Implementing Health Reform and Improving MCH: Opportunities Kay Johnson, MPH, EdM February 14, 2012 Association of Maternal and Child Health Programs, Washington DC
Acknowledgements This presentation builds on thinking from: New issue briefs from the Center for the Study of Social Policy (www.cssp.org), project on: Health Reform Implementation: Opportunities for Place- Based Initiatives. and project director Amy Fine. The national Preconception Health and Health Care Initiative, Policy and Finance Work Group, particularly my past and current Work Group co-chairs Sara Rosenbaum and Susan Wood at The George Washington University. Johnson. Health Reform Opportunities. AMCHP, 2012.
What is not happening that should be in terms of women s health? In the current US health care system: Millions of uninsured women. The quality of primary care for millions of women of childbearing age is inadequate. Many providers not focused on reproductive risks, preconception health, or recurring adverse pregnancy outcomes. Prevention messages not reaching women. Johnson. Health Reform Opportunities. AMCHP, 2012.
What might health reform bring? Health coverage for millions of women currently uninsured or underinsured Greater affordability of care Improved benefit packages Changes in the delivery system More emphasis on prevention, wellness, and social determinants Johnson. Health Reform Opportunities. AMCHP, 2012.
What does ACA implementation mean in terms of health for women and infants? Overarching Issues Know thine Exchange Plan for Medicaid expansion Understand benefits design Take action on prevention strategy Empower consumers with information about their benefits and rights Monitor performance Johnson. Health Reform Opportunities. AMCHP, 2012.
What does ACA implementation mean in terms of health for women and infants? Know thine Exchange Start now Health Insurance Exchanges: Starting January 1, 2014, Exchanges will help individuals and small businesses compare plans, choose from Qualified Health Plans (QHPs), enroll, apply for subsidies, etc. Marketplace for individuals and small businesses Role in consumer informing and eligibility determination process Some states have started design (e.g., CA, CO, MI, MN, NV, RI, VT) Exchange QHPs use essential health benefits Plans sold through Exchange (2014) Four levels of QHPs ( metals ) plus catastrophic plan Sliding scale tax credits and subsidies on out-of-pocket costs for those with income up to 400% FPL. (2014) Suggested reading: http://www.whitehouse.gov/sites/default/files/01-18-12_exchange_report.pdf Kingsdale J and Bertko J. Insurance exchanges under health reform: Six design issues for the states. Health Affairs. 2010; 29(6);1158-1163
Source: Johnson. Community Roles in Assuring Coverage and Benefits. Health Reform Implementation: Opportunities for Place-Based Initiatives. Issue Brief #3. January 2012. www.cssp.org
What does ACA implementation mean in terms of health for women and infants? Plan for Medicaid Expansion Medicaid with income to 133% (138%) FPL (2014) How will eligibility and enrollment process be set up? Apply what was learned from CHIP, worry about churning Understand benefits for newly eligible For women s reproductive and preconception health Medicaid family planning coverage (under SPA, without waiver) for women (NOW) Interconception care demonstration waivers (NOW) CMS Center for Innovation opportunities (NOW)
What does ACA implementation mean in terms of health for women and infants? Preventive Benefits Eliminates cost sharing on preventive services for new, not grandfathered, private plans (includes individual small group, large group and selfinsured employer plans) 1. U.S. Preventive Services Task Force (A or B) (9/23/2010) 2. Advisory Committee on Immunizations (9/23/2010) 3. Preventive services for children (9/23/2010) Bright Futures Secretary s Advisory Committee on Heritable Disorders in Newborns and Children 4. Preventive services for women based on IOM (8/1/2012)
What does ACA implementation mean in terms of health for women and infants? Women s Preventive Services Based on IOM recommendations the women s clinical preventives services covered without cost sharing for new, not grandfathered plans (8/1/2012) Well-woman visits (including prenatal and preconception) Contraction methods (all FDA approved) and related counseling HPV screening with DNA test STI counseling and HIV screening/counseling Breastfeeding support, supplies, and counseling Domestic violence screening Gestational diabetes screening
What does ACA implementation mean in terms of health for women and infants? Essential Health Benefits Essential Health Benefits for Qualified Health Plans (QHPs) through Exchange. Categories defined: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental Health and substance use disorder services Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Preventive & wellness services and chronic disease management Pediatric services, including oral and vision care. HHS to develop details. Dec. 2011 Bulletin proposed flexibility for states. Preventive services rules apply over and above this list and to a broader array of plans See Center for Consumer Information and Insurance Oversight. Essential Health Benefits Bulletin. December 16, 2011. http://cciio.cms.gov/resources/files/files2/12162011/essential_health_benefits_bulletin.pdf
