[PPT] - Reproductive Health Policy in 2017: Whats Changed, What Hasnt? PowerPoint Presentation

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2017 ObGyn Update: What Does the Evidence Tell Us? October 20, 2017

Michael S. Policar, MD, MPH Clinical Professor of Ob, Gyn, & RS UCSF School of Medicine michael.policar@ucsf.edu

Reproductive Health Policy in 2017: What’s Changed, What Hasn’t?

No commercial disclosures for this lecture

Health Care Reform…Always a Tough Road Health Policy versus Health Politics

Health Policy: Which policies, structures, and financing lead

to optimal clinical and economic health outcomes? – The Clinton Health Security Act

Health Politics: What is possible…winners and losers

– Patient Protection and Affordable Care Act – Origins in conservative Heritage Foundation – Based on Massachusetts Health Connector program

Health Posturing

– Legislation to “pay a debt to the base” – We need a win!

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7 Years into the ACA… Has the Promise Been Kept?

Women…

With commercial insurance have more women’s

health benefits with lower or no out-of-pocket costs

Enrolled Medicaid now have comprehensive health

insurance, including a PCP and an OBGYN

Women who have no insurance still have safety net

coverage through state FP programs + Title X

Something for everyone!

P

“Patient Protection and Affordable Care Act” (ACA)

March 23, 2010

‘‘Patient Protection and Affordable Care Act” (ACA)

First step:

Expand access to health insurance

 Everyone has coverage  Fairer insurance practices  Expand coverage to 32 million by 2019

Second step:

Improve quality of care

Focused on prevention and primary care

Third step:

Stabilize cost of health care

Change incentives: shared risk, P4P Reduce waste and fraud

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ACA Step 1: Expanding Access A Three Part Formula

1. Insurers must offer coverage to everyone
2. Federal subsidies to help afford coverage

– Share the cost of insurance premiums – Tax credits for co-payments, deductibles

3. Individual mandate: everyone must have health insurance

– Risk pool must include healthy people – Only way to cover pre-existing conditions – All of us need will coverage sooner or later

Phase 1 of ACA: 2010-2013

Coverage on parents plan until 26 years of age
Improved Part C Medicare drug coverage
Ban on lifetime benefit caps and rescissions
Insurance rate increase restrictions
Plans must spend > 80% of premiums on health care
First dollar coverage of many preventive services (no-

cost sharing…i.e., no deductible or co-payments)

Phase 2 of ACA: 2014-Present

Individual mandate to by insurance (or pay a tax penalty)
State health insurance exchanges opened
State Medicaid expansion (now 2/3 of states)
State essential health benefit (EHB) standards
Insurance market reforms

– No restrictions for pre-existing conditions – No gender discrimination

Employer shared-responsibility penalties (now delayed)

Insured through employer Military Veterans Admin Undocumented individuals Little or no change Medicare Medicaid Minor changes Uninsured Self employed Major changes Small business

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Uninsured
Self employed
SB <50 employees
Small business

(50-100)

5 % 1 % State Health Insurance Exchanges OR Healthcare.gov

Medicaid

5 %

Employer based HI <50: business can purchase <25: business tax credits fine pay

Major Changes

State Health Insurance Exchanges

State regulated “insurance marketplaces”

– “Travelocity” of health plans – Compare by quality and cost – All offer same “essential health benefits” – Optional participation by plans

Subsidies for families 133-400% FPL (fed poverty level)

– 399% FPL: $44,680 individual; $92,200 family of 4

States without marketplace default to federal exchange

State Health Insurance Marketplaces

Metal Level Plan covers Platinum 90% Gold 80% Silver 70% Bronze 60% Catastrophic < 30 yrs old

Premiums are higher at

each level

Subsidy based on silver

plan cost

Out-of-pocket costs are

lower if subsidized premium (cost-sharing subsidy…CSR)

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State Medicaid Expansion

Medicaid eligibility for adults with income <138% FPL

– Before: “Broke plus something else” – Now: men + women with incomes below

$15,867 individual; $32,500 for a family of 4
Feds cover 100% costs until 2017, then 90% by 2020

– Reason for rejection of expansion by many states…

Preventive services with no cost-sharing (in blue)

– USPSTF grade [A] or [B] – AAP Bright Futures – CDC ACIP vaccination recommendations

8 additional women’s prevention benefits not

addressed by USPSTF…intended to “close the gaps”

– (In red)

Reproductive Health Cancer Healthy Behaviors Pregnancy related Immunizations Chronic conditions STI and HIV counseling Breast Cancer

