The Impact of the Affordable Care Act on Cancer Care and Prevention

Overview and Key Considerations

Katie Horton, RN, MPH, JD

Cancer: Compelling Case for Health Reform

No more compelling case for health reform than cancer treatment and survivorship 12 million survivors in US 1.6 million new cases of cancer diagnosed annually Cancer survivors living longer Need comprehensive follow-up care over longer period of time
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Cancer: Compelling Case for Health Reform

Impact of cancer and its treatment difficult even for those with reasonable financial means and strong support network 11 percent of all cancer patients under 65 are uninsured Higher for members of racial and ethnic minority groups 1 in 4 struggle with under-insurance
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Cost of Cancer
Cancer costs climbing Now estimated to cost $264 billion annually including direct medical expenditures and lost productivity 33% of cancer patients have health care costs that are equal to or greater than 10% of annual family income

Pre-ACA Health Care System

~ 50 million without coverage Unstable insurance markets with discrimination against persons needing health care Fragmented--care coordination often poor Weak individual market Challenges intensify for uneducated, poor, uninsured and underinsured

ACA Goals
Establish near-universal coverage Improve fairness, quality and affordability of health insurance coverage Improve health care value and efficiency Strengthen primary care access Make strategic investments in publics health (preventive care and community investments) Law not perfectcorrections needed

Where Are We Headed? Estimated Health Insurance Coverage in 2019

Total Nonelderly Population = 282 million

SOURCE: Kaiser Family Foundation analysis of Congressional Budget Office estimates, March 20, 2010

ACA Coverage Expansions

By 2022, ACA Coverage Expansions will Reduce Uninsured by Approximately 32 Million

Medicaid Health Insurance Exchanges Employer Coverage Uninsured

Approximately 10-16 million additional individuals enrolled in Medicaid

Coverage for approximately 20-23 million individuals

Between 4-6 million fewer people estimated to have coverage through an employer
Approximately 30 million will remain uninsured (8% of US population)

Source: Estimates for the Insurance Coverage Provisions of the Affordable Care Act Updated for the Recent Supreme Court Decision. Congressional Budget Office. July 2012. http://www.cbo.gov/sites/default/files/cbofiles/attachments/43472-07-24-2012-CoverageEstimates.pdf

Promoting Health Coverage

Universal Coverage

Medicaid Coverage (up to 133% FPL)

Individual Mandate
Health Insurance Market Reforms

Exchanges (subsidies 133-400% FPL)

Employer-Sponsored Coverage

Return to KaiserEDU

How Do We Get There?

Individual responsibility Employer responsibility Insurance market reforms (individual and group markets) Exchanges Medicaid Restructuring and expansion Medicare Payment reform Delivery system reform Tax reforms
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Shared Responsibility
2014: All individuals required to obtain
coverage or pay a penalty unless they have a religious objection or face financial hardship

2014: Large employers (50+ employees) will

be subject to fees if they do not offer affordable coverage and any employees receive subsidized coverage through a health insurance exchange

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Market Reforms

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Key Insurance Market Reforms (2010)

Health plans may not place lifetime limits on coverage, rescind
coverage, or deny coverage to children with pre-existing conditions

Dependent coverage to age 26 Preventive services with no cost sharing (USPSTF, ACIP
recommended immunizations, additional HRSA-recommended preventive care for women and children)

Pricing transparency and medical loss ratio/rebates Patient protections

Non network ED coverage

Direct access to pediatric and ob-gyn services Internal and external appeals
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Key Insurance Market Reforms (2014)

Adults with pre-existing conditions cannot be denied coverage or pay more based on their health status Rating limitations Premium rates for qualified health benefits plan can vary by only a few factors and with limitations

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Grandfathered Health Plans

Plans in place before passage of ACA, with no significant changes to benefits/coverage or premiums/cost-sharing since that time Grandfathered plans exempt from certain market reforms (i.e. annual limits, preventive services, appeals, emergency services etc.) Number of plans meeting definition of grandfathered decreasing over time: 48% of covered workers enrolled in grandfathered plans in 2012, down from 56% in 2011
Source: Kaiser Employer Health Benefits Survey. 2012.

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New Coverage Expansions

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Health Insurance Exchanges

New market for individuals and small businesses/groups One stop shopping for insurance products that meet certain federal and state standards Called qualified health plans Exchanges expected to assure quality of coverage, provide information and enrollment assistance, coordinate with Medicaid and calculate subsidy eligibility, among others

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Health Insurance Exchanges

Subsidies only in Exchanges State administered/federal default Critical issues for states include:
Whether to operate at all Adverse selection Active purchaser vs. passive shopping center Geographic size (state vs. regional) Medicaid relationship Governance

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Subsidies
Premium subsidies available for individuals and families with incomes between 100% and 400% of the poverty level; subsidies on a sliding scale
2012 Federal Poverty Level Individual 100% FPL: 400% FPL: $11,170 $43,320 Family of Four $23,050 $88,200

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Subsidies-Timeline
2010: Tax credits for small employers 2010: Temporary high risk pools (pre-existing
condition coverage) for people with pre-existing conditions

