women's health in primary care norma jo waxman md the impact of health care reform on women’s...
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Women's Health in Primary Care
Norma Jo Waxman MD
The Impact of Health Care Reform on Women’s Health Services
Norma Jo Waxman MDNorma Jo Waxman MD
Private Practice, San FranciscoPrivate Practice, San Francisco
Associate Professor of Family and Community MedicineAssociate Professor of Family and Community Medicine
University of California San FranciscoUniversity of California San Francisco
[email protected]@fcm.ucsf.edu
Women's Health in Primary Care
Norma Jo Waxman MD
Objectives:
■At the end of the talk participants will be able to:
■Describe 5 highlights of the Affordable Care Act (health care reform) implemented in 2010
■List 3 components of the health care reform which will directly impact women's health care preventive services
■List 3 features of coverage for abortion in state health insurance exchanges
Women's Health in Primary Care
Norma Jo Waxman MD
Acknowledgments
■ Thanks to Michael Policar and Tracy Weitz for generously sharing their slide sets
■ Thanks to the Kaiser Family Foundation for their fantastic analysis and coverage of this subject
Women's Health in Primary Care
Norma Jo Waxman MD
Health Care Reform is a Woman’s Issue
Women's Health in Primary Care
Norma Jo Waxman MD ■ Access is worsening■ 46 million Americans lack health
insurance■ 38 million 10 years ago
■ Health outcomes are inferior■ USA: 31st life expectancy, 37th
infant mortality
■ Costs continue to escalate■ 1993: $1 trillion, 2012: $3 trillion■ National spending/ person
■1960:$1,066 ■2007: $7,421 ■2018: $13,100
Why Health Reform Now?
Women's Health in Primary Care
Norma Jo Waxman MD
Women's Health in Primary Care
Norma Jo Waxman MD Access is worsening– 46 million Americans no insurance– 38 million 10 years ago
Health outcomes are inferior– USA: 31st life expectancy, 37th infant
mortality Costs continue to escalate– 1993: $1 trillion, 2012: $3 trillion– National spending/ person–1960:$1,066 2007: $7,421 –2018: $13,100
Why Health Reform Now?
Women's Health in Primary Care
Norma Jo Waxman MD
Making Sense of Health Care Reform
■What does the new law do?
■How will this help uninsured women?
■Key Issues for Women:■Affordability ■Preventive Services■Primary Care■Reproductive Health■Medicare/Long-term care
Women's Health in Primary Care
Norma Jo Waxman MD
What does the law do?
Women's Health in Primary Care
Norma Jo Waxman MD
“Patient Protection and
Affordable Care Act” (ACA)
First step: First step: Expand access to health Expand access to health insuranceinsurance
Everyone has coverageEveryone has coverage Fairer insurance practicesFairer insurance practices Expand coverage to 32 Expand coverage to 32 million by 2019million by 2019
Second step: Improve quality of careSecond step: Improve quality of care Change the practice of Change the practice of medicinemedicine
Third step:Third step: Stabilize cost of health care Stabilize cost of health care Improve efficiencyImprove efficiency Reduce fraud and wasteReduce fraud and waste
The ACA is just the beginning of health reformThe ACA is just the beginning of health reform
Women's Health in Primary Care
Norma Jo Waxman MD
A Three Part Formula
■Require insurers to offer coverage to anyone who wants it
■Require everyone to have health insurance■Preferred way to cover pre-
existing conditions■Broaden risk pool to include
healthy + less healthy
■Help people to afford the coverage that they are required to have through government subsidies
Women's Health in Primary Care
Norma Jo Waxman MD All citizens, legal immigrants must have coverage
Tax penalty no coverage (2016)higher of– $695/person; up to 3x for a family, or – 2.5% of household income
Exemptions granted for– Undocumented persons– No coverage for less than 3 months– Lowest cost plan > 8% personal
income– Financial hardship or Religious
objection
Why The Individual Mandate
Women's Health in Primary Care
Norma Jo Waxman MD
Promoting Health Coverage
Medicaid Coverage
(up to 133% FPL)
Employer-Sponsored Coverage
Exchanges(subsidies 133-
400% FPL)IndividualMandate
Health Insurance Market Reforms
Universal Coverage
Women's Health in Primary Care
Norma Jo Waxman MD
Health Reform Implementation Timeline
Women's Health in Primary Care
Norma Jo Waxman MD
How Insurance Expansion Works
Women's Health in Primary Care
Norma Jo Waxman MD
■ State regulated “insurance marketplaces”■ Consumers will compare plans by quality
and cost■ All will offer the same “essential benefits”■ Optional participation by health insurance
plans
■ Subsidies for families 133-400% FPL ($88K family of 4)■ Premium credit (toward purchase of
insurance), and■ Cost-sharing credit (rebate on OOP costs)
■ Limited to citizens, legal immigrants
What Are State Health Insurance Exchanges?