Mammography

Alcohol S&C

Alcohol

S&C

TdaP, Td
MMR, varicella

CV: HTN, lipids Ct, GC, Syphilis screening

Genetic S&C

Tobacco C&I

Tobacco

C&I Influenza T2DM screen HIV screening (adults at HR; all sexually active F)

Preventive

medication counseling Diet counseling if CVD risk

Folic acid

supplement

Hepatitis A, B
Meningococcal

Depression screen Contraception (women w/repro capacity Cervix:

Cytology
HPV + cytology

Interpersonal and DV S&C

GDM

screen

Rh, anemia

screen

HPV

(women 19-26) Osteo- porosis screen Colorectal:

FOBT,
Colonoscopy,
Sigmoid

Well-woman visits

STI screen
Bacteruria

screen

Pneumococcal
Zoster

Obesity screen; C&I if obese

Lactation

Supports

S&C: screening and counseling C&I: counseling and interventions

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Women's Preventive Services

HHS Guideline for Insurance Coverage Frequency Well-woman visits annually including preconception and prenatal care

Several visits may be

needed to obtain all recommended services, depending on health status, health needs, and

ther risks
National direct access to Ob-Gyn’s
Includes visits to PCP, ObGyn, or both

Women's Preventive Services

HHS Guideline for Insurance Coverage Frequency All FDA approved contraceptive methods, sterilization procedures, and patient education & counseling for women with reproductive capacity As prescribed

All methods must be covered, but not all products
Limited exemption for religious institutions (e.g., churches)

from providing contraceptive coverage for insured employees

7 Years of the ACA… Has the Promise Been Kept?

Yes, but…

There are major variations, depending upon your

state of residence

Women in the poorest states (those with no

Medicaid expansion) have the least improvement in coverage…“the coverage gap”

Obama B. US Health Care Reform Progress to Date and Next Steps JAMA online July 11, 2016

9.8%

Uninsured: 49 million in 2010  29 million in 2015 20 million more covered by ACA

25% 15%

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Commercial: 65%  67%

19-64 years old

(Medicare excluded)

Medicaid: 13%  17% Uninsured: 19%  11%

Obama B. US Health Care Reform Progress to Date and Next Steps JAMA online July 11, 2016

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State Of Birth Control Coverage

55 million women have accessed birth control without

cost-sharing

2/3 OC and 3/4 CVR users are not paying out-of-pocket
In 2013, women saved more than $483 million in out-
f-pocket costs for birth control, or $269 per woman
70% of Americans support this requirement

NWLC, 2015

2017: What’s Changed

Multiple attempts to “repeal and replace” the ACA
Efforts to weaken the ACA by the Executive Branch
Entry and exit of Tom Price, MD, as Secretary of DHHS
Proposed DHHS regulations

– Exemptions to contraceptives as a preventive service

Loosening of EHB standards: association health plans
New restrictions in OPA/Title X: mainly failure to renew

research projects…more on the way

“Repeal and Replace”

Long-standing campaign promise of Republicans
Objections to the ACA

– Minimizes “free market” in health care economics – Government take over of health care – Medicaid expansion: too many “free riders” – Too expensive for federal government and states – In some markets

Few or no health plan options
Expensive, and rising, premiums for >400% FPL
Very high deductibles in bronze + silver plans

5 Attempts to “Repeal and Replace”

Similarities

– Repeal individual and employer mandate – Repeal subsidies for out-of-pocket costs – Keep “dependent coverage until 26 years old”

Differences

– Degree of state control over insurance rules – What to do with Medicaid expansion – What to do with all Medicaid funding

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Congressional Attacks on Medicaid

70 million recipients: largest single payer in the US
Reverse Medicaid expansion feature of ACA
Switch Medicaid funding to block grants to states
Caps on all federal Medicaid expenditures
?? Contribution requirements for recipients
?? Lock-out requirements based on coverage years
To what purpose?

– Purported: to reduce government waste – Actual: to pay for federal tax cuts

After Failing to Repeal the ACA, the Executive Branch is Actively Trying to Sabotage It 12 Ways Trump is Scaling Back the ACA

Haeyoun Park, NY Times, Oct 12, 2017

1. End subsidies to health insurance companies that help

low-income people pay out-of-pocket medical costs – Executive action announced on Oct. 12, 2017

Known as cost-sharing reduction (CSR) payments

– $9 billion next year – Nearly $100 billion in the coming decade – Paid out through the executive branch each month

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Ending Cost-Sharing Subsidies

Payments may stop almost immediately
Insurers have the option to adjust rates or pull out of the

markets immediately when subsidy payments end – Covered CA: surcharge added to some policies

Current Senate effort to extend CSR payments

– Sen. Lamar Alexander (R-TN) and Patty Murray (D-WA) – Backed by 12 Democrats and 12 Republicans

