Week 1-11 politics

determinants of health are

factors that contribute to a persons current state of health (CDC)

True or False? Generally speaking, we are not privy to the lawmakers' rationales for the laws they write and the judges' reasoning for their legal opinions.

false

tuskegee

validation of penicillin as effective cure marked ethical turning point withheld treatment, prevented participants from accessing treatment in other programs included men and their wives

True or false?

when a problem is identified as a public policy problem, the only means of a solution involves a government intervention

Medicaid Financing

medicaid is jointly financed by the federal and state governments matching system -federal medical assistance percentage determines the matching rate, rate is tied to each states per capita income w/ poorer states receiving a higher federal match, must be at least 50/50, up to 80/20 -highest match in 2019, Mississippi 76.98% -13 states at 50%, PA at 52.25% beneficiary cost sharing -Prior to DRA, very limited cost sharing allowed -DRA Provides expanded cost-sharing options

persons with cognitive and physical impairment

mental health and mental retardation act 1966 rehabilitation act of 1973 section 504 americans with disabilities act 1990

enactment/implementation of ACA

expand affordable health insurance coverage reduce # of uninsured through individual mandate and medicaid expansion, mandate employer coverage pay for coverage w/o increasing federal deficit pursue triple aim: -slow rising cost of health care (bend cost curve) -encourage innovative solutions to increase access, reduce cost and improve quality -improve population health (CHNAs, focus on prevention) strengthen medicare and private insurance system

entitlement

everyone who is eligible for and enrolled in the program is legally entitled to receive benefits from the program. Beneficiaries may not be refused service for lack of funds or other reasons.

disproportionate growth in healthcare spending

faster than GDP rising expectations abt value of healthcare growth in medical technology gov. financing nature 3rd party payment aging society lack of real competitive forces bad distribution of physicians

Medicaid

federal state public health insurance program for the indigent program administration: Federal- center for medicare and medicaid services (CMS) outlines mandatory and optional populations and benefits covered under medicaid state- state medicaid agencies run programs, select which optional populations and benefits to cover in the state program all states participate in medicaid

private health insurance

financing and pooling- pool dollars for healthcare through employee and employer contributions employer is risk pool purchaser health insurance exchange shifts risk pool get employer out of decision loop e.g. germany sickness funds provisions of services- U.S. insurers negotiate agreements w/ eahc healthcare prover ACA- innovation to create risk bearing entities such as ACOs

financing healthcare in U.S.

fragmented, multiple payers varied sources of funds for coverage -employers, gov., personal gaps in coverage, variability if coverage

Interest groups have a variety of tools at their disposal when developing strategies for lobbying, such as trying a BLANK strategy and harnessing the influence of community leaders and other prominent individuals.

grasstop

context that led to ACA

health insurance coverage 2012: 170.9 mil employment based insurance 50.9 mil medicaid 48.9 mil medicare 40-60 mil uninsured 40 mil underinsured

Numerous health reform attempts in the U.S. over the past 100+ years

healthcare coverage increasingly important prior to 2010, attempts at reform have failed some successes at state level (Hawaii, Oregon, Massachusetts) with few exceptions health reform attempts have been limited to the margins - incremental, not radical reform radical-medicare/medicaid

financing of health care

how we pay for care, who pays, how transactions occur bt users and providers, how much is spent

reduce health equity gap

improve housing, enforce fair wage laws, increase access to quality education, improve access, working conditions

affordable care act

individual mandate- most people have to purchase health insurance or pay a penalty starting in 2014 exemptions for certain populations and based on affordability penalty for individual mandate repeated in 2017 tax cut and jobs act controversy too much gov. interference w/ private lives? constitutional?

factors that contribute to health and healthcare disparitites

individual- healthcare provider bias, cultural expectations and differences, location and financing of healthcare systems, social factors -race, ethnicity, socioeconomic status, age, geography, language, gender, disability, citizenship, sexual identity

difficulty of reform in U.S.