2014: Premium and cost-sharing subsidies for

low and moderate income individuals and families; premium assistance for small employers purchasing Exchange products

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Essential Health Benefit Coverage

All new qualified health plans (including health plans offered through the Exchange) must include the essential health benefit package Will reflect standard employer-sponsored plantypical employer coverage Coverage under the Medicaid Expansion will also include the essential health benefit package

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Essential Health Benefit Coverage

10 broad categories of coverage in ACA Ambulatory patient services Emergency services Hospitalization Maternity & newborn care Mental health and substance use disorder services including behavioral health treatment Prescription drugs Rehabilitative and habilitative services and devices Laboratory services Prevention and wellness services and chronic disease management Pediatric services including oral and vision care Rules out for comment in December

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 18 States Declared State-based Exchange 6 States Planning for Partnership Exchange 6 States Undecided 21 States Default to Federal Exchange
Source: Kaiser Family Foundation, December 10, 2012

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Medicaid
Fundamentally restructures Medicaid to allow states to cover all non-elderly, non-disabled citizens and legal US residents with family incomes below 133% (approx. $30,000 for family of four) Primarily assists adults who have never had children or whose children are grown Benchmark coverage and preventive care for newly eligible persons Benchmark coverage will resemble essential benefits package (approximation of employer coverage)

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Prevention

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Coverage of Preventive Services

ACA requires new health plans to cover without cost-sharing: (1) Evidence-based items or services rated A or B by the USPSTF (2) ACIP-recommended immunizations (3) Preventive care for infants, children, and adolescents recommended by HRSA, and additional preventive care and screenings for women recommended by HRSA

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Prevention in Medicare
Sixty percent of cancer diagnoses occur among individuals age 65 or older Provides for annual wellness visit, health risk assessment and personal prevention plan Requires Medicare-covered services that are classified as A or B by USPSTF to be covered without cost-sharing (doesn't require Medicare to cover them all); also applies to colorectal cancer screening

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Prevention in Traditional Medicaid

ACA expands the scope of optional preventive services under traditional Medicaid to include all USPSTF-, ACIP- and HRSA-recommended clinical preventive services required under Section 2713 (Effective January 1, 2013) Additional 1% increase in FMAP percentage for any recommended preventive service provided, so long as the state does not impose any beneficiary cost-sharing

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Public Health
Sustained funding for prevention and public
health (Prevention and Public Health Fund) - $15 billion over 10 years - Mandatory appropriation

- To invest in community prevention, core capacity and building the evidence

National Prevention and Health Promotion

Strategy (and Council)

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Prevention and Public Health Fund

$15 billion mandatory appropriation over 10 years ($2 billion a year beginning in FY 2015) Can fund any program authorized by the Public Health Service Act So far, the PPHF has been used to strengthen the health and public health workforce; expand existing Public Health Service Act programs; bolster public health infrastructure through grants to states; and create and maintain new health promotion programs

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Community Transformation Grants

New grant program for community prevention: supports communities in creating comprehensive change in the factors that affect peoples health across multiple environments.
2011: $103 million to 61 state and local government agencies and nonprofit organizations in 36 states to improve the health of their communities Focus is on obesity, nutrition, tobacco; but some may include increasing access to broader set of clinical services 2012: $70 million awarded to 40 small communities (fewer than 500,000 residents) to implement broad, sustainable strategies that will reduce health disparities and expand clinical and community preventive services
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Other Payment, Coverage and Delivery System Reforms

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Clinical Trials
Beginning 2014, routine medical costs must be covered for all individuals who are participating in clinical trials (excluding traditional Medicaid) Routine costs include all costs typically covered for an individual not enrolled in clinical trial Costs for specific investigational item or service excluded

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Clinical Trials
Insurers are prohibited from dropping or limiting coverage for participants in cancer clinical trials Plan may compel patient to use a network participating provider for the trial Trial costs must be covered even if approved clinical trial is conducted outside the state of the patients residence

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Closes Medicare Doughnut Hole

Provides immediate $250 rebate to seniors who hit the prescription drug coverage gap Coverage gap will be closed completely by 2020

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Payment and Delivery Reforms

Accountable Care Organizations (effective 1/1/12): New model of care in which groups of primary care providers work together to coordinate patient care and reduce costs while offering high-quality care to Medicare beneficiaries Medicaid Health Homes (effective 1/1/12): ACA gives states the option to create health home models in which a designated provider or team of health professionals will provide coordinated care to individuals with one or more chronic conditions; Oregon is including cancer
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Delivery System and Quality

Multi-payer, national quality improvement
strategy

Continued movement toward provider

reimbursement tied to quality outcomes

Demonstration projects on medical homes,

gain sharing, medical liability, bundling, geographic payment variation, accountable care organizations

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Delivery System and Quality

Patient-Centered Outcomes Research Institute Assists patient, clinicians and others with making informed decisions by identifying and analyzing national research priorities FY 2012, direct appropriations of $150 million FY 2013-2019, funding source sustained (trust fund plus per capita charges per enrollee from insurance plans) Restricts use of CER by public or private payers in coverage or reimbursement decisions
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Controlling Costs
New Independent Payment Advisory board
with expanded powers (IPAB)

