Medicaid Advisory Committee February 22, 2017 WEBINAR MEETING Please mute your phone when not speaking to limit background noise. If you need to go on hold, please drop off the call and call back in. Thanks!
Welcome and Introductions 9:00 Laura Etherton, Co-chair 9:15 Federal Health Policy Update David Simnitt, OHA 9:45 Section 1115 Waiver 2017-2022 Veronica Guerra, OHA 10:15 Legislative Preview/Update Brian Nieubuurt, OHA 10:45 Public Comment All 10:55 Closing Laura Etherton, Co-chair 2
Welcome, Overview & Introduction
Emerging Federal Health Policy Changes: Understanding proposals and assessing impacts on Oregon’s Health System Transformation David Simnitt, Director of Health Policy, OHA
Overview • Overview & Update on OHA & DCBS Efforts to Analyze and Assess Changing Federal Landscape • Update on Congressional Actions and Potential for ACA Changes in Current Congressional Session – Budget Reconciliation process and ACA repeal • Key Themes of ACA Alternative Plans Offered in Recent Years • Broad Highlights of 5 High Profile ACA Alternative Proposals 5
Congressional Time for Repealing and/or Replacing ACA Keeps Changing • Congressional Work Throughout 2017, into 2018 • Scope of Repeal / Replace Getting Less Clear – Full repeal before replacement bill becoming less likely – Targeted repeal proposals emerging – Medicaid “reform” part of emerging House plan • Uncertain prospects in US Senate • Challenges Facing Congress: – Fully repealing entire bill requires 60 votes in US Senate – Congressional leaders & administration have not agreed upon replacement proposal 6
Budget Reconciliation – Multi-Step Process Now Underway • First step: House & Senate enacted a budget resolution – The resolution itself DOES NOT repeal ACA; provides framework to repeal parts of ACA through process requiring only 51 votes in Senate • Reconciliation bill starting in the House – Limited to budgetary items & may not be able to repeal some policy & regulatory provisions of the ACA – House bill may include block grants / other Medicaid caps – Final bill dependent on Senate rules & parliamentary decisions • Parts of ACA replacement may be included in reconciliation bill, but many could NOT be enacted through this process – Provisions not able to go through reconciliation process require 60 votes in the U.S. Senate 7
Notable E lements of many (not all) Replacement Proposals • Eliminate individual and employer mandates (& penalties) • “Consumer driven” plan designs – Higher deductibles (less generous actuarial value) paired with tax- advantaged health savings accounts. • Eliminates federal exchanges & linking federal tax credit subsidies to Qualified Health Plans as defined by the ACA – Smaller tax credits – Age-adjusted instead of income-based • Grants to states to help operate / establish high risk pools • Cross-state sales of health insurance • Eliminates ACA’s taxes on medical devices & “Cadillac” health plans 8
Elements of Reform: Consumer Protections • Many plans keep: – G uaranteed renewal, eliminating lifetime/annual benefit caps, maintaining dependent coverage up to age 26 and eliminating pre- existing condition exclusions and medical underwriting • Many plans eliminate/revise guaranteed issue requirements to apply only for consumers who maintain continuous coverage for 12-24 months – Individuals without continuous coverage could be charged more • Eliminating Essential Health Benefits Requirements – Some shift responsibilities to states while others weaken state authority in name of “cross - state sales” of health insurance • Shift towards high-deductible plans w/ Health Savings Accounts 9
Elements of Reform: Medicaid • Many ACA Alternative Reduce Federal Medicaid Spend Through New Approaches & Shift Costs to States • Block Grants – Eliminates matching-rate structure of Medicaid – Sets total funding levels for states – uncertainty around baseline – Annual growth set by fed. govt., designed to reduce fed spending – States able to set eligibility & covered services, but responsible for all spending in excess of federal block grant • Per-capita Caps / Capped Allotments – Caps federal funding on per-enrollee basis – Set federal allotment for enrollees based on their eligibility category – Greater state flexibility to determine Medicaid service package, but funding still tied to specific eligibility categories limits state flexibility regarding eligibility 10