individualistic culture, dislike of big government, lack of consensus, federal system rules and structure make it difficult to achieve reform, states generally home to social welfare issues, powerful interest groups against national health reform, path dependency

Medicaid: provider reimbursement

levels vary by state and type of provider states have a lot of discretion setting rates fee for service providers paid on state determined fee schedule managed care providers paid according to contracts between the state and managed care organization medicaid reimbursement is typically much lower than private insurance or medicare reimbursement

Medicaid: Eligibility

medicaid generally covers low income: pregnant women children adults in families with dependent children individuals with disabilities elderly must meet 5 eligibility requirements: categorical, income level, resources, residency, immigration status ACA medicaid expansion requires coverage up to 133% of federal poverty level (less than 200%)

political/legislative process that produced ACA

obamas legacy opposition from republicans, continuing conflict making future of act uncertain signed into law march 3 2010 polarization of gov. and nation mixed popularity of law

Childrens health insurance program

overview: 10 yr $40 bil block grant program designed to provide health insurance to low income children whose family income is above medicaid eligibility level in their state established in balaned budget act of 1997 reauthorized in 2009 and extended in the ACA, authorization through 2019, separate bills fund through 2027 all states participate in CHIP Just as with medicaid, federal participation rate varies by state per capita income

Medical legal partnership

patient care team, medical and legal professionals legal service attorney address underlying social conditions

politics of ACA

patient protection & affordable care act 2010 no republican support republican strategy was to overturn new law -lawsuits initiated by republican governors -repeal in congress 2016 election bought trump to presidency and republican majorities in house and senate with promise to repeal obamacare repeal and replace why did it fail?

vulnerable pop.

pregnant women, fetuses, neonates, prisoners, children, cognitively and physically impaired persons, students/employess, minorities/immigrants, economically and educationally disadvantaged, AIDS?HIV, terminally ill

right to criminal legal representation

right to legal representation exists no right to lawyer in civil matters- immigration status, domestic violence, disability, family, housing, public benefits (medicaid, food stamps, social security), employment, special ed.

Medicaid eligibility: PA

seniors 65+, pregnant women, blind/disabled, families w/ children younger than 21 adults 19-64 w/ incomes at or below 133% of federal poverty level

health equity

situation in which everyone has the opportunity to attain his or her full health potential

SDH

social conditions in which people are born and that affect their daily lives and well being as they move through life WHO- conditions in which people are born, grow, live, work and age CDC- shaped by distribution of money, power, resources at both local and national levels

affordable care act

state health insurance exchanges american health benefit exchanges for individual small business health options program for small businesses, effectively ended 2018, may be revised must offer essential health benefits (abortion compromise) four cost levels for plans based on actuarial value subsidization of insurance plans based on income less than 400% of federal poverty level many participants pay low or no premiums

Medicaid: waivers

states may apply to federal government for waivers of medicaid requirements section 1115 waivers secretary of health and human services may grant a section 1115 waiver to allow for a research and demonstration project that assists in promoting the objectives of medicaid use states as policy laboratories to test health reform ideas health insurance flexibility and accountability act

True or False? It could be said that the affordable care act shows a curbing of the free market perspective and an elevation of the social construct perspective

true

Health disparity

when 1 pop. group experiences a higher burden of disability or illness than another group differences bt the health of disadvantaged groups and the health of the healthiest must see differences and address them

affordable care act

why did it pass when so many prior attempts failed? commitment and leadership presidential leadership is key congressional leadership essential learned lessons from past failures (clinton health plan, SCHIP) interest groups can sink legislation (harry and louise, HIAA) political pragmatism- bring critical interest groups into process (AHA, health insurers, AMA, AARP) engage a win win diplomacy improvements in health insurance and medicare, advantage boom to insurers

history of rise of health insurance

•Late 1800s-early 1900s—European social insurance movement resulted in the creation of "sickness" insurance throughout many countries. •1929—Blue Cross established its first hospital insurance plan at Baylor University. •1939—Blue Shield began. •1954—Internal Revenue Service declared that employers could pay health insurance premiums for their employees with pre-tax dollars. •1965—Medicaid and Medicare were created.

managed care

•Managed care integrates the provision and payment of healthcare services. •Ideally, managed care contains costs while providing necessary and high-quality health care services. •Some fear that managed care companies provide fewer services than necessary or lower quality services to save money.

