Thurston County Board of Health BriefingSeptember 30, 2010

America leads the world in medical research and medical care

And

America leads the world in medical spending

But

American’s life expectancy is not even among the top 25 countries, behind countries like Bosnia and Jordan

Patient Protection and Affordable Care Act signed into law by President Barack Obama on March 23, 2010.

Here is what it must do to be effective:

• Help more people get health insurance

• Control health care costs

• Improve our health system

1 in 5 adults from 18 to 64 have no health insurance

Many lose insurance when unemployed

Health care costs are increasing dramatically

By 2050, at current rates of increase, Medicaid and Medicare will eat up 20% of the entire economic output of the country

By 2050, Medicare and Medicaid alone will cost more than the entire Federal Budget of 2007

Prevent disease – chronic disease, smoking-related disease, infectious diseases etc. PUBLIC HEALTH

High costs but poor outcomes• “Fee for service” leads to more services, not better care

• Higher incomes for specialists undermines primary care practice

• Lack of electronic health information systems does not support coordinated care

• Little emphasis on prevention PUBLIC HEALTH

• Little emphasis on quality of outcomes

Thurston County purchases millions of dollars each year of health services

• Care for employees as employment benefits

• Care for high-need, often chronically ill people (mental health and substance abuse treatment, corrections systems)

• Coordinate parts of the safety net in current system

Roles may change

• Integration of systems of care: physical, mental, and oral health

• New public health funding

• Transition – over months and years

• Technology impacts, investments

• Social justice and policy issues

Integrated Care, Person-Centered Health Home, Care Management

Payment-reform driven by integrated care

Provider relationships change

New, Emerging Models Quality / Outcomes Focused

Accountable Care Organizations

Exchanges

Increased use of non-physicians

Revenue shifts across workforce

Cost / Quality conundrum

Benefit (Health Insurance) Reform Payment Reform Care integration (mental health, substance use,

medical treatment) Community Clinic expansion Electronic health records Health prevention focus Workforce recruitment and retention Home Visitation programs Health disparities data collection

Requires most U.S. citizens and legal residents to have health insurance• Expands Medicaid to 133% of the federal poverty level

(non- Medicare, under age 65, children, pregnant women, and adults with dependent children)

• US citizens and legal residents must have coverage or pay penalties, based on income

• States will receive federal funding to cover expansion BUT must maintain current effort

• Benefits will match Exchanges

• CHIP – Children's Health Insurance –continues

• Undocumented not eligible for Medicaid

Creates state-based American Health Benefit Exchanges • Individuals can purchase coverage, with premium and cost-

sharing credits available to individuals/families with income between 133-400% of the federal poverty level

• Small businesses can purchase coverage • Requires employers to pay penalties for employees who receive

tax credits for health insurance through an Exchange, with exceptions for small employers

Employer Mandate• 200+ = Automatically enroll; may opt out• 50+ = Pay assessments per employee (offset individual cost)• 50 or fewer: Exempt from penalties• Free choice vouchers for employees under 400% FPL• Tax credits and exemptions available for small employers

Imposes new regulations on health plans in the Exchanges and in the individual and small group markets, including coverage of clinical preventive services

Requires coverage of clinical preventive services in Medicare; creates state option in Medicaid

Medicaid payment rates increase to match Medicare

The term ‘health home services’ means comprehensive and timely high-quality services

• Inclusion of mental health and substance use treatment in primary care settings

• comprehensive care, managed care coordination, and health promotion;

• comprehensive transitional care, including appropriate follow-up, from inpatient to other settings;

• patient and family support (including authorized representatives);

• referral to community and social support services, if relevant; and

• use of health information technology to link services, as feasible and appropriate.

This will cause us to rethink how care is delivered and accessed

$11 Billion over five years for:• National Health Service Corps

• Community Health Centers

• School based health centers

• Nurse-managed health clinics

Public health departments could choose to become community health centers (not recommended)

SeaMar Community Health Centers operate in Thurston County (Federally Qualified Health Center – FQHC)

“Meaningful Use”: The required future standard Health Information Technology for Economic and

Clinical Health (HITECH) Act• Improve health outcomes

• Expand access

• Improve health status

• Provide incentives to states

• Health Care Authority to oversee in Washington State

State legislation also supports

Prevention, Health Promotion, and Public Health Advisory group

Public Health and Prevention Fund: funding for prevention and public health programs, broadly defined

• Expanded and sustained national investment in prevention and public health programs: prevention, wellness, and public health prevention research

• The Fund DOES NOT assure additional federal money for any particular program

• Competitive grants to reduce chronic disease rates, address health disparities, and develop a stronger evidence-base of effective prevention programming

• Competitive grants for pilot programs to provide public health community interventions, screenings, and clinical referrals for 55-64 year olds

• Community based public health interventions include improved nutrition, increased physical activity, reduced tobacco use and substance abuse, improved mental health and healthy lifestyles

• Epidemiology and Laboratory Capacity grants will be available

Subject to funding through Congressional appropriations

National Workforce Advisory Committee to develop national strategy

Improve primary care provider capacity• Loan repayment• More mid-level providers (ARNP, PA)• Attention to underserved areas• Expansion of residency programs• Increased payments for primary care

$3 Billion in grants to states for evidence-based early childhood home visitation to measure improvement in: • Maternal-child heath• Injury prevention• School readiness• Juvenile delinquency• Family economic factors• Community resource coordination

Requires the collection and reporting of data on:• race and ethnicity• gender• geographic location• socioeconomic status (including education, employment

or income)• primary language• disability status

Preventive Services and Community Preventive Services Task Forces

Immunization Demonstrations Public Health Services Research Workplace Wellness Support for nursing mothers at work Diabetes Prevention Program Non-profit hospitals must conduct & implement a

community health needs assessment with community leaders and public health experts

Nutrition labeling of standard menu items at chain restaurants (at least 20 outlets) and in vending machines

Attention to clinical and population-based prevention: screening, policy development (nutrition and physical activity)

Health system workforce development Change in reimbursement for primary medical

care Volume and demand for primary care services

will increase

Access to insurance does not mean access to care – especially shortage areas. What will happen here?

What safety net is needed? (Such as undocumented)

How will the role of public health change regarding quality improvement, integration of services, disease prevention?

How can we work best with our community partners, maximizing opportunities?

National Association of Counties: http://www.naco.org/programs/csd/Pages/HealthReformImplementation.aspx

National Association of County & City Health Officials: http://naccho.org/advocacy/health-reform.cfm

Governor’s Office: http://www.governor.wa.gov/priorities/healthcare/reform.asp

Joint Legislative Committee: http://www.leg.wa.gov/jointcommittees/HRI/Pages/default.aspx

Health Care Authority: http://www.hca.wa.gov/ Office of Insurance Commissioner:

http://www.insurance.wa.gov/consumers/reform/national_health_care_reform.shtml

Timeline for National Health Reform: http://www.healthcare.gov/law/timeline/index.html