives, Poorer Health”

US vs. Other Industrialized Countries:• Lower life expectancy• Higher infant mortality/low birth weight• More disability• More obesity, heart disease, COPD• EVEN WHEN CONTROLLING FOR RACIAL AND

ETNIC DISPARITIES

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What about Cancer Care?

• US spends more on cancer care than European countries and US does better re: longevity– Especially breast and prostate

• BUT do we diagnose earlier?• Is longevity the same as quality of life?• What is the metric here?

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ACA–The Law of the Land

• Patient Protection and Affordable Care Act – Or ObamaCare

• Signed into law by President Obama, March 23, 2010

• Supreme Court Challenge, June 27, 2012• Full Implementation in 2014

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How Does ACA address: The Triple Aim

• Access• Cost• Quality

Reforms phased in

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Overview

• All must be covered–but subsidies to help–Medicaid to 133%/simplified until SCOTUS• 24 states still say NO, including Maine

– Tax credits 133-400% fpl• New marketplaces for individuals and small

business–Travelocity/state based• Employers provide or pay penalty if EEs get

subsidy• New investment in cost and quality reforms

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Access

• Maintains employer coverage– Penalties if employees access subsidies– Small business exempted– Grandfathers plans

• Individual mandate• Young adults–parental coverage to 26• Medicaid expansions to 133% FPL (optional)• Tax credits (subsidies) to 400% FPL

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Access (cont’d)

• Investments in health centers/workforce• Insurance reforms– Cannot be denied coverage– No pre-ex/recissions– No annual or lifetime limits– Essential health benefits/qualified health plans

• Limits coverage costs based on income– Cannot exceed 9.5% income– OOP limits: $6,350 ind/12,700 family

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Medicaid Exchange

Income ≤133% FPL$15,520

133-250% FPL$15,521-29,172

251-400% FPL$29,173-46,600

Premiums None Limited to 3.00-8.05% of Income

Limited to 8.05-9.50% of Income

Cost SharingLimited to nominal amounts for most

servicesCredits based on

sliding scaleLimited to

$6,350/12,700

Medicaid vs. Subsidized Exchange Coverage: Differences in

Eligibility and Benefits

Kaiser Family Foundation

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How Subsidies Work

Older couple in Thomaston ME with anIncome of $30,000 (193% FPL)

Premium : $14,325/yrTax Credit: $12,526

THEY PAY: $ 1,800/yr

OOP limit: $4,500

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Costs/Affordability

• Coverage reduces hidden tax of charity care• 100% coverage for prevention/immunization– USPSTF A and B– Breast, cervical, colorectal screening

• Insurance Exchanges–States– Choice of plans–bronze, silver, gold, platinum/transparency– Members of Congress

• Small business tax credits

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Costs (cont’d)

• Pt. D–Donut hole• Payment Reform Demos• CMS Center for Innovation• Insurance reforms– Rate review– Medical loss ratio–must spend at least 80% on care

– Community rating–sick won’t pay more

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Quality

• National Quality Strategy• Prevention and Public Health Trust Fund• Non-payment for hospital acquired infections

and re-admissions• Demos to promote quality

– Team approaches– Health homes, etc.

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Patient-Centered Outcomes Research Institute

• Authorized thru 2019 @ $3.5 Billion– Funded by general fund and fee on all insurers

• “To provide info on best available evidence to help patients and providers make more informed decisions…and

• Give patients better understanding of prevention, treatment and care options and science that supports them

• www.pcori.org

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From “Death Panels” to Palliative Care

• Penalties for re-admission within 30 days• ACOs and Medical homesIssues:◦ Who manages cancer care in a medical home?◦ How are prevention and screening assured?◦ Will there be registries, outreach, reminders?◦ Does continuity of care include palliative, end-of-

life and survivorship?◦ Will NCCN guidelines be used?

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Consultants in Medical Oncology and Hematology, PC

• Serves three health systems in SE Pennsylvania• First oncology practice to receive NCQA Level

III Physician Practice Connections–PCMH designation–April 2010

• Key characteristics:– Partnership patient/practice – Oncology manages cancer care and links with PCP– Specialized, improved EMR–measure

quality/improve outcome

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Comprehensive Reform

• Requires new ways of doing business• Payment and delivery reform–Pay for

outcomes, not volume of procedures–Patient centered

• Are ACOs, medical homes, team practice going to work? How will we know? Data?

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Hope for Cancer Care

• Prevention focus• No more job lock–everybody can get health

coverage and sick don’t pay more• Affordability–subsidies/Medicaid (except here)• Coverage for clinical trials• More Rx coverage (Medicare Donut hole)• Payment reform and innovation• Outcomes research/patient engagement

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Health Reform is a Journey, Not a Destination

• Not universal–Still leaves many uninsured• Work in progress• But remember: It’s taken 100 years to get here