ACA

•The Supreme Court justices heard the suits filed by 26 states and by the National Federation of Independent Business, challenging the federal health law's individual mandate •In 2011, two federal courts of appeals have said the mandate is constitutional under Congress's authority to regulate interstate commerce •One, the 11th Circuit in Atlanta, had ruled the law unconstitutional, and one said it could not reach a decision on the mandate because tax laws cannot be challenged until they are in effect

CHIP eligibility

•States may cover children up to 300% Federal Poverty Level (FPL). •Children who are eligible for Medicaid must be enrolled in Medicaid, not CHIP. •States may impose waiting periods, enrollment caps, and other measures to limit expenses.

outcome

•The ACA stands •Medicaid expansion voluntary •Individual upheld • What is the current status of the Individual Mandate? - Tax Reform Law of 2018 What is the current status of the ACA? - Texas v United States 12/14/18

What historical perspective became dominant in the 1990's and continues to be a forceful influence today?

Free market perspective

Health economics

How scarce resources are allocated (health care services) The production, distribution, consumption of goods and services (related to health care) Thinking like an economist

Current Secretary of U.S. department of health and human services

Alex Azar

has ACA succeeded

•Yes and no •Number of uninsured dropped to record lows •Mostly due to Medicaid expansion •Medicaid expanded in only 38 states •Number of uninsured went up this year for the first time since 2014 •Modest contribution to slowing of growth of health care costs •Expansion of accountable care organizations and patient centered medical homes •Republican attempts to repeal •Prior to 2017, repeal votes were largely symbolic •In 2017 attempts to repeal and replace failed •ACA more republican than the alternatives •Swing vote by Senator McCain sunk attempts to repeal and replace •Presidential executive orders and HHS actions •Court challenges

Medicaid (Jointly Funded, State Administered)

-collection of 50 state administered programs + US territories -health insurance for low income residents -enrollment and costs skyrocketed in 1990s -became target to state budget cuts to control medicaid costs -cost containment measures enacted in 2000s -expansion of program mandated in ACA -supreme court converted mandate to option 38 states expanded medicaid voluntarily -covered 70 mil in 2017 (up from 60 2014) impact on reduction in the uninsured

key characteristics of policy processes

1. each health payment and regulatory program has distinct sub systems leading to complexity 2. fragmentation of government institutions makes enactment of health policy difficult -divided control of president/congress -federal state relations complicates further 3. implementation of policy is critical -subject to interpretation by executive branch -undermining aspects of ACA such as health marketplaces by reducing advertising budget 4. establishment of programs reconfigures policy subsystems and political factors affecting sustainability

key failed attempts at national health reform

1912 progressive party candidate teddy roosevelt supported social insurance platform that had health insurance 1915 american association for labor legislation proposal for working class health insurance 1935 roosevelt proposed inclusion of health benefits in social security legislation - opposed by AMA truman supported national health insurance platformin 1948 nixon initial health reform proposal in 1969, revised 1972 clinton health security act 1993

helping those who remained uninsured

2000s- 46 million americans uninsured, major issue in presidential campaign election of wofford in 1998 was bellwether of focus on healthcare access decline on coverage by employer sponsored insurance 1990s/2000s will mandating coverage work? it did in MA focus on coverage for children (SCHIP 1997) following clinton health insurance plan debacle SCHIP expanded 2009 and 2017 # of uninsured continued to rise healthcare reform debated in 2008 campaign obama made health reform top priority recession of 2008pushed health reform back ACA passed 2010

CHIP: structure

3 options incorporate chip into medicaid programs as an expansion population create separate chip program hybrid program: some chip children are in medicaid and some are in a separate chip program all 3 options used by states

Marginal utility

Added satisfaction of consuming one more good or service Diminishing marginal utility First pair of glasses-high utility Second pair- medium Etc.