Essential Benefits for 68 million Americans Individual Private Market Qualified health plans purchased through the state or federal Exchanges at any of the four defined levels (platinum, gold, silver, and bronze); Catastrophic health plans for eligible persons (e.g., persons under age 30, those who face hardships) purchased through the Exchanges; Individual and family policies or plans purchased outside the Exchanges in the individual market; Plans offered by Consumer Operated and Oriented Plans (CO-OPs) (nonprofit, member-run); Plans offered through Interstate Health Care Choice Compact; and Multistate plans, offered by the federal Office of Personnel Management. Small Group Private Market Qualified health plans purchased by small businesses via the Exchanges; Small employer-sponsored insurance plans purchased outside the Exchange; QHP offered by CO-OPs (nonprofit, member-run health insurance). Publicly Subsidized Coverage Medicaid Benchmark and Benchmark-Equivalent programs, which states will use to cover newly eligible Medicaid beneficiaries and, at state option, certain other existing groups of Medicaid beneficiaries; State Basic Health Plans, which provide coverage for persons with incomes between 133 and 200 percent of the federal poverty level, and for legal resident immigrant snot eligible for Medicaid. Programs Not Subject to Essential Benefits Requirements Self-insured employer-sponsored plans; Grandfathered employer-sponsored plans, small group market plans, and individual plans in the non-group market; and Existing Medicaid plans which would continue to use Medicaid benefits defined under federal law.
What does ACA implementation mean in terms of health for women and infants? Public Health and Prevention Prevention and Public Health Fund Pay attention to funding and tell policymakers not to divert $ National Prevention Strategy Help reach the goal to improve the health and quality of life for individuals, families and communities by moving from a focus on sickness and disease to one based on prevention and wellness http://healthyamericans.org/health-issues/category/implementationof-the-affordable-care-act/national-prevention-strategy Community Transformation grants Did your state/community apply? Win? http://www.cdc.gov/communitytransformation/funds/index.htm
Elements of National Prevention Strategy Four Strategic Directions 1. Building Healthy and Safe Community Environments 2. Expanding Quality Preventive Services in Both Clinical and Community Settings 3. Empowering People to Make Healthy Choices 4. Eliminating Health Disparities http://www.healthcare.gov/news/factsheets/ 2011/06/prevention06162011a.html Image Source: Community Commons http://profiles.communitycommons.org/site/nps/default2.aspx
What does ACA implementation mean in terms of health for women and infants? Special MCH Opportunities New program investments (track $$) Home visiting (MIECHV) program School-based health clinic program Community-based Collaborative Care Networks Community Health Teams to support patient-centered medical home, including OB-GYNs. For women with postpartum depression. Pregnancy Assistance Fund with competitive grants to States to assist pregnant and parenting teens and women, and victims of domestic violence and sexual assault. Personal Responsibility Education grants to States to educate adolescents on both abstinence and contraception. Pilots to provide community health center patients with a comprehensive risk assessment and an individualized wellness plan.
What does ACA implementation mean in terms of health for women and infants? Patient Protections and Rights The Departments of Health and Human Services (HHS), Labor, and Treasury issued regulations to implement a new Patient s Bill of Rights under the ACA. Effective 9/23/2010 federal law: Prohibits denial of coverage to children due to a pre-existing condition, now. Does the same for adults in 2014. Prohibits discrimination and guarantees renewability. Bans lifetime dollar limits and restricts annual dollar limits on coverage. Prohibits retroactive cancellations (rescissions) of coverage when an individual becomes sick or based on a mistake on an application. Protects choice of primary care provider and direct access to OB-GYN. Protects the right to appeal denials of coverage. Requires accessible consumer information. Source: Johnson. Consumer Protection and the Patient s Bill of Rights. Health Reform Implementation: Opportunities for Place-Based Initiatives. Issue Brief #2. January 2012. www.cssp.org See Fact sheet on the Patient s Bill of Rights. http://www.healthcare.gov/law/features/rights/bill-of-rights/index.html Also see links to supporting regulations. http://cciio.cms.gov/resources/regulations/index.html#pbr
What does ACA implementation mean in terms of health for women and infants? Monitoring Performance Monitoring system performance Eligibility, coverage, access, utilization, or out-of-pocket costs Tracking population level outcomes and results accountability across a community, county, or state Linking home visiting program with early childhood system results
What does ACA implementation mean in terms of health all? The ACA can help to assure that women (and men) attain good health in childhood and adolescence, maintain it during their reproductive years, and age well in later years. Advances in coverage, access, and prevention would lead to improved health across the life span. Public health & MCH leaders at the state and local level play a key role in effective implementation. Photo Johnson.