The Outlook for "Obamacare" in Two Maps

By Tracy Weber and Charles Ornstein; originally posted at ProPublica, Nov. 8, 2012, 10:30 a.m.

It wasn't just President Barack Obama who won Tuesday. His signature health care plan did as well. But while the Affordable Care Act remains alive, less clear is how its various mandates will proceed and who will participate.
To a large extent, the success of the health overhaul lies in how many of the nation's uninsured get coverage. And that is largely in the hands of the states, which have been all over the map in their willingness to cooperate.
We mean that literally. The maps here show the lack of consensus on two key parts of the act: Creating insurance exchanges and expanding Medicaid.
Here's why each map matters.

Map 1: Where Will We Buy Insurance?

Source: Kaiser Family Foundation, current as of Sept. 27, 2012.

The health care act requires all Americans who aren't already insured to buy coverage. But where? That's where insurance exchanges come in.
States have to decide whether to set up these online marketplaces, where individuals can choose among different insurance plans. Setting up an exchange allows states to customize the offerings to the needs of their residents.
States can also partner with the federal government on exchanges. But if they elect not to, the federal government will take over with its one-size-fits all exchange. States are supposed to decide which course to take by Nov. 16.
Along the West coast, legislatures have already voted to set up exchanges. Other states, including Texas, Maine and Alaska, have decided to punt.
But many states in the Midwest and South haven't committed either way. Some governors, such as New Jersey's Gov. Chris Christie, have held off setting up a state insurance exchange until after the election.
A health care consultant group predicted yesterday that 20 states will elect to operate exchanges.

Map 2: Will States Cover More Poor People?

Source: The Advisory Board Company
Obamacare hopes to expand coverage to 30 million of the country's 48 million uninsured residents. A big part of that would come though Medicaid.
States must also decide whether to expand Medicaid to all residents under 133 percent of the federal poverty line (about $14,893 for an individual and $30,657 for a family of four).  Medicaid currently covers poor children, pregnant women, seniors and some disabled adults. The federal government will pay the full cost for the expanded coverage for three years, and then gradually reduce its contribution to 90 percent over the next three years.
As passed in 2010, the Affordable Care Act required states to expand Medicaid or risk losing all federal matching funds for the program. But the U.S. Supreme Court ruled in June that it was coercive to force states to expand their program just to keep money they were already getting.
Now, states that don't opt in will keep their current funding, but residents who might have qualified under an expansion will likely remain uninsured. There isn't a deadline for the expansion, but the federal government says states will receive less federal help if they decide to expand later, according to The New York Times.
As with exchanges, the states are divided.
So far, a handful u2013 including California, Washington and Illinois u2013 have already embraced the expansion. Florida, South Carolina, Mississippi and Louisiana have opted out.
(The states marked with scales participated in litigation against the Act that culminated in June's U.S. Supreme Court decision.)

Too Murky to Map  
Not everything is left to states. Other issues remain murky about the law, perhaps because the deadlines are further in the future.
The requirement for individuals to either buy insurance or pay a fee to the IRS begins Jan. 14, 2014. But the federal government has not made clear how vigorously it plans to pursue those who don't comply.
Here's a flow chart showing who has to pay and who doesn't.
Also unclear is the impact on employers, who will be required to provide health insurance to full-time workers beginning in 2014. Some, according to The Wall Street Journal, are responding by moving employees to part-time positions.
Finally, the Act's opponents in Congress and on the grassroots level will likely do what they can to delay or dilute these requirements, which are among its most unpopular.
If you're interested in comparing the politics further, here's a link to the final presidential election results by state.
Help Us Investigate Patient Safety Have you or a loved one been harmed in a medical facility? Share your story with us. Are you a provider? Tell us your observations about patient harm.

The Cook County Health & Hospitals System (CCHHS) 1115 Medicaid Waiver—What is CountyCare?

Blog Post by Margie Schaps, Executive Director, Health & Medicine Policy Research Group 

Last month the Cook County Health & Hospitals System received word from the Federal Centers for Medicaid and Medicare that their request for an 1115 Waiver to the Illinois Medicaid system had been conditionally approved, pending the State of Illinois officially accepting the “terms and conditions” of the Waiver. So, as of right now, the expectation is that the State will make this official within the next couple of weeks.