Markets

Context in which goods and services are bought and sold Supply and demand expressed Buyers (patients) Sellers (physicians, hospitals, pharma)

supply

Amount of goods and services that producers are able and willing to sell Driven by profit maximization Influencers of supply: Sale price Input costs, cost to provide, produce Technological advances Size of market

Factors that influence demand for health care

Being sick, having a need Insurance status, income, ability to pay Price Geographic accessibility Advertising Perception of quality Salience, relevance

Opportunity cost

Cost of foregoing the next best option If you choose option A you cannot choose option B

Assumptions economists make

People are rational, have preferences Utility (satisfaction) maximizers Society characterized by scarcity Infinite wants, needs, but limited resources, difficult choices about who gets what

Medicaid: Benefits

Medicaid covers extensive acute care and long term benefits some benefits are mandatory, others optional early and periodic screening, diagnostic and testing services are a comprehensive set of mandatory services for children Deficit reduction act of 2006 (DRA) created a new benefit option that allows states to use one of 3 benchmark or benchmark equivalent options to set their benefit package

Demand

The quantity of goods or services that a consumer is willing and able to purchase

insurance coverage overview

U.S. does not have single national program 2016- 88% of pop. uninsured most w/o obtain through employer

Block Grants

defined sum of money (often from the federal government to the states) is allocated for a particular program over a certain period of time. Beneficiaries may be refused service for lack of funds or other reasons. No legal entitlement to the benefits

healthcare disparity

denotes differences in access to healthcare services or health insurance, or in the quality of care actually received

Law as a SDH

design and perpetuate social conditions, bad effects on populations behaviors,prejudices health harming

risk factors for vulnerability

age, gender, ethnicity, language, education, emplyoment, income, insurance, mental/physical/social health health literacy, culture, where you live, resources, food, sanitation, health services, poverty, community

ACA changes to medicaid: significant eligibility expansion

all non medicare eligible adults under 65 with incomes up to 133% of poverty will be eligible in every state do not have to fit a category standardized resource test all children 6-19 at 133% of poverty immigrants have a 5 year bar, states have option to cover legal immigrant pregnant women and children who have been in country 5> yrs keep in mind public change executive order

Premiums and cost sharing (DRA)

beneficiary cost sharing -prior to deficit reduction act of 2006, very limited cost sharing allowed -DRA provides expanded cost sharing options States may charge limited premiums and enrollment fees on the following groups of medicaid enrollees -pregnant women and infants w/ family income at/above 150% -qualified disabled and working individuals w/ income above 150% FPL disabled working individuals eligible under the ticket to work and work incentives improvement act of 1999 (TWWIIA) disabled children eligible under the family opportunity act (FOA) medically needy individuals

ACA changes to medicaid

benefits newly eligible individuals entitle to essential health benefit package, not traditional medicaid services financing federal gov pays 100% of newly eligible expansion for 2 years, phases down to covering 90% by 2020 states have a maintenance of effort requirement for adults and children

factors

biological- genetic mutation psychosocial- conflicts with ones family, stress, anger, depression behavioral- alcohol, smoking, unprotected sex social- conditions in which people are born, affect daily lives and overall well being

What type of law is central to legal systems in many countries, particularly those that were territories or colonies of England, which is how the United States came to rely on it as part of its legal system?

common law

What type of law governs the relationship between individuals and their government and define the role of government in society?

