A Trail Guide to Health Care Reform

1. A Trail Guide to Health Care Reform Roberta Rifkin, Vice President for Government Affairs

2. The Map • The Patient Protection and Affordable Care Act (ACA) was signed into law on March 23, 2010 and provides the way to reform. • The ACA map is designed to lead us toward: • A Better Patient Experience; • Improved Community Health; and • Lower Costs. • Though there are different ways to get there, the destination is the same and we all need to move forward together. 2

3. Three Main Groups Carving Trails to Reform Federal State Community 3

4. Federal Team is Providing State and Community Teams an Understanding of the Terrain Coverage Affordability Quality 4

5. Federal Team is Leading the Way Federal Team • Creates guidance and support for states and communities • Providing states and communities with tools • Grants • Flexibility • Access 5

6. Landmarks on the Federal Trail - 2014 Individual Mandate Employer Responsibility Health Exchange 6

7. Obstacles on the Federal Trail Legal Challenges: • Supreme Court will be hearing arguments regarding the following issues: • Constitutionality of individual mandate and Medicaid expansion • Severability • Anti injunction tax act • Decision expected in June Political Challenges Republican Opposition • “Repeal and Replace” • Defund provisions • Election Issue • Creates State uncertainty • Implement or wait 7

8. A New Challenge on the Federal Trail The Budget Control Act of 2011 To raise the debt ceiling by a total of $2.1 trillion Congress must either Congressional vote on a balanced budget amendment; or Super Committee proposal for $1.2-$1.5 trillion cuts. Without a balanced budget amendment or a proposal from the Super Committee across the board cuts will occur January 2013, including cuts to Medicare, but not Medicaid 8

9. State Trails Each state has opportunities to chart their own course. • Grants for Reform • Health Insurance Exchanges 9

10. New York State Trail • Federal Grants ($40.8 million) • Exchange Early Innovators • Exchange Planning Grants • Establishment Level 1 • Rate Review • Consumer Assistance • Exchange Legislation • Waiting for Senate to vote on Exchange bill 10

11. Obstacles on the State Trails Implementation Challenges: • Budget shortfalls • Reconcile ACA with existing state law • Uncontrolled Costs 11

12. Navigation Challenge: Payment Reform • Medicaid: over $53 billion for 4.7 million people • Highest Medicaid costs per capita • Governor Cuomo developed a Medicaid Redesign Team to propose reforms • Medicaid Redesign Team (MRT): • Short term: 2011-12 budget proposals • Long term: multi year reform proposals 12

13. Navigating the Community’s Trail Creating a Culture of Health Community Planning Promoting Health and Self-management Improving Quality in Health Care Delivery Expanding Health Information Technology Networks 13

14. Keeping Everyone on the Trail Recognize and engage within your spheres of influence: FAMILY COMMUNITY PHYSICIANS WORK 14

15. Reaching Our Destination Together • The Federal team is charting the course according to the Affordable Care Act. • The State teams are proceeding along the path within federal guidelines, but in accordance with their state’s needs. • The Community teams are being formed as local leaders emerge to help guide their residents. • To ensure that all hikers reach the goals of health care reform, all team must continue to move forward together. 15

16. Individual Mandate • Everyone is required to have health insurance or pay a penalty up to $695 or 2.5% of gross income. • Medicaid eligibility expanded to 133% of Federal Poverty Level (FPL). • Premium subsidies and cost sharing available for incomes between 133%- 400% FPL ($14,484/$29,726 to $43,560/$89,400). • Individuals with a religious conscience exemption are not required to have health insurance. • Exemptions from the penalty for economic hardship and low income levels. • Individuals are required to have minimum essential coverage which is defined as coverage under a government program like Medicaid. 16

17. Employer Responsibility • Employers with at least 50 Full Time Equivalents (FTEs) have a responsibility to provide affordable coverage that meets minimum standards. • Employers that do NOT offer coverage and at least 1 worker receives a subsidy will pay $2000 times total FTEs minus 30. • Employers that DO offer coverage will pay a penalty for each worker receiving a subsidy: • Lesser of total employees X $2000 or $3,000 for each employee requiring a subsidy 17

18. Health Exchange • The exchange is an electronic marketplace for purchasing health coverage. • Individuals and Small Groups are eligible in 2014. • Large Groups eligible to join in 2017. • All plans that are offered through the exchange must be certified as a Qualified Health Benefits Plans and offer bronze, silver, gold, platinum, and/or catastrophic plans. • State-based exchange must be operational by 2014 or the • Federal Government will offer its exchange. • NY State will face many issues in designing its exchange: • Governance, Financing, Market Dynamics, • Products, Consumer & Employer Experience, • Operations and Technology. 18