Medicaid Reform Considerations • Congressional Disagreement RE: ACA’s Expansion – 31 expansion states want to protect $ (many with R Gov/Sen) – Non-expansion states want new funding added to baseline – Status of ACA’s CHIP funding bump is unclear? • Federal Caps Affect States Differently – States already taking steps to reduce spending growth (Oregon) could be disadvantaged – States with higher Medicaid spending could disproportionately benefit from caps & federal flexibility – Ultimate impact on Oregon will depend on details not yet available – especially regarding expansion funding 11
Prominent ACA Alternatives - Summarized Ryan Price Hatch Cassidy/ A. Roy Collins Mandates Repeal Repeal Repeal State option Repeal Block Grant / Repeal Per-Capita Cap State opt: ACA Move to Medicaid per-capita Cap Expansion or HSA-based Exchanges, LTSS to States Yes Yes Yes No No X-State Sales Tax Age-Based Age-Based Age-Based ACA cont OR Income & HSA-based Age Credits? HSAs Higher Higher Higher Roth HSA Subsidized Contributions Contributions Contributions (post-tax, pay 4 premiums) 12
Common Challenges / Opportunities • Reduced federal Medicaid investment shifts costs to states • Cross-state sales of health insurance takes away states ability to regulate their own insurance market • Reduced federal regulatory oversight shifts regulatory authority back to Oregon • “State Flexibility” may be good for Oregon given state’s historical focus on innovative health policy • Executive branch changes - waivers, etc 13
Questions? 14
Oregon’s Waiver: 1115 Demonstration Renewal with the Centers for Medicare & Medicaid Services Veronica Guerra, Policy Analyst, OHA
Agenda • Waiver overview and goals • Targeted changes under renewal • Next steps
Oregon’s Medicaid 1115 Demonstration Waiver Renewal • Expedited approval: preserves Oregon’s Medicaid system, continues Oregon’s Health System Transformation (HST) momentum, and provides continuity for CCOs • Approval period: five year contract with the federal government from January 12, 2017 through June 30, 2022 • Federal investment: Oregon will continue to receive federal match to cover the Medicaid population
Waiver Goals 1. Build on transformation with focus on integration of physical, behavioral, and oral health care through a performance driven system 2. More deeply address social determinants of health and health equity with the goal of improving population health and health outcomes 3. Commit to ongoing sustainable rate of growth, advance the use of value-based payments, and promote increased investments in health related services 4. Continue to expand the coordinated care model
Continuing the Success of the Oregon Health Plan • The waiver renewal preserves OHP’s core tenets: – Integrated physical, behavioral, and oral health care – Provide services to OHP members through CCOs – Advance the coordinated care model – Pay for value rather than volume of services – Continue to hold down costs to a sustainable rate of growth – Offer evidence- based benefits through the state’s prioritized list of services
Waiver Renewal Targeted Changes • Oregon received additional flexibility to: – Continue the Hospital Transformation Performance Program (HTPP) – Promote increased investments in health related and flexible services – Promote primary care and pay for value – Expand access to coordinated care – Advance Tribal Health Programs
Hospital Transformation Performance Program Extension • The waiver provides flexibility to: – Extend the current HTPP program through June 30, 2018 – Redesign the program upon expiration of the one-year approval
Increased Investments in Health-Related Services • The waiver renewal: – Provides definitions: in lieu of services and health related services (flexible services + community benefit initiatives) – Provides clarity on how non-traditional services that improve health are accounted for in global budgets – CCOs encouraged to invest in health related services that improve quality and outcomes – CCOs that reduce costs through use of these services can receive financial incentives to offset those cost reductions
Promote Primary Care and Pay for Value • The waiver provides flexibility to: – Require CCOs to enter into value-based payment (VBP) arrangements with network of providers OHA will work with CCOs and stakeholders to develop a framework to advance the use of VBPs – Offer new performance incentive payments to Patient Centered Primary Care Homes (PCPCH) and Comprehensive Primary Care Plus (CPC+) providers that reflect provider performance in these programs
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