CountyCare, as the new Medicaid program will be known, has been provided for through the Affordable Care Act. CountyCare will allow the CCHHS to enroll tens of thousands of currently uninsured people into this Medicaid Program. People can begin applying on November 5th by phone 312-8648200 or toll free at 855-6718883. Coverage will start January 1, 2013.

This provides a great opportunity and enormous challenge for the health system to transform care by creating patient-centered medical homes rather than relying on expensive and inefficient use of emergency rooms. The focus of the program will be primary care centric with all specialty care, diagnostic and inpatient services coordinated through the medical home.

Eligible people include:

• Live in Cook County 

• Be 19-64 years old 

• Have income at or below 133% FPL 

• Not be eligible for “state Plan” Medicaid 

• Not be eligible for Medicare 

• Be a legal immigrant for 5 years of more or a US citizen 

• Have a social security number of have applied for one 

Not all doctors within the CCHHS system will be part of the network, and there will be many community health centers that will be part of the network (this list has not officially been released yet)

The CCHHS website has a list of answers to Frequently Asked Questions: http://www.cookcountyhhs.org/patient-services/county-care/


Advocates, providers and patients still have unanswered questions, many of which have been submitted by us to the CCHHS leadership and consultants. We anticipate getting answers to these in the coming weeks and will provide updates to this blog post as we get the information.

Why Physician Groups Support the Affordable Care Act

Physician groups support the Affordable Care Act (ACA) because it will improve health care for our patients. Doctors care about patients, and we support laws that help us do our work for patients—laws that protect those to whom we’ve dedicated our careers. By helping us provide better care, the ACA will make your healthcare better.

Our organization–the National Physicians Alliance (NPA)–was formed in 2005 and is committed to advancing the core values of the medical profession: service, integrity, and advocacy. The organization has key guiding principles that focus on putting our patients health and wellness above all other concerns. NPA’s advocacy has emphasized the need to ensure patient protection and to repair the broken covenant that our nation’s healthcare system must benefit all Americans. Our commitment and our obligation to care for our patients is limited by many factors: insurance company policies that restrict the care we can provide, health disparities that persist despite individual efforts to address them, and a lack of insurance that limits access to health insurance and healthcare.

As a result of NPA’s determination to ensure equitable and affordable healthcare for all Americans, the organization has worked to secure the passage of the ACA and to advocate for its full implementation. In keeping with NPA’s guiding principles, our support of the ACA has been focused on the benefits the law provides to patients as well as its protection of the doctor-patient relationship we hold as a sacred responsibility as professionals.

How does the ACA protect patients?

The ACA provides important benefits for ALL Americans: The ACA provides multiple benefits for the middle class. Considering the major role that healthcare costs play in personal bankruptcies (PDF), it is clear that ensuring the affordability of healthcare provides a crucial protection for middle class Americans. Affordable insurance–made more so by government support to help lower income families and changes in insurance enrollment that are predicted to reduce the cost for all–will allow most Americans to see the health benefits of having health insurance (PDF). Adult children will now be able to stay on parents’ insurance policies until they are 26 years old, thereby enhancing their ability to access health insurance while in school and starting out in the workforce. Coupled with reforms that will remove limits on annual and lifetime coverage benefits for patients, Americans will be better protected as they look to move into the middle class and secure a better future for themselves and their families. In addition, preventive care services including vaccines, pap smears, colonoscopies, and other necessary services will be made available to Americans without requiring co-pays, making them more available than ever before.

The ACA promotes fairness and equality in medical care: The ACA reverses one of the most egregious facts of healthcare insurance in the US: the fact that a person’s gender was the basis for charging women more for health insurance than men. This difference exists only because a woman was a woman, and is not due to specific coverage (PDF) such as for pregnancy or maternity care. The ACA will also target national healthcare inequalities by strengthening the nation’s community health centers, increasing the number of physicians working in medically underserved areas by increasing National Health Service Corps scholarships. Finally, the ACA begins to address our national need for more primary care physicians and move towards a healthcare workforce that is accessible to all.

The ACA protects patients from insurance company abuses: Thanks to the ACA, insurance companies will have less control over patients’ healthcare. Insurers will be required to offer insurance to everyone regardless of whether or not they have a preexisting medical condition–a benefit that has already gone into effect for children and is planned to go into effect for adults in 2014. The ACA prevents insurance companies from setting arbitrary limits to patients’ lifetime health insurance benefits, and as of 2014 will eliminate annual limits to care. Insurance companies are required to spend 80-85% of members’ premiums on providing benefits to those members, as opposed to using that money for administrative costs or executive salaries. The ACA bans the practice of rescissions, in which insurance companies would seek reasons to retroactively cancel members’ insurance coverage once those members became ill and most needed the protection. The ACA provides greater governmental scrutiny of unreasonable insurance rate hikes, helping insure that Americans are not being harmed by insurers willfully increasing policy costs without reason or justification. Finally, by establishing health insurance marketplaces (or exchanges), the ACA will require all insurers to show the purchasers of their products–our patients–that the companies are effective and responsive to their customers’ needs or they will risk patients finding coverage elsewhere. This should increase transparency and provide greater benefits to patients who will be able to vote with their feet and leave ineffective companies to look for better options.

The NPA is not the only physician organization to support the ACA. The law is also supported by the American Medical Association, the American Academy of Pediatrics, the American Academy of Family Physicians, the American College of Physicians, the American Congress of Obstetricians and Gynecologists, the Association of American Medical Colleges, the American Osteopathic Association, and the American Medical Student Association. This broad-based support has been given additional voice by nonprofit organizations such as NPA and Doctors for America.

The reasons all of these physician groups support the ACA is simple. As physicians, the law’s reforms allow us to provide better care for our patients–without being limited by insurance regulations or lack of access to health insurance. The ACA removes important barriers to care, and lets us get back to the core focus of our profession: the covenant to do whatever we can to improve our patients’ health and wellness.

This post, by Mark Ryan, MD, originally appeared here, on the National Physicians Alliance blog, on November 4, 2012

Healthcare by the Numbers

In the United States in 2012:

• Annual health care costs: $2.7 trillion
• Percent of healthcare costs linked to individual behaviors: 70%
• Cost of tobacco, alcohol, soda, illicit drugs, unsafe sex, sedentary lifestyle, etc: $1.89 trillion.

The numbers tell a story—of how much money we can save on medical spending if as a society, we find ways to change individuals’ risky health behaviors.

Fee for service reimbursements to doctors:

• 5 minute cardiac stent: $1500
• 45 minute behavioral counseling: $15

Current reimbursements favor intervention, not prevention. We pay big bucks for sick care not health care.

Average annual salary:

• Interventional cardiologist: $320K
• Family physician: $168K
• Nutritionist: $53K
• Athletic trainer: $45K

We need to fairly reimburse the care that will keep people well. We need less high tech and more high touch interventions to empower people to change their lifestyles. We need more athletic trainers, yoga instructors, exercise physiologists, nutritionists, and dietitians, working together with the medical team to promote healthy behaviors. As a society, we need to make healthy choices easy choices.Simplify food labeling.Subsidize fruits and veggies instead of commodities like corn. Ensure the creation of bike trails and city parks.

“We don’t need to spend ourselves into poverty on health care,” cautioned a speaker in the documentary film Escape Fire. “We just need to do it differently.”


We need to reimburse health and wellness instead of more-more-more medical care. We need to pay fee for value instead of fee for service.

If health care inflation applied to the rest of the economy from the 1950s to today, food costs would be:

• A dozen eggs: $55.
• A gallon of milk: $48.

We can’t afford the status quo in the way we spend our healthcare dollars. We need to value health, and shift from desperate medical interventions to stave off death to gentle lifestyle changes to promote health. Together, we can pay for the powerful, simple, low tech low cost interventions that motivate patients to change their risky health behaviors, and stop the runaway inflation of our medical costs.

By Dr. Kohar Jones 
This post originally appeared on the Doctors for America blog. 

Affordable Care Act ("Obamacare"): Things Businesses Should Know

Either as an individual or the owner of a small business, you may be affected by the Affordable Care Act tax provisions. The Affordable Care Act (also known as Obamacare) was signed into law by President Obama on March 23, 2010, and recently survived a challenge in the United States Supreme Court. While the main focus of the Affordable Care Act is health reform legislation, there are several tax provisions that will take effect as different parts of the legislation are implemented. The following is an outline of some of the important tax-related consequences of the Affordable Care Act that have already been implemented and some information for what you can expect as the legislation is fully rolled out between now and 2014.

In addition to making sweeping changes to the U.S. health care system, the health care reform legislation added a number of new taxes and made various other revenue-increasing changes to the Code to help finance health care reform.

One of the provisions that were enacted in 2010 was the Small Business Health Insurance Tax Credit. For tax years from 2010 through 2013, the maximum credit is 35% of health insurance premiums paid by small business employers. A small employer is one that has fewer than 25 full-time equivalent employees, pays an average wage of less than $50,000 a year, and pays at least half of the employee’s health insurance premiums. The credit is scheduled to increase to 50% for small business employers after 2013. However, in tax years that begin after 2013, an employer must participate in an insurance exchange in order to claim the credit, and other modifications and restrictions on the credit apply.

In 2011, insurance companies were required to prove they spent at least 80% of the premium payments on medical services, rather than on things like advertising and executive salaries. Those that didn’t were required to provide rebates to policyholders. You may have seen letters, or even rebate checks, hitting your mailboxes recently stipulating to these facts. These rebates may be taxable income to you if you previously received a tax benefit from a deduction for the insurance premiums paid. Your tax advisor should be consulted.

In 2012, employers are required to disclose the aggregate cost of applicable employer-sponsored coverage on an employee’s annual Form W-2. Reporting is for informational purposes only. However, for 2012 Forms W-2 (and W-2s issued in later years, unless and until further guidance is issued), an employer is not subject to reporting for any calendar year if the employer was required to file fewer than 250 Forms W-2 for the preceding year.

Upcoming changes in 2013 include an increase in the deduction for medical expenses. Under prior law, medical expenses had to exceed 7.5% of adjusted gross income in order to be deductible for regular tax purposes, and 10% of adjusted gross income for Alternative Minimum Tax (AMT). The Affordable Care Act increases the regular tax limitation to 10% of adjusted gross income for those who are under the age of 65, bringing it in line with the AMT limitation.

The Medicare Surtax will also kick-in in 2013. For single taxpayers making more than $200,000 and married filing jointly taxpayers making more than $250,000, an additional 3.8% Medicare tax on dividends, capital gains, and rental and royalty income will apply. The KOS Bottom Line Bulletin September 2012 edition included an article titled “Get Ready for the Medicare Surtax in 2013.” To read this article, click here or go to the KOS website at www.koscpa.com/announcements.

If you contribute to a Flexible Savings Plan that your employer provides, beginning in 2013 the amount you may contribute annually to that plan will be limited to $2,500. This is down from the $5,000 prior limitation and will be adjusted annually for inflation.

In 2014, the state-run health exchanges will be set up and the penalties for individuals who do not purchase insurance will kick-in. The penalty will increase over the three year period from 2014 to 2017 as follows:

2014 – The greater of $95 or 1% of income.
2015 – $325 or 2% of income.
2016 – $695 or 2.5% of income

Businesses with 50 or more workers will be subject to a $2,000 per worker penalty if they don’t offer health insurance. Those that do receive a tax credit of 50% of the premium cost.

Nearly all businesses will have to make changes in order to comply with the Affordable Care Act. Do you have questions about how this act affects you? As an employer, are you aware of what changes you need to make? If so, you should attend our breakfast seminar on November 14 titled “What Does the Affordable Healthcare Act (AKA “Obamacare”) Mean for Employers?” This FREE program takes place from 8:30 until 10:30 a.m. at the KOS office at 1101 Lake Cook Road, Suite C in Deerfield, Illinois. To reserve a space, contact Kelly Wallaert at 847.580.4100 or kwallaert@koscpa.com.

Christie Butcher, CPA, MST
Manager, KOS Public Accountants

(This article was originally posted on the Kessler Orlean Silver website here)

The Seven Things We Learned From Escape Fire

 
We hope you make time to see the documentary, Escape Fire, which premiered tonight in cities across the US. Thank you to those of who joined us for the Chicago screening and lively discussion afterwards.

For those of you who haven’t seen it, the film tackles the American healthcare system, a subject that carries with it decades of debate and misinformation.

Recent media attention has focused on partisan politics, rather than what is broken in the system and how best to move forward. There is wide agreement that something has to be done, but until now there hasn’t been a unbiased lens to view the problem. Escape Fire finally provides that lens. The film “seeks to explore possibilities to create a sustainable system for the future and to dispel misinformation in order to create a clear and comprehensive look at healthcare in America."