$15 million funded for FY2012 In 2015, will make recommendations about
Medicare spending if targets not met

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Controlling Costs
Center for Medicare and Medicaid Innovation $5 million dollars for the design and
implementation of models in FY 2010

$10 billion funding for FY2011 through

FY2019

Numerous initiatives underway: bundled

payments, value-based purchasing

Medicare payments for diagnostic imaging

reduced
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Exhibit 8

Health Reform: Medicare Savings

Fraud, Waste, Abuse 1%Reducing Hospital
Readmissions 1% Delivery

Sources of Savings

Part D Premiums 2%
Part B Premiums 5% Independent Payment Advisory Board 3%

System Consumer Pilots 1% Protections 1%

Part D Enrollment/

Provider payments, including DSH and home health - $219 billion Disproportionate Share Medicare Advantage $136 billion Income-related premiums $36 billion New Independent Payment Advisory Panel $16 billion

Other 5%

Hospital (DSH) Payments 4%

Home Health Payments 7%

Interactions* 14%

Annual Provider Payment Updates 29%

Medicare Advantage Payment Reforms 25% Medicare

Delivery system reforms and hospital readmissions $12 billion

Annual Provider Payment Updates 29%

Advantage Payment Reforms 25%

Ten-Year Medicare Savings = $533.1 Billion Source: Kaiser Family Foundation analysis of Congressional Budget Office (CBO) cost estimates as provided on March 20, 2010.
Notes: *Savings include interactions with Medicare Advantage and TRICARE; spending includes implementation of Medicare changes, Part D interactions with Medicare Advantage provisions, Part B interactions with Part D provisions, and Medicaid interactions with Medicare Part D provisions.

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Other Provisions
Understanding Health Disparities All Federally-funded health programs must collect and report data on race, ethnicity, sex, primary language and disability status Oct. 2011: ASPE issued implementation guidance

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Other Provisions
National Center for Health Workforce Analysis HRSA $7.5 million through FY2014, Additional $4.5 million per year through FY2014

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Other Provisions
Hospital Readmissions Reduction Program Reduces Medicare payment to hospitals with high readmissions for certain conditions Final rule for FY 2012 released on Aug. 18, 2011 Quality reporting and pay for performance pilots for PPS exempt cancer hospitals

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Figure 16

Health Reform Implementation Timeline

2010
Some insurance market changesno costsharing for preventive services, dependent coverage to age 26, no lifetime caps Pre-existing condition insurance plan Small business tax credits Premium review

2011-2013
No cost-sharing for preventive services in Medicare and Medicaid

2014
Medicaid expansion Health Insurance Exchanges Premium subsidies

Increased payments for primary care

Reduced payments for Medicare providers and health plans New delivery system models in Medicare and Medicaid Tax changes and new health industry fees

Insurance market rules prohibition on denying coverage or charging more to those who are sick, standardized benefits
Individual mandate Employer requirements

Return to KaiserEDU

Paying for Health Reform

ACA estimated to cost $938 billion over a decade Because of higher taxes and fees and billions of dollars in Medicare payment cuts to providers, the package will narrow the federal budget deficit by $143 billion over 10 years, according to the Congressional Budget Office

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Paying for Health Reform

Starting in 2013, individuals with earnings over $200,000 and married couples earning more than $250,000 will pay a Medicare payroll tax of 2.35 percent (up from 1.45 percent) High income taxpayers will pay a 3.8 percent tax on unearned income (dividends)

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Paying for Health Reform

Starting in 2018, imposes a 40 percent excise tax on the portion of most employersponsored health coverage (excluding dental and vision) that exceeds $10,200 a year for individuals and $27,500 for families Law raise the threshold for deducting unreimbursed medical expenses from 7.5 percent of adjusted gross income to 10 percent Limits to FSA applied
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Future Directions
Continued consolidation likely to result from delivery system reforms and other provisions Current model of oncology care will change Further focus on quality benchmarks, outcomes, efficiency and reduction of duplicative services

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Future Direction
Increased bundling of payments Disease pathways, assessments of episodes of care and clinical decision supports applied more by payers Greater focus on shared decision-making with patient, value in care and use of evidence based care

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Outstanding Considerations
Over 25 million likely to remain uninsured What impact of fiscal cliff, sequestration and debt discussions on ACA and other discretionary funding? Will states expand Medicaid (optional post supreme court ruling)? What impact to cancer care of $500 billion Medicare cuts in ACA?

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Outstanding Considerations
What impact on employer-based insurance? Will essential health benefits package provide for adequate cancer prevention, treatment and other services? End of life care not addressed in ACA ACA doesnt require insurers to cover follow up diagnostic exams/biopsies if abnormality found during preventive service

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Outstanding Considerations
Who will care for the newly covered individuals? Workforce challenges remain

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Resources
HHS Key provisions by date: http://www.healthcare.gov/law/timeline/full.html Kaiser Family Foundation Implementation Timeline http://healthreform.kff.org/timeline.aspx

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Katie Horton KHorton@gwu.edu 202-994-4129

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