12 Ways Trump is Scaling Back the ACA

Haeyoun Park, NY Times, Oct 12, 2017

2. Opened the door for sales of less expensive plans with

fewer benefits and protections for consumers – Less comprehensive “association health plans” – Greater use of short-term health insurance coverage – May permit interstate health insurance sales – Could escape state health insurance regulation

Destabilizes ACA by siphoning out younger and healthier

from exchanges  premiums skyrocket for sicker people

Contraception as a Preventive Service…

Exempt employers (mainly churches)

– Exists for the purpose of inculcating religious values – Employs & serves persons who share religious tenets – Contraceptive benefit is not available to employees

Accommodation (mainly hospitals, universities)

– Religiously-affiliated employers who do not meet exemption, but who have a religious objection – Insurer offers rates that excludes contraceptives, but health plan covers contraceptive benefit

Burwell v. Hobby Lobby Stores

June 30, 2014 US Supreme Court Ruling

The contraceptive mandate, set forth in the ACA, as applied

to closely-held for-profit corporations whose Christian

wners believe that life begins at conception, violates RFRA

Application

Closely held for-profit companies can limit (or eliminate)

coverage contraceptive services for female employees

Same as religious exemption (not accommodation)

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DHHS Expansion of Hobby Lobby Decision

October 6, 2017

“Religious Exemptions and Accommodations for Coverage
f Certain Preventive Services under the ACA”

– Interim final rules expand exemptions “to protect religious beliefs for certain entities and individuals whose health plans are subject to a mandate of contraceptive coverage through guidance issued pursuant to the ACA” – Administration thinks fewer than 10 will end coverage based on “moral objections” – “No more than 120,000 women would be affected”

ACA Contraceptive Requirement

Any and all businesses can choose either exemption
r accommodation, based on religion or moral beliefs

– No special notice required to employees – No required process for employers to certify their religious or moral beliefs

As final interim rule, it is in effect now
Suits have been filed against the DHHS to block the regs
May have little or no impact on 26 states with

contraceptive equity laws

NY Times 10/6/17

What’s Next?

New Secretary of DHHS

– Seema Verma, MPH (Administrator of CMS) – Scott Gottleib, MD (Commissioner of FDA)

Attempts to repair the ACA
Single payer: Medicare for all?

Repair the ACA

Policy makers should build on ACA progress

Continue to implement the marketplaces and delivery

system reform

Increase federal financial assistance for marketplace

enrollees

Introduce a public plan option in areas lacking individual

market competition

Take actions to reduce prescription drug costs

Obama B. US Health Care Reform Progress to Date and Next Steps. JAMA online July 11, 2016

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Medicare for All?

Require national acceptance of the concept that…

– Health care is a right, not a privilege – Common to every country that has universal coverage

Likely would be patterned after Canadian health care

system; with some degree of state control

Aggressively opposed by for-profit insurance companies
Funding mechanisms will take time to hammer out

Sanders Plan: Medicare for All

Federally administered single-payer program
Separates health insurance choice from employment
No more copays, no more deductibles

– “Go to the doctor and show your insurance card”

How to pay for it?

– 6.2 % income-based premium paid by employers – 2.2 % income-based premium paid by households – Progressive income tax rates – Taxing capital gains + dividends as ordinary income – Savings from health tax expenditures

Closing Thoughts…the Pessimist

President or Congress is successful in repeal (without replace)
Disaster for most of 10-20 million American who obtained

health insurance…back to pre-2010 status

Women could lose much of what they have gained, especially

first dollar coverage of contraception and preventive services – An employer’s beliefs may override a woman’s own religious or moral views and her health needs

Commercial plans could further leave the state marketplaces
Medicaid could be worse off than before the ACA

A “slow moving train wreck for health insurance markets”

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My Closing Thoughts…the Optimist

Americans influence Congress to block these changes
1st choice: Fix the ACA

– Based on successes with Covered California – Medicaid expansion in every state – Shore up the commercial insurance market

2nd choice: Medicare for All with 2 options

– Fee for service with Medi-Gap insurance – Medicare Advantage, HMO style

Take it Home….

As a result of the ACA, great strides have been made in

improving access to women’s health services – Much of the improvement is via Medicaid enrollment

We owe it to each patient that has no insurance, or who

receives care thru categorical programs, to give advice regarding health insurance enrollment

We have the credibility and standing to advocate for the

health care system that we would like to see and object to what is not in the best interest of our patients

Additional Resources

National Women’s Law Center

– Excellent advice re: accessing preventive services – nwlc.org

Kaiser Family Foundation

– Analysis of the effect of ACA on consumers, providers – kff.org

National Family Planning and Reproductive Health Assn