Below are the seven things or “big ideas” about the American health care system captured by this film. Many of these things you may have already heard about or experienced yourself; however, seeing them packaged in 90 minutes of intense storytelling through the eyes of patients, providers, the military and business leaders makes the messages hit home loud and clear.

After you see the movie, tell us what you think. What did you learn about health and healthcare? What new questions came up for you as you watched? What changes in attitude or behavior are being sparked and inspired by the film? What can you do now or in the future to make a difference in your own health and healthcare as well as the health and healthcare of those around you? Drop us a line at info@illinoishealthmatters.org and let us know!

Barbara Otto, CEO
Health & Disability Advocates

Seven Things

1. PAYING MORE, GETTING LESS

The average per capita cost of healthcare in the developed world is $3,000. In the U.S., it’s around $8,000. As a country, we spend about $2.7 trillion on healthcare annually, and about one-third of healthcare costs, roughly $700 billion, do not improve health outcomes. In fact, for the first time in the history of our country, life expectancy is going down for many disadvantaged Americans. The high price of healthcare affects all of us, even if we’re already covered by health insurance. As costs spiral out of control, individuals are the ones who make up the difference, be it through higher premiums or taxes. The first step in changing the system is understanding that the current model is unsustainable.


2. TREATING THE WHOLE PERSON

Most doctors only have time for quick fixes, for putting Band-Aids on the problem. We need the healthcare system to provide incentives for leading healthier lifestyles, changing our diets, and being open to holistic methods of healing that can address the body and the mind — in other words, the whole person.


3. PREVENTING DISEASE

Roughly 75% of healthcare spending goes to treating preventable diseases. That’s a lot of unnecessary money and a lot of unnecessary illnesses. For too long, the American healthcare system has emphasized tests, screening, and awareness of disease. While these practices might lead to earlier detection, they’re no match for true disease prevention. We don’t have to wait for disease to set in to live healthier lives. If we can make fresh food as cheap as processed food, and if we can live more active lives, we can curb disease before it ever has a chance to strike. But we need support: from our workplaces, from our communities, and from our healthcare system.


4. OVERMEDICATION

We spend $300 billion on pharmaceutical drugs. That’s almost as much as the rest of the world’s medicine spending combined. Prescription drugs play a vital role in helping patients who need them; however, too many drugs are being marketed to patients who don’t need them, leading to situations where the drug has the potential to do more harm than good. The military recognizes the problem, and they’re trying to wean soldiers off their drugs by putting more emphasis on alternative approaches: physical therapy, exercise, yoga, and meditation. They are preaching patient-centered care that better meets the needs of injured veterans.


5. OVERTREATMENT

For patients, “more” doesn’t necessarily mean “better.” When it comes to our health, recent studies show that “more” can actually mean “worse.” The reason? Any time we go into a hospital, we take on risk. Medical errors do happen. Harmful drug interactions do occur, especially when so many doctors and nurses are giving you care. A recent study showed that as many as 187,000 people a year die from medical error or hospital-related illness. If that were an official cause of death, it would be the third largest killer in the U.S.


6. AN ENTRENCHED SYSTEM

Pharmaceutical companies, medical device manufacturers, hospitals, and insurance companies are profiting from our declining health. Some of the $2.7 trillion dollars we spend on healthcare every year goes to supporting lobbyists and politicians in Washington who maintain business as usual. To get back on track, we need to remember that healthcare is about more than just making money. It’s about making Americans healthier.


7. REIMBURSEMENT

“When you reward physicians for doing procedures instead of talking to patients, that’s what they’re going to do - procedures.”
- Dr. Leslie Cho, Cardiologist, Cleveland Clinic 

In general, the system rewards higher-tech, higher-cost procedures over low-cost, high-touch treatments. Primary care physicians aren’t paid to have long conversations about nutritional counseling or exercise regimens. Most alternative therapies aren’t covered. We need to shift payment to reward everyone in the system for providing the right kind of care rather than more of the wrong kind of care. If we can start reimbursing doctors and hospitals to keep patients healthy or, better yet, keep Americans from ever becoming patients, then we’ll see a rapid change in the way we give care.

[These "Seven Things" were adapted from the Escape Fire Screening & Discussion Guide. You can use this guide to hold your own screening - at your workplace, in your community, in your schools or at home.]