constitutional law

managed care, common structures

•Health Maintenance Organization (HMO) •Pays providers a salary or capitation •Beneficiaries may only use in-network providers •HMO coordinates and controls receipt of services •Preferred Provider Organization (PPO) •Pays provider on a discounted fee schedule •Beneficiary may use in- or out-of-network providers •Point of Service Plans (POS) •Combines features of HMO and PPO •Pays providers with capitation or other risk-sharing arrangement •Has a provider network; beneficiaries may use out-of-network provider for designated services •Has a gatekeeper to control and coordinate care

ACA: Employer Mandate

•In 2014, employers with 50 or more employees must provide affordable health insurance or pay a penalty. •Insurance is affordable if it has an actuarial value of at least 60% or is not more than 9.5% of an employee's income. Penalty is per employee after first 30 employees.

basic terminology

•Beneficiary—Consumer; the individual who is covered by the plan •Premium—Annual fee paid by the beneficiary to the health plan, usually in monthly installments, to secure health insurance coverage •Health Savings Account - Fund that can include employer and employee contributions (in pretax $); can accumulate. Source of payment for non-covered expenses •Deductible—Amount of money a beneficiary must pay out-of-pocket before the insurance company assists with paying for services •Deductibles can be minimal; but can be $10,000 or more •High deductible plans often associated with Health Savings Accounts •Cost-sharing—Co-payment or co-insurance, an amount the beneficiary pays per service after the deductible is met •Co-insurance - percent share of charges paid by beneficiary (e.g. 20%) •Co-payment - fixed $ amount paid by beneficiary (e.g. $20 for primary care; $40 for specialist care)

CHIP benefits

•CHIP programs must provide "basic" benefits. •Inpatient and outpatient hospital care •Physician services •Laboratory •X-ray •Well-baby and well-child checkups •Dental coverage or dental-only supplemental coverage •CHIP programs may provide additional benefits such as prescription drugs, mental health, vision, and hearing. •Benefit packages are based on one of five benchmark health plans. •Similar to DRA option in Medicaid •Overall, Medicaid programs generally offer much more comprehensive benefits than CHIP programs.

king vs. burwell

•Challenge to the ACA that the Supreme Court heard on March 4th. At issue: whether the IRS extend tax-credit subsidies to coverage purchased through exchanges established by the federal government •34 states have a federally run exchange. Without the subsidies, which are estimated at $25 bil across the 34 states, oversight millions of Americans may lose their insurance •Congress designed the exchanges to be state deferential, to give the states the choice. The ACA statute uses the phrase "state flexibility" five times •Exchanges have a federalism structure where Congress enacts a nationwide program, but offers the states the right of first refusal to implement a part of it. There is a federal fallback mechanism that requires the federal government to operate the program when the states decline to do so

ACA: Financing Health Reform

•Changes to Medicare provider reimbursement •Changes to Medicare Advantage reimbursement •Medicare Part A increases for high earners •Changes in Medicare Part D subsidies •Changes in Medicare employer subsidy •Changes in disproportionate share payments •Increase Medicaid prescription drug rebate paid by manufacturers •Income tax code changes •Health industry fees •Tax on high-cost health insurance plans

uncertainty and risk

•Employers provide health insurance to employees. Why? •People choose to be insured because of uncertainty and risk. •There is uncertainty whether an expensive and unforeseen event that impacts their health status will occur. •There is risk of financial exposure due to the unexpected event. •This is a desirable benefit and one subject to labor union negotiations (e.g. General Motors strike at present) •Insurance companies are concerned about uncertainty and risk because they are businesses that need to cover the cost of their expenditures. •Uncertainty and risk may lead to adverse selection. Unhealthy people over-select a particular plan, making the plan more expensive

texas vs. azar

•Federal judge in Texas found ACA unconstitutional in its entirety. •Basic arguments •Congress in 2017 Congress eliminated penalties on individuals imposed by the ACA if they did not purchase insurance •The individual mandate is a cornerstone of ACA - with no penalty then the entire law is invalidated •Trump administration announced in June 2018 that it would not defend the ACA •Case headed eventually to Supreme Court •What a Republican Congress could not accomplish, SCOTUS may effectuate.

CHIP financing

•Federal-state matching program •"Enhanced" match: CHIP match will always be higher than the state's Medicaid match •States receive payments in 2-year allotments •Rebased every 2 years to reflect actual use •Higher cost sharing allowed as compared with Medicaid •Under the ACA, beginning on October 1, 2015, and ending on September 30, 2019, the E-FMAP is increased by 23 percentage points, not to exceed 100 percent, for all states •12 states at 100%; 14 states at 88% 2020 drops back; range 76.5% to 95.39%

managed care, utilization control tools

•Gatekeeper •Managed care organization uses a primary care provider to make sure only necessary and appropriate care is provided. •Utilization review •Managed care organization reviews and approves or denies services requested by provider. •Case management •Managed care organization manages and coordinates patient care.

legal issues

•Health Insurance Portability and Accountability Act of 1996 (HIPAA) •HIPAA-covered group plans may not exclude or limit otherwise qualified individuals due to pre-existing conditions. •HIPAA-covered group plans may not charge different premiums based on identified health factors to similarly situated individuals. •State laws on medical underwriting vary.

setting premiums

•Insurance companies set premiums to cover most of their expenses •Subject to state insurance regulation and rate approval •Experience rating •Based on health status and claims of insured group in prior year(s) •Also referred to as medical underwriting •Community rating •Based on factors unrelated to previous use of medical care, such as geography or age •All persons in the community rating system pay the same amount (ACA Health Insurance Marketplace)

argument

•Mandate that individuals purchase insurance if not covered •U.S. District Court in FL ruled the entire law unconstitutional •Vinson rejected administration arguments that the law was grounded in Congress' power to regulate commerce because, he said, the law is not aimed at "economic activity," but rather "inactivity," that is, a decision not to purchase insurance •One judge rejected the argument that the Commerce Clause can't compel people to buy health insurance because that would be regulating inactivity •He wrote: "Far from "inactivity," by choosing to forgo insurance, plaintiffs are making an economic decision to try to pay for health care services later, out of pocket, rather than now, through the purchase of insurance •One judge said choosing not to buy insurance has an impact on health care providers and taxpayers and, therefore, is an example of "activities that substantially affect interstate commerce."

paying for medicare

•Medicare Part A - no cost •Medicare Part B - $135.50 / month in 2019, rising to $144.20 in 2020; Medicaid pays premium for dual eligible if qualified •Medicare Premiums and Deductibles for 2019 •Parts C & D - numerous plans to select from with varying premiums •Medigap policies - private health insurance supplementary to Parts A and B.

medicare eligibility

•Medicare covers two main groups of people: elderly and disabled •Elderly requirements •At least 65 years old •Eligible for Social Security by having worked and contributed to Social Security for at least 10 years •Disabled requirements •Individual is totally and permanently disabled and has received Social Security Disability Insurance for at least 24 months, or •Has end-stage renal disease

Moral hazard in health insurance

•Moral hazard means that a situation exists where one party has an incentive to use more resources than otherwise would have been used because another party bears the costs •Health insurance bears the cost of purchasing health services •Moral hazard is a term used in economics in relation to an individual who is willing to take risks because he or she will not have to bear the cost of his or her action. •People smoke and know that someone else will bear cost of ill-health •What are the implications of health insurance? •Affordable Care Act - increase coverage; does this create or enhance moral hazard? Or •Does health insurance make consumers better off? Society better off?