Women's Health in Primary Care
Norma Jo Waxman MD
Problem Example Solution When
Recission If costly disease, insurance revoked retroactively
Prohibited 9/2010
Gender rating Women charged more than men for the same coverage
Prohibited 1/2014
Exclusion of pregnancy coverage
Only 13% of individual plans now include pregnancy coverage
Guaranteed maternity coverage
1/2014
Pre-existing condition exclusions
38% women denied coverage• Prior pregnancy• Prior caesarean section• Domestic violence
Prohibited 1/2014
Market Reforms… Individual and Small Group
Women's Health in Primary Care
Norma Jo Waxman MD
Who will it help?
Women's Health in Primary Care
Norma Jo Waxman MD
Insured through employer
MilitaryVeterans Admin
Undocumentedindividuals
Little or no change
Medicare Medicaid
Minor changesMinor changes
Uninsured Self employed
Major changes
Small business
Women's Health in Primary Care
Norma Jo Waxman MD
Major ChangesMajor Changes
Uninsured Self employed Small business(50-100)
50%
100%
State Health Insurance Exchanges
MedicaidMedicaid
50%
California Health Benefit Exchange
Small Business Health Options Program
? ?
EmployerEmployerbasedbased
Women's Health in Primary Care
Norma Jo Waxman MD
New Insurance Protections in 2014
■ Insurance Reforms■ Modified community rating
■ Prohibit insurers charging people more based on gender, health status, or occupation
■ Variations in premiums based on age (3 to 1) & tobacco use (1.5 to 1) would be limited
■ Bans on pre-existing condition exclusions
■ Prohibits annual and lifetime limits
■ Guarantee issue and renewability (regardless of health status)
■ Benefit Standards (uniform benefits packages within tiers of coverage)
Women's Health in Primary Care
Norma Jo Waxman MD
Assistance For Uninsured Women Under Health Reform
Other includes programs such as Medicare and military-related coverage. The federal poverty level for a family of four in 2009 was $22,050.
SOURCE: KFF/Urban Institute analysis of 2010 ASEC Supplement to the Current Population Survey, U.S. Census Bureau.
96.2 million women ages 18-64
Medicaid <138%
Type of Assistance Potentially Available in 2014
Tax Credits 139-399%
No Subsidies > 400%
19.1 million Uninsured
20%
Medicaid12%
Individual6%
Employer59%
Other3%
Women's Health in Primary Care
Norma Jo Waxman MD
Preventive Screening Services
U.S. Preventive Taskforce A and B Level Recommendations
Lifestyle/Healthy Behaviors
Cancer STI/STDs Chronic Conditions Pregnancy
Alcohol Screening Colorectal HIV Hypertension Tobacco
Depression Screening
Breast Screening Gonorrhea Diabetes Rh Incompatibility Screening
Healthy Diet Counseling
Breast Chemoprevention
Chlamydia Obesity Screening Hepatitis B Screening
Tobacco Breast/Ovarian High Risk/BRCA
Syphilis Osteoporosis Iron Deficiency Anemia Screening
Immunizations Cervical Cancer Lipid Disorders Bacteriurea Screening
U.S.P.S.T.F. A and B Recommendations • No Cost Sharing• Medicare, Medicaid, Qualified Health Plans
Women's Health in Primary Care
Norma Jo Waxman MD
Expanding Covered Prevention Services
■ Institute of Medicine “Preventive Services for Women”
■ Report due 8/2011
■ Key Questions■ What is the scope of preventive services for women not
included in those graded A and B by the USPSTF?
