A CHANGING PARADIGM: IMPLICATIONS OF THE AFFORDABLE CARE ACT AND THE MEDICAID 1115 WAIVER PROGRAM J. Eric Evans: Sierra Providence Health Network

The Affordable Care Act

• The Patient Protection and Affordable Care Act (ACA) became law on March 23, 2010

• The ACA makes health insurance

coverage a legal expectation on the part of U.S. citizens and those who are legally present

The Affordable Care Act

• Strengthens existing forms of health insurance coverage

• Builds a new, affordable health insurance market for individuals and families who do not have affordable employer coverage or another form of “minimum essential coverage” such as Medicare or Medicaid

The Affordable Care Act

In expanding existing coverage, the ACA restructures Medicaid to cover all citizens and legal U.S. residents with family incomes less than 133% of the federal poverty level and to streamline enrollment

The Affordable Care Act

Full implementation occurs on January 1, 2014• Individual and employer responsibility

provisions take effect• State health insurance Exchanges begin

to operate• Medicaid expansions take effect• Individual and small-employer group

subsidies begin to flow

The Affordable Care Act

• The ACA will cut the number of uninsured Americans by more than half

• Will result in coverage for 94% of the population• reducing the uninsured by 31 million

people• increasing Medicaid enrollment by 15

million• Approximately 24 million people

expected to remain without coverage

The Affordable Care Act

The ACA has five major aims: • The first—and central—aim is to achieve

near-universal coverage and to do so through shared responsibility among government, individuals, and employers

The Affordable Care Act

• A second aim is to improve the fairness, quality, and affordability of health insurance coverage

• A third aim is to improve health-care value, quality, and efficiency while reducing wasteful spending and making the health-care system more accountable to a diverse patient population

The Affordable Care Act

• A fourth aim is to strengthen primary health-care access while bringing about longer-term changes in the availability of primary and preventive health care

• A fifth aim is to make strategic investments in the public's health, through both an expansion of clinical preventive care and community investments

The Affordable Care Act

The Affordable Care Act begins to realign the health-care system for long-term changes in health-care quality, the organization and design of health-care practice, and health information transparency

The Affordable Care Act

• Introduces broad changes into Medicare and Medicaid

• Empowers both the Secretary of the U.S. Department of Health and Human Services (HHS) and state Medicaid programs to test new modes of payment and service delivery:• medical homes, payments for

episodes of care, and bundled payments

The Affordable Care Act Changes are intended to: • Encourage the health-care system and

health professionals work in a more clinically integrated fashion

• Measure the quality of their care and report on their performance

• Improve quality outcomes for serious and chronic health conditions that result in frequent hospital admissions and readmissions

The Affordable Care Act The law requires nonprofit hospitals to engage in major community health planning• Hospitals expected to demonstrate how

investment of resources into the communities they serve reflects the priorities contained in their plans

• Agencies and communities assure optimal use of resources that will be invested in community planning activities and the resulting impact on hospitals' community benefit expenditures

Texas 1115 Waiver

Allows the state to expand Medicaid managed care while preserving hospital funding, provides incentive payments for health care improvements, and directs more funding to hospitals that serve large numbers of uninsured patients

Texas 1115 Waiver Summary

The 1115 waiver provides flexibility for Texas to expand risk-based managed care statewide

Texas 1115 Waiver Goals

• Expand risk-based managed care statewide

• Support the development and maintenance of a coordinated care delivery system

• Improve outcomes while containing cost growth

• Protect and leverage financing to improve and prepare the health care infrastructure to increase access to services

Texas 1115 Waiver Goals (continued)

• Transition to quality based payment systems in managed care and in hospital payments

• Provide a mechanism for investments in delivery system reform including improved coordination in the current indigent care system in advance of health care reform

A Changing Paradigm

Improving the U.S. health care system requires simultaneous pursuit of three aims: • improving the experience of care• improving the health of populations• reducing per capita costs of health care

THE TRIPLE AIM• Improving the

experience of care• Improving the

health of populations

• Reducing per capita costs of health care

A CHANGING PARADIGM: IMPLICATIONS OF THE AFFORDABLE CARE ACT AND THE MEDICAID 1115 WAIVER PROGRAM J. Eric Evans: Sierra Providence Health Network