CALIFORNIAS ESSENTIAL ROLE

TAKE CHARGE OF YOUR HEALTH September 21, 2013

Forum hosted by Alameda County Supervisor Keith Carson

WINNING THE ACA:

Deborah LeVeen, Professor Emerita San Francisco State University dleveen@earthlink.net

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Four Key Points 1) Winning the ACA: A major battle 2) Winning the ACA: Major gains 3) Implementing the ACA: The battle intensifies 4) California: essential to ACA success
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OVERVIEW:

A MAJOR BATTLE: Powerful opposition

A century of reform failure A powerful health care industry ($2.7 Tr) A growing conservative movement:
Empower individuals: voucherize health care benefits Free the market: deregulate health insurance

Well-funded conservative organizations to fuel Tea Party explosion

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A MAJOR BATTLE: Barely won!

Unprecedented effort:
Presidential leadership, Congressional effort, public mobilization

Major compromises:
Access for undocumented, public option, reproductive rights

Final passage: March 23, 2013

House: 219-212. Senate: 56-43
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Enshrining progressive principles

Society must ensure access to health care for all. Share of income for healthcare must be limited. Everyone must be in; everyone must contribute. Insurance must cover sick people, not discriminate against them. Most important: ENSURING THESE PRINCIPLES REQUIRES A STRONG GOVERNMENT ROLE.
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WINNING THE ACA:

Increasing Coverage More comprehensive, affordable, for almost all

1. Almost everyone* has access to one of three sources: Employer, expanded Medicaid, Insurance Exchange. *except undocumented residents. 1. Comprehensive: new essential benefits standard: 10 categories, limits on cost-sharing. 2. Affordable: Subsidies for coverage, through Exchange, To limit % income for premiums and cost-sharing.
for everyone up to 4X poverty level ($46/94K)
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ACA GAINS

Insurance reforms to protect consumers No denials No exclusions of pre-existing conditions. No consideration of health status or gender in setting premiums Transparency and standardization of benefits
Allowing easy comparison and informed choice

ACA GAINS:

More Fair Financing Everyone in, everyone contributes

Employers: contribute if employees qualify for subsidies in Exchange. Small businesses exempt: <50 Individuals: must have coverage unless cost exceeds 8% income

ACA GAINS:

Cost Containment - Limiting Prices In Medicare:

Reduced rate of increase in payment formulas; Reduced subsidies to Medicare Advantage plans.

ACA GAINS:

In private insurance:
Minimum Medical Loss Ratio (MLR) % premiums spent on care; Review of unreasonable rate increases, > 10% Possible exclusion from state Exchanges.
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Cost Containment Payment and Delivery Reforms

In Medicare:
Increased research and innovation. Payment incentives for cost-effectiveness: e.g. Move away from Fee-For-Service (FFS) Shift to salary, capitation, global budgets, etc Improved delivery and quality: e.g. care management, coordination, pay linked to quality, etc etc

ACA GAINS:

In private insurance:
Private plans must report on efforts to improve quality and efficiency
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Medicare Beneficiaries
Medicare eligibility unchanged:
Seniors (65+) stay in Medicare

ACA GAINS:

With increased benefits and reduced costs:

Elimination of donut hole. No copays for preventive services Annual wellness visits

And improved quality:

Payment and delivery reforms focus on Medicare.
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IMPLEMENTATION: The battle continues

Supreme Court challenge: began March 23, 2010
Outcome: Medicaid expansion voluntary

2010 elections: Tea Party surge, Republicans capture House

Vote to repeal ACA, voucherize/privatize Medicare

Opposition attacks intensify:

Warn of massive government overreach, liberty threatened. Refuse to Enrollcampaign

Congressional Republicans threaten government shutdown

unless Obamacare funding is halted

Why?
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IMPLEMENTATION: Why the opposition?

Fear of success:
Will strengthen progressive government.
Its rejection by Congress and the public would be a monumental setback for the president, and an uncontestable piece of evidence that Democratic welfare-state liberalism remains firmly in retreat.
William Kristol, leading conservative strategist, advising Congress to oppose, unseen the Clinton reform plan. 1994
Quoted in Skocpol, Boomerang: Health Care Reform and the Turn Against Government, 1997.

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IMPLEMENTATION: Why the opposition?

Fear of success: The public will like it!
its now or never. President Obamas strategy is simple: on January 1, the subsidies kick in. President Obama wants to get as many Americans addicted to the subsidies because he knows that in modern times, no major entitlement has ever beenunwound.
Senator Ted Cruz (R Texas) Interview with The Daily Caller, August 15 2013.
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IMPLEMENTATION:
Impact of opposition
Congress refusing implementation funding States refusing to implement: Medicaid expansion: No: 22. Maybe: 4. Yes: 25. State Exchanges: No: 27. Partnership: 7. Yes: 17. Unexpected demands on federal government: 34 exchanges! Public confusion, hence less support. though polls show support for key elements
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Key role of Medicaid expansion

Expansion: everyone up to 138% FPL
($16,000 / $32,000)

IMPLEMENTATION:

People eligible for expansion:

25.4m: Half the uninsured Two thirds live in states resisting expansion

Newly eligible childless adults

15.1m (1.8m in CA) 11.5m: < 100% FPL. Not eligible for Exchange subsidies.
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Key role of insurance Exchanges

Certify and offer Qualified Health Plans (QHPs ) to
All individuals without alternative coverage Small businesses; larger (> 100) in 2017.

IMPLEMENTATION:

Aggregate purchasing power, pool risk. Provide affordability subsidies, available only in the Exchange. Potential to drive broader system reform:
Through requirements for QHP certification.
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Progressive leadership
Approved Medi-Cal expansion The first state to establish an Exchange: Covered California. Chose active purchaser vs clearinghouse model Selected 12 plans: Anthem Blue Cross, Blue Shield, HealthNet, Kaiser, Average statewide premium: $321/month for silver plan For people up to 400% FPL:
Premiums vary by region, age, family size and by plan.
and 8 smaller: e.g. Alameda Alliance for Health, Contra Costa Health Plan, Chinese Community Health Plan

CALIFORNIA:

Income-based subsidies limit premiums See calculator on CoveredCA.Com

CALIFORNIA: Payment & delivery innovations

Received ACA State Innovation grant:
To develop multi-payer payment & delivery reforms

Supported by collaboration of providers, insurers, policymakers

through the Berkeley Forum Two key recommendations: * Global budgets * Integrated delivery systems

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CALIFORNIA: KEY FOCUS NOW Ensuring enrollment!

Covered California potential enrollment:
5.3m total; 2.6m subsidy-eligible.

Medi-Cal expansion potential enrollment:

1.4m newly eligible 2.5m already eligible but not enrolled

Single application, no wrong door Massive commitment to outreach, education, and enrollment
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Remember the big picture

Enrollment and providing care will be hard work! Failure of ACA = failure of progressive principles Success will build political support: for ACA and for positive government role. California has a critical role to play! We are lucky to be able to help!
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KEY NEEDS NOW: