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A New Mexico Vision for Implementing the Affordable Care Act
New Mexico Legislative ConferenceSanta FeJanuary 24, 2013
Alan WeilExecutive DirectorNational Academy for State Health Policy
Presentation Outline• State roles in the ACA• Defining a vision• Applying the vision to– Health Insurance Exchange– Medicaid– Insurance Regulation
• Putting it all together
What States Have to Get Right Implementing the ACA1. Be Strategic with the
Insurance Exchange 2. Regulate the Commercial
Health Insurance Market Effectively
3. Simplify and Integrate Eligibility Systems
4. Expand Provider and Health System Capacity
5. Attend to Benefit Design
6. Promote Care Coordination7. Use Your Data8. Pursue Population Health Goals9. Engage the Public in Policy
Development and Implementation
10. Demand Quality and Efficiency from the Health Care System
Weil, Alan, “State Policymakers’ Priorities for Successful Implementation of Health Reform,” Portland, ME: NASHP, May 2010.
New Mexico State Scorecard- 2009
Source: Commonwealth Fund Scorecard on State Health System Performance, 2009.
2009 Ranking
2007 Ranking (revised)
OVERALL 42 35
Access 50 50
Prevention & Treatment 50 38
Avoidable Hospital Use & Costs 10 7
Equity 35 43
Healthy Lives 29 18
Elements of a Vision
• Triple Aim• Care integration and coordination• Reducing disparities• Expanded and continuous coverage• Patient and consumer engagement• Transparency and information
Triple Aim
• “Improving the U.S. health care system requires simultaneous pursuit of three aims: improving the experience of care, improving the health of populations, and reducing per capita costs of health care.”– Donald Berwick
Donald M. Berwick, Thomas W. Nolan and John Whittington. “The Triple Aim: Care, Health, and Cost.” Health Affairs, May 2008.
Triple Aim
What Is An ACA Health Insurance Exchange?• Online marketplace of qualified health plans intended to simplify
and structure health insurance choices for individuals, families, and small businesses
• Exclusive mechanism for people with incomes between 100 and 400% FPL to apply their federal premium assistance tax credits towards the cost of insurance coverage
• Only Qualified Health Plans can be offered• Plans tiered by actuarial value; subsidies tied to lower price plans• Separate small business exchange (SHOP)• Open enrollment begins October 2013, coverage begins January
2014, and exchange must be financially self sustaining one year later
9
Four Ways of Thinking About an Exchange
Marketplace for subsidized
private coverage
Continuous coverage option
alongside Medicaid and
CHIP
Integrated delivery system
alongside Medicaid and
CHIP
Component of an overall approach to improving the
health care system
What can the Exchange achieve?• Performance standards• Transparency and data• Consumer choice incentives• Multi-payer payment policies• Continuity of coverage
The ACA & Medicaid: Eligibility• Simplifies eligibility to be based on modified adjusted
gross income (MAGI) with no asset or resource test and a standardized income disregard of 5% FPL
• Expands to 133% of the federal poverty level for all under age 65 without regard to family structure as of January 1, 2014 (HHS cannot enforce against states that decline to do so)
• Maintains children’s CHIP and Medicaid eligibility levels through 2019
The ACA & Medicaid: Benefits & Access
• Provides all newly-eligible adults with a benchmark benefit package or benchmark-equivalent that is based on essential health benefits package
• Increases payments in fee for service and managed care for primary care services provided by primary care doctors to 100% of the Medicare payment rates for 2013 and 2014
The ACA & Medicaid: Financing• Provides full federal funding (100% FMAP) for
individuals newly eligible for Medicaid for 2014-2016• FMAP for this group phases down to 90% in 2020 and
thereafter• Full federal financing for the primary care rate
increase described above• Enhanced federal matching funds available for various
activities such as care coordination, IT systems improvements, moves out of nursing homes
Estimated Effects of the Medicaid Expansion for New Mexico• Medicaid in 2022:– No ACA: 464,000 enrolled– ACA, no expansion: 503,000 enrolled– ACA with expansion: 711,000 enrolled
• With the expansion, the number of uninsured in New Mexico will be 276,000, while it would have been 565,000 without the ACA. This cuts the number of uninsured in half.
SOURCE: Holahan, John; Buettgens, Matthew; Caroll, Caitlin; Dorn, Stan. Urban Institute for the Kaiser Commission on Medicaid and the Uninsured. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis. (2012)
Estimated Effects 2013-2022 (cont.)• If New Mexico undertakes expansion…– The state will receive $4.9 billion in new federal
funding.– State Medicaid costs will increase by 1.6% over
non-expansion Medicaid costs, with an additional $268 million in state expenditures due to expansion.
– New Mexico will save $104 million in reduced uncompensated care costs, bringing net new state spending to $164 million over this period
SOURCE: Holahan, John; Buettgens, Matthew; Caroll, Caitlin; Dorn, Stan. Urban Institute for the Kaiser Commission on Medicaid and the Uninsured. The Cost and Coverage Implications of the ACA Medicaid Expansion: National and State-by-State Analysis.
What can an expanded Medicaid achieve?
• Integrated eligibility options• Effective outreach• Coordinated provider networks• Aligned payment policy• Platform for medical homes, health homes,
other efforts• Improved reliance upon quality metrics
The ACA & Insurance Regulation• Prohibit pre-existing condition exclusions• Require guaranteed issue and renewal• Lifetime limits eliminated • Annual caps eliminated beginning in 2014• Limits on deductibles and out of pocket
maximums
The ACA & Insurance Regulation • Minimum medical loss ratio – Rebates to consumers if less than 85% (large
group) or 80% (small group and individual) of premiums is spent on medical services.
• State-based premium rate reviews • First dollar coverage for certain preventive
services • Mental health and substance abuse parity
What Can Effective Insurance Regulation Achieve?
• Selection of appropriate Essential Health Benefit plan
• Meaningful rate review• More effective competition• Protection of local plans and providers
Statereforum.org is a space for…• Peer-to-peer learning and discussion• Exchanging reform ideas• Posting, organizing, and sharing useful state
documents• Announcing off-line events and activities• Spotlighting the keys to successful implementation• Mapping states’ progress in implementing health
reform