ACA changes to medicare

•New coverage for preventive services without cost sharing •Eventually closes Part D doughnut hole •Short-term relief as well •Reimbursement changes •Cost changes to beneficiaries •Creation of Independent Payment Advisory Board •CMS innovation center

medicare

•Overview: A federally funded health insurance program for the elderly and some persons with disabilities •Medicare is administered by CMS •No state administration •National rules, apply uniformly in all states

medicare financing

•Part A •Trust fund funded through a mandatory payroll tax •Deductibles and cost-sharing paid by beneficiaries •Part B •General federal tax revenues •Monthly premiums, deductibles, and cost-sharing paid by beneficiaries •Part C (Medicare Advantage) •Receives funding for Part A and B services through funding sources described above; plans may also require monthly premiums, deductibles, and cost-sharing to be paid by beneficiaries •CMS enters into risk sharing agreement with private health plans to administer Medicare Advantage health plans •Part D (Prescription Drugs) •General federal tax revenues •Monthly premiums, deductibles, and cost-sharing paid by beneficiaries •Infamous "donut hole" created in Medicare Prescription Drug Act of 2003. State payments for dual enrollees

medicare structure

•Part A (1965): inpatient hospital care •Part B (1965): outpatient care •Part C (1997; 2003; 2010): managed care program •Part D (2003): prescription drug coverage •Part A Mandatory - all persons age 65 and older must enroll •Parts B through D - voluntary •Limitations on Basic Medicare - Deductibles and copays; lifetime limits on hospital coverage; no drugs, dental or long term care •Medigap or Medicare Advantage - take your pick! •Seniors living in poverty also eligible for Medicaid (dual eligibility)

medicare benefits

•Part A: Hospital insurance—inpatient hospital, skilled nursing facility, hospice •Part B: Supplemental medical insurance—physician services, outpatient services, limited preventive services •Part C: Managed care—same services (sometimes receive additional services) delivered through a managed care arrangement; Part C includes other types of plans as well •Part D: Prescription drug coverage—may receive through private drug plans or managed care arrangement

managed care, cost containment tools

•Performance-based salary •Provider receives a salary as a managed care organization employee. •Salary is subject to bonuses or withholds. •Discounted fee schedule •Provider accepts less than fee-for-service rates to participate in managed care network. •Capitated payment •Provider receives a per member/per month payment for all services rendered within scope of practice.

medicare provider reimbursement

•Physicians •Fee-for-service basis according to a Medicare fee schedule •Hospitals •Prospective payment system based on diagnosis •Diagnostic-related groups for inpatient care •Ambulatory payment classification for outpatient care •Managed care •Capitated rate negotiated by the federal government with private health plans and pharmacy benefit management plans

ACA: Premium and Cost Sharing Subsidies

•Premium tax credits available for individuals who purchase insurance in an exchange and have income between 133% and 400% of poverty •Cost-sharing subsidies available for individuals who purchase insurance in an exchange and have income up to 250% of poverty •To qualify, must be a U.S. citizen or legal resident, not eligible for any type of public insurance, and not have access to employer-sponsored insurance

ACA

•Private insurance market changes •No preexisting condition exclusion •Dependent coverage to age 26 •Preventive services without cost sharing •Prohibitions against lifetime and annual coverage limits •No rescission without fraud •New appeals process Premium rate reviews •Private insurance market changes (cont.) •Guaranteed issue and renewability •Rate variation limits •Essential health benefits •Wellness plans •Some plans may be grandfathered in and not subject to all of these changes

CHIP waivrs

•States may apply to the federal government for waivers of CHIP requirements. •States may cover pregnant women without a waiver, but no new waivers will be granted for other adults. •States may also use waiver for premium assistance.

10 parts of the ACA

•Title I Quality, affordable health care for all Americans •Title II The role of public programs •Title III Improving the quality and efficiency of health care •Title IV Preventing chronic disease and improving public health •Title V Health care workforce •Title VI Transparency and program integrity •Title VII Improving access to innovative medical therapies •Title VIII Community living assistance services and supports •Title VIIII Revenue provisions •Title X Reauthorization of the Indian Health Care Improvement Act