■ What additional screenings and preventive services have been shown to be effective for women? Consideration may be given to those services shown to be effective but not well utilized among women disproportionately affected by preventable chronic illnesses.
■ What services and screenings are needed to fill gaps in recommended preventive services for women?
■ What models could HHS and its agencies use to coordinate regular updates of the comprehensive guidelines for preventive services and screenings for women and adolescent girls?
Women's Health in Primary Care
Norma Jo Waxman MD
Expanding Covered Prevention Services
■The battle to include contraception has started!!!
■ Pro: contraception “prototype” of preventable medicine
■ Con: Pregnancy is not a “disease” to be prevented
Women's Health in Primary Care
Norma Jo Waxman MD
Key Issues for Women
Women's Health in Primary Care
Norma Jo Waxman MD
Impact of Health Reform on Women’s
Reproductive Health Services
■ Direct access to Ob-Gyns (qualify as a medical home)
■ Ends pre-existing coverage exclusions for women who are pregnant, prior c-section, IPV history, breast mass
■ Maternity Care
■ Maternity and newborn care defined as essential benefit in plans
■ Medicaid coverage for all newborns who lack acceptable coverage
■ Tobacco cessation for all pregnant women
■ Grants to states for home visitation programs
■ Grants to states for postpartum depression services
■ Workplace breastfeeding protections for nursing mothers
■ Option to cover midwife-led birth centers
.
Women's Health in Primary Care
Norma Jo Waxman MD
Reproductive Health Services (con’t)
■ STIs/HIV
■ Screening for HIV, Chlamydia, Gonorrhea, Syphilis considered preventive services in benefit package in Medicaid and Medicare (no cost sharing effective 2011) and Exchange plans (2014)
■ Teen Pregnancy Prevention
■ Establishes a new state program for evidence based education to reduce teen pregnancy and STIs. ($75m/year)
■ Restores Abstinence Only Funding ($50m/year)
■ Abortion Coverage Excluded
.
Women's Health in Primary Care
Norma Jo Waxman MD
So…What is a SPA??
■ Family Planning State Plan Amendment authorized in Section 2303 of the ACA
■ Capitalize on the success of federal “1115 waivers”■ Contraceptive and “FP-related” services available to persons
not eligible for Medicaid■ Optional for states to choose SPA (or not); may convert
existing 1115 Waiver to SPA (or not)■ Programs operate side-by-side with Title X grants■ CMS released guidance (7/10) but not final regulations
Waivers SPAs
Budget neutrality Required Not required
Research/ Evaluation Required Not required
Renewal Every 3 yrs None
Eligibility State discretion Men, teens included
DRA eligibility requirements
Incompletely enforced Fully enforced
Women's Health in Primary Care
Norma Jo Waxman MD
Contraceptive services for women and menContraceptive services for women and men ““FP-related” conditions FP-related” conditions identified at a FP identified at a FP
visitvisit– STI screening, diagnosis, and treatment STI screening, diagnosis, and treatment
(except drugs for HIV and hepatitis)(except drugs for HIV and hepatitis)– Lower urinary tract infectionsLower urinary tract infections– Genital skin infections and disordersGenital skin infections and disorders– HPV vaccinationHPV vaccination– Treatment of major contraceptive Treatment of major contraceptive
complicationscomplications Transportation must be covered (as per Transportation must be covered (as per
Medicaid)Medicaid)
AGI, NFPRHA 2010AGI, NFPRHA 2010
Family Planning SPA: Covered Services
Women's Health in Primary Care
Norma Jo Waxman MD
