The Affordable
Care Act and
Integrative
Medicine
Michael R. Cousineau
Professor, Departments of
Family Medicine and Preventive
Medicine
Patient Protection and Affordable Care Act
• Became Public Law
No: 111-148,
• March 23, 2010
• H.R.3590
• Related Bills:
•
•
•
•
•
•
H.CON.RES.254
H.RES.1203
H.R.3780
H.R.4872
S.1728
http://www.thomas.gov/cgibin/bdquery/z?d111:HR03590:@@
@D&summ2=3&
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How does PPACA Expand Coverage?
Beginning January 1, 2014
• Expands Medicaid to all up to 138%
of the federal poverty threshold
• Health Insurance Exchange with
Approved Health Benefit plan and
subsidies for those between 139%
and 400% of FPL
• Estimated 35 million Americans
• Up to 4 million in California
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Eligibility for Health Coverage under PPACA in
California, 2011
Eligible for
exchange no
subsidies,
970000
Ineligible due
to
immigration,
1,070,000
Eligible for
exchange with
subsidies,
780000
Source: UC Berkeley Labor Center
and UCLA Center for Health Policy
Research
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Previously
eligible for
Medi-Cal,
880000
Newly eligible
for Medi-Cal,
1,180,000
Medicaid Expansion
• Eliminates many of the
categorical eligibility criteria
and replaces it with a
Modified Adjusted Gross
Income
• All up to 138%* of the
federal poverty threshold will
be eligible
• Federal government pays
100% of the cost until 2021
when state cost-sharing
• State option to expand
Medicaid (Supreme Court)
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Health Benefit Exchange
• A new market for those in the individual market
• Approved plans with an essential benefit package but
different tiers based on what percentage of the actuarial
costs will be covered
• Co payments and deductibles but maximum out of pocket
costs
• Provides subsidies in the form of tax credits for those
from 138-400% FPL
• Family premium limits ranging from 2.0% to 9.5% of
income
• Provision for small businesses
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Essential Benefit Package
•
These benefits fit into the following 10 categories:
– Ambulatory patient services
– Emergency services
– Hospitalization
– Maternity and newborn care
– Mental health and substance use disorder services, including behavioral
health treatment
– Prescription drugs
– Rehabilitative services and devices
– Laboratory services
– Preventive and wellness services and chronic disease management
– Pediatric services, including dental and vision care
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Benefits for Individuals
•
http://www.coveredca.com/PDFs/English/CoveredCA-HealthPlanBenefitsComparisonChart.pdf
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Cost to The Individual or Family
• Varies depending on income
• Paid through a tax credit
• Premium subsidies and for co payments
•
http://www.coveredca.com/fieldcalc/#calculator
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Who is excluded?
• Does not include undocumented
immigrants
• Non citizens - 5 year waiting period for
subsidies
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How Does it Affect Private Insurance?
• Guaranteed Issue No Pre-existing
conditions, children now, adults 2014
• (limits underwriting)
• Rate Restructuring,
– age (3:1);
–
tobacco use (at a rate of 1.5:1);
– family composition; and
– geography
• High-risk pool established (temporary)
• Young adults can remain on their
parents’ health plan until age 26, now
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Young adults can remain on their parents’ health
plan until age 26. Young and invincible?
adults ages 19 to 29 when offered
health insurance benefits through
an employer,
• two-thirds took the coverage.
• For those who did not they
were covered by a parent,
spouse, or partner or
• they couldn’t afford the
premiums.
Commonwealth Fund, 2013
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Insurance Changes
• No lifetime caps or restrictive annual limits
on coverage, now
• Medical Loss Ratio Limited to 80/20,
– No more than 20% spent on administration,
or no medical care expenses
– Rebates already occurred
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How Does it Affect Coverage: Individual Mandate
Penalties for being uninsured:
$695 per adult
$2,085 per family
2.5% of household
income
Maximum Amount - Whichever is greater
Exceptions:
• No prosecutions 2014-2016
• Income below tax filing threshold
• Financial hardship
• Cost of least expensive plans >8%
income
• Religious objections
• American Indian ethnicity
• Uninsured for <3 months
• Incarcerated
• Undocumented
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Health Care Delivery Reform and Practice Redesign
Accountable Care Organizations
Payment for Quality Outcomes
Medical Homes, Team Management, Integrated Care
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Problems and Limitations
• People not covered
• Undocumented immigrants
• Those unable or unwilling to
purchase coverage
• Was the penalties/taxes high
enough
• Longer term State Medicaid
Payments
• States’ involvement
• Funding for safety net facilities
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Challenges Moving Forward
• Workforce
• Political Challenges
• Legal Challenges
• Financial
• The on going state budget crisis and the
federal deficit
• General economy
• Logistical Challenge
• Getting people enrolled
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Clinicians
• Section 2706 of the Affordable Care Act
prohibits discrimination against licensed
health practitioners, including those who
practice integrative medicine
• Section 5101 of the law says that all "doctors
of chiropractic," and all "licensed
complementary and alternative medicine
providers, integrative health practitioners"
are included in definition of the national
health care work force
Prevention
•
Establishing a National Prevention, Health Promotion and Public Health Council, charged with
providing “coordination and leadership at the Federal level, and among all federal departments
and agencies, with respect to prevention, wellness and health promotion practices,
the public health system, and integrative health care in the United States.”
•
Appointment of an Advisory Group on Prevention, Health Promotion, and Integrative and Public
Health that includes “a diverse group of licensed health professions, including
integrative health practitioners” to “develop policy and program recommendations and
advise the Council on lifestyle-based chronic disease prevention and management, integrative
health care practices, and health promotion.”
•
Definition of a healthcare workforce that includes preventive medicine physicians, doctors
of chiropractic, licensed complementary and alternative medicine providers, and
integrative health practitioners.
•
Funding for patient-centered outcomes research (PCORI) to measure the comparative clinical
effectiveness of a variety of treatments and services, including “integrative health
practices,” with emphasis on chronic conditions and attention to “the potential for
new evidence to improve patient health, well-being, and the quality and cost of care.”
•
Establishing (through HRSA) a National Coordinating Center for Integrative Medicine (NccIM)
that will provide technical assistance to and evaluate integrative medicine residency (IMR)
programs.
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Source: http://www.functionalmedicine.org/home/Affordable_Care_Act/
Resources
•
•
http://holisticprimarycare.net/topics/topics-h-n/news-policy-a-economics/1443healthcare-reform-no-birthday-for-holistic-medicine.html
•
http://www.functionalmedicine.org/home/Affordable_Care_Act/
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http://www.sciencebasedmedicine.org/cam-practitioners-as-pcps-under-the-aca-part-2/
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http://www.scnm.edu/news-events/262-affordable-care-act-the-future-of-naturopathicmedicine
Additional Resources
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Kaiser Family Foundation http://healthreform.kff.org/
•
Commonwealth Fund http://www.commonwealthfund.org/
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California Health Care Foundation http://www.chcf.org/
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Covered California (California’s Health Exchange)
http://www.coveredca.com/
•
http://www.cms.gov/Outreach-and-Education/Medicare-LearningNetworkMLN/MLNProducts/downloads/Disproportionate_Share_Hospital.pdf
•
http://www.urban.org/health/
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