Both women and men of all ages must be Both women and men of all ages must be coveredcovered
Medicaid rules relating to citizenship and Medicaid rules relating to citizenship and immigrationimmigration
States may choose to provide presumptive States may choose to provide presumptive eligibilityeligibility– Citizenship documentation is not Citizenship documentation is not
requiredrequired– Eligibility ends on day of eligibility Eligibility ends on day of eligibility
determination or no later than the last determination or no later than the last day of the following monthday of the following month
AGI, NFPRHA 2010AGI, NFPRHA 2010
Family Planning SPA: Client Eligibility
Women's Health in Primary Care
Norma Jo Waxman MD Minimum income limit is Minimum income limit is << 133% of 133% of Federal Poverty Level (FPL), but Federal Poverty Level (FPL), but higher thresholds permittedhigher thresholds permitted– Eligibility formula same as for Eligibility formula same as for
pregnant womenpregnant women– May count applicant as two May count applicant as two
people…men included!people…men included! For example, at 200% of FPLFor example, at 200% of FPL
−Single woman: Single woman: $21, 660$21, 660
−Single pregnant woman:Single pregnant woman:$29,140$29,140
AGI, NFPRHA 2010AGI, NFPRHA 2010
Family Planning SPA: Income Eligibility
Women's Health in Primary Care
Norma Jo Waxman MD
Family Planning SPA: Barriers to Adoption
State share of cost; competing State share of cost; competing state budget prioritiesstate budget priorities
State political process & “sensitivities” State political process & “sensitivities” ■ Perception that support of family Perception that support of family
planning programs is equivalent to planning programs is equivalent to support of abortionsupport of abortion
■ SPA requires contraceptive SPA requires contraceptive services for adolescentsservices for adolescents
Undersupply of primary care Undersupply of primary care providers…could be worsened by providers…could be worsened by ““diversion” to family planning servicesdiversion” to family planning services
Women's Health in Primary Care
Norma Jo Waxman MD
Family PACT services averted Family PACT services averted 205,000* pregnancies that would 205,000* pregnancies that would
have led to…have led to…
94,000
79,000
30,000
2,000
Avert
ed P
regnancy
Outc
om
es
CY 2002
UnintendedbirthsAbortions
Miscarriages
EctopicPregnancies
*due to the provision of contraceptive services to females only*due to the provision of contraceptive services to females only
Women's Health in Primary Care
Norma Jo Waxman MD
Long Term Care: The Forgotten Women’s Issue
Nursing Home Residents Home Health Users
Total = 1.5 million
Private room average $77K/year
Total = 2.5 million
average $29/hour
Women's Health in Primary Care
Norma Jo Waxman MD
CLASS ACT: New Help for Long-Term Care Costs
■ Voluntary saving program to provide cash benefit to those with disabilities to purchase non-medical services and supports
■ Working adults can make voluntary contributions through payroll deductions through employer or directly.
■ Adults with multiple functional limitations or cognitive impairments eligible for cash benefits if they have paid monthly premiums for at least 5 years and have been employed during 3 of those 5 years.
■ Cash benefit can be used for non-medical services and supports necessary to maintain community residence as well as institutional care
■ Cash benefit is based on the degree of impairment or disability, averaging no less than $50 per day.
■ CLASS will generally be the primary payer for individuals who are also eligible for Medicaid.
Women's Health in Primary Care
Norma Jo Waxman MD
Other Improvements for Seniors
■Helps Improve Coverage for 50-65 Year-Olds■Healthier When They Turn 65
■Improves Protections for Seniors in Nursing Homes
■Provides Incentives for Improved Quality in Delivery of Health Care
■Improves Part D for Low-Income Seniors
Women's Health in Primary Care
Norma Jo Waxman MD
Medicare’s Drug Benefit is Inadequate
■Deductible – Seniors Pay 100%■Grew from $250 in 2006 to $310 in 2010
■Basic Benefit – Seniors Pay 25%■$250 to $2250 in 2006 ■$310 to $2830 in 2010
■Donut Hole – Seniors Pay 100%■$2250 to $5100 in 2006■$2830 to $6440 in 2010
■Catastrophic Threshold – Seniors Pay 5%■$5100 in 2006 -- $6440 in 2010
Women's Health in Primary Care
Norma Jo Waxman MD
Reform Lowers Prescription Drug Costs
■Closes Part D Donut Hole■$250 Rebate in 2010■50% Discount on Brand-Name Drugs
in 2011■Co-Pays Reduced to 25% for Both
Brand-Name and Generics by 2020
■Easier to Reach Catastrophic Limit■Senior Out-of-Pocket Spending Plus
Drug Company Discounts Counted■Threshold Rises More Slowly
■Typical donut hole savings for seniors■$250 in 2010■$700 in 2011■$3,000 by 2020
Women's Health in Primary Care
Norma Jo Waxman MD
Physician Payment Initiatives
MedicareMedicare■ 10% PCP bonus if charges for 10% PCP bonus if charges for
office visits, SNF and home office visits, SNF and home visits are >60% total Medicare visits are >60% total Medicare paymentpayment
■ 10% Gen Surgeon bonus in 10% Gen Surgeon bonus in shortage areas (2011-16)shortage areas (2011-16)
■ Mental health services: 5% Mental health services: 5% bonusbonus
MedicaidMedicaid■ PCPs paid Medicare rates for PCPs paid Medicare rates for
E/M visits, immunizations in E/M visits, immunizations in 2013-142013-14
Women's Health in Primary Care
Norma Jo Waxman MD
Physician Payment Initiatives
Medicare SGR Medicare SGR (sustainable growth rate (sustainable growth rate formula)formula)
− Temporarily on hold Temporarily on hold Medicare Relative Value PaymentsMedicare Relative Value Payments
− Possibly more for E/M; taken from surgical Possibly more for E/M; taken from surgical services services
Independent Medicare Advisory Board (IMAB) Independent Medicare Advisory Board (IMAB) 20152015
− Recommend payment cuts, but not servicesRecommend payment cuts, but not services Medicare Value Based Payment Modifier Medicare Value Based Payment Modifier
(2015)(2015)
− Adjustment to rates based on quality& cost Adjustment to rates based on quality& cost performanceperformance
Women's Health in Primary Care
Norma Jo Waxman MD
Post Partum Depression
Federal support for patient Federal support for patient education, research, and clinical education, research, and clinical treatment treatment
2010 to 2019 NIMH longitudinal 2010 to 2019 NIMH longitudinal studystudy
$3M grants in 2011 and 2012 $3M grants in 2011 and 2012 through community health centers through community health centers and others for inpatient and and others for inpatient and outpatient counseling and other outpatient counseling and other servicesservices
Public service radio and TV adsPublic service radio and TV ads
Women's Health in Primary Care
Norma Jo Waxman MD
8% of women in US will not have coverage8% of women in US will not have coverage– Mainly undocumented or women between Mainly undocumented or women between
jobs jobs – Clinics will continue as a safety net Clinics will continue as a safety net
providersproviders 92% of women in US will have full coverage92% of women in US will have full coverage– During transition years, Feds and states During transition years, Feds and states
will continue support thru SPAs, 1115 will continue support thru SPAs, 1115 waivers, Title Xwaivers, Title X» Primary care provider shortagePrimary care provider shortage» Enrollment challengesEnrollment challenges
Look to Massachusetts!!Look to Massachusetts!!
The Future of Family Planning Clinics
Women's Health in Primary Care
Norma Jo Waxman MD 1973: Hyde Amendment: no federal 1973: Hyde Amendment: no federal funding for abortion, unless the funding for abortion, unless the pregnancypregnancy is the result of “rape or is the result of “rape or incest” or “would, as certified byincest” or “would, as certified by a a physician, place the woman in danger of physician, place the woman in danger of death unless an abortiondeath unless an abortion is performed”is performed”
CurrentlyCurrently– 17 states cover all or most medically 17 states cover all or most medically
necessary abortions under Medicaidnecessary abortions under Medicaid– 33 states provide no or minimal 33 states provide no or minimal
Medicaid coverage of abortion Medicaid coverage of abortion beyond federal requirementsbeyond federal requirements
Federal Funding of Abortion
Women's Health in Primary Care
Norma Jo Waxman MD The Stupak-Obama CompromiseThe Stupak-Obama Compromise– Presidential Executive Order (3/24/10)Presidential Executive Order (3/24/10)– No federal subsidies for abortion coverage No federal subsidies for abortion coverage
beyond Hydebeyond Hyde– Applies to exchanges, Medicaid, Applies to exchanges, Medicaid,
Community Health Center Fund Community Health Center Fund In state health insurance exchanges (starting In state health insurance exchanges (starting
in 2014)in 2014)– At least 1 plan that covers + 1 does not At least 1 plan that covers + 1 does not
cover abortioncover abortion– No plans can be required to offer abortion No plans can be required to offer abortion
coveragecoverage– State laws may ban abortion coverage in State laws may ban abortion coverage in
exchangeexchange
The Impact of the ACA on Abortion
Women's Health in Primary Care
Norma Jo Waxman MD
Plans in exchange that cover abortionPlans in exchange that cover abortion– Must notify enrollees of abortion benefitMust notify enrollees of abortion benefit– Must pay with “separate check” for Must pay with “separate check” for
abortion coverageabortion coverage– Abortion premiums and pay-outs are Abortion premiums and pay-outs are
kept in separate account, apart from kept in separate account, apart from taxpayer moneytaxpayer money
No plan can discriminate against a provider No plan can discriminate against a provider or facility because of unwillingness to or facility because of unwillingness to provide abortion servicesprovide abortion services
Does not apply to health plan products that Does not apply to health plan products that have no members with federal supporthave no members with federal support
The Impact of the ACA on Abortion
Women's Health in Primary Care
Norma Jo Waxman MD Extends the Hyde Amendment to middle class Extends the Hyde Amendment to middle class individuals using state health insurance individuals using state health insurance exchangesexchanges
Sends the message that abortion is not “health Sends the message that abortion is not “health care”care”
Further institutionalizes the moral view of Further institutionalizes the moral view of some members ofsome members of CongressCongress
Unlikely that many women will write the Unlikely that many women will write the “separate check…will not have coverage when “separate check…will not have coverage when they need itthey need it
The Impact of the ACA on Abortion
Women's Health in Primary Care
Norma Jo Waxman MD
Opportunities for Engagement
■ Family Planning/Contraceptive Coverage■ No specific mention as a benefit in package
or as preventive service■ Not addressed in USPSTF guidelines■ HSS requested IOM convene a committee of
experts to further define women’s preventive services
■ States can establish Medicaid family planning programs without federal waiver to prenatal eligibility levels
■ States can establish SPAs
■ Advocates will need to be engaged throughout the process locally, at the state-level and nationally
Women's Health in Primary Care
Norma Jo Waxman MD
Summary: IMPLEMENTATION is a key women’s health issue
■ Implementation: Ongoing need for women to be vigilant and involved in process
■ Affordability and Scope of Coverage: Still central concerns for women
■ Reproductive Health: Improvements in some areas and retrenchment in others. States will continue to play a pivotal role
■ Primary Care and Prevention: Investments in building primary care infrastructure and prevention important but may not be sufficient
■ Long-term Care: CLASS is something to build on… but will still fall short, esp. for low-income women and their families who don’t qualify for Medicaid
■ Excluded Populations: Many women (and men) will not qualify for assistance because of their immigration status. Safety-net providers will still be critical