WHAT DOES HEALTH CARE REFORM MEAN FOR
YOU AND YOUR FAMILY?
Bringing Health Reform Home
April 2010
Opening
In March Congress passed and the President
signed comprehensive health reform
legislation

As a non-partisan organization PICO
worked to give families a voice in the health
care debate.

We made our voices heard on reform
because of the stories affecting our families

Opening
Reform builds on the current system with
changes phased in over several years

Now that the legislation has passed it is
important for us to know what is in it and
how it will affect each of us

Reflection
One-to-Ones
What about reform are you hopeful about?
What questions or concerns do you have?
Pre health care reform blueprint
Post health reform blueprint (UPDAT
Key Elements of Health Reform
Greater regulation on insurance companies
Illegal to deny coverage to people
with pre-existing conditions
Cannot charge more or terminate
your insurance if you are sick
No more annual or lifetime limits
Greater scrutiny on premium
increases and the ability to appeal
insurance company denial of care
Key Elements of Health Reform
Expands coverage to
32 million people
currently without
insurance
Key Elements of Health Reform
Creates state-based
Exchanges, a place that
uninsured individuals and
small businesses can buy
coverage
The Exchange will also be a
safety net for those currently
with insurance if they lose a
job.
Members of Congress will get
their insurance through the
Exchange.
Key Elements of Health Reform
Measures to Control Health Care
Costs for Families
•80-85% of premiums have to go to medical
care rather than administration costs and
profits
•Limits on out-of-pocket costs ($5,950 for
individuals and $11,900 for families in
2010) to prevent medical bankruptcies;
applies to plans in the Exchange and
incentives for employers to provide this
•Exchanges make it easier to compare plans
and find the best value
•Cost containment of rising costs of
healthcare (subsequent slides)
Key Elements of Health Reform
Tax credits for small
businesses to purchase
health insurance for
employees
Key Elements of Health Reform
Focus on prevention
Expands health care work force of
doctors and nurses
Youth can stay on their parents’ health
insurance plans up to age 26
Everyone must have health insurance
unless you have a religious objection
or financial hardship
An additional $11 billion in funds for Community
Health Centers, which is estimated to double the
number of people served
How is it paid for?
Starting 2010: cost saving changes in Medicare
Greater oversight and enforcement to reduce fraud, waste and abuse; greater
efficiency and collaboration among doctors and reduced over-payments to the
Medicare Advantage companies.
Starting in 2011-2013: increasing penalties on contribution
loopholes in Health Saving Accounts
Increased penalties on nonqualified distributions from Health Saving Accounts, a
lower cap on Flexible Spending Accounts contributions, and a standardization of
the definition of qualified medical expenses.
How is it paid for?
Starting in 2013: high-income earners will contribute more to the
Medicare fund
Individuals earning over $200,000 and families earning over $250,000 will
contribute 2.35% for income above the threshold instead of the current 1.45%.
They will also pay a 3.8% tax on net investment income (excluding retirement
plans).
Starting in 2018: insurers will have to pay a 40% excise tax on
high cost group plans
The tax is on the cost of coverage in excess of $27,500 (family coverage) and
$10,200 (individual coverage). There are higher thresholds for retirees and
employees in high risk professions.
Cost Containment
Including:
 A Medicare Commission to cut through the political gridlock and
make decisions on efficiency and reaching spending targets
 A tax on high cost “Cadillac plans” as an incentive to buy insurance
plans that hold down costs
 Modernizing Health Care Information Technology (IT) infrastructure
(e.g. electronic medical records)
 Pilot programs such as Medicare “bundling” to reward coordination
and quality over quantity. In “bundling” Medicare will pay a doctor
or hospital for the total care for a person with a certain disease,
rather than a payment for every test or procedure; this will start as
a pilot program and be expanded if it works
Cost Containment, continued


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Gathering and disseminating research on which treatments work,
and which don‘t
Investing in preventative care
Reducing overpayments to private insurance companies that
participate in Medicare Advantage
The bill tries out almost every approach that leading health care experts
have suggested for cost containment in the hopes that some of the
ideas will work well. Successful strategies can be expanded on by the
administration - without needing approval from Congress in the face of
opposition from providers, suppliers and other interests.
The bill is a testing ground of different ideas and we can build on what
works.
What happens in the first year
Begin to close the Medicare
“donut hole” for Seniors so
prescription drugs are more
affordable
Donut hole closes
completely in 2020.
What happens in the first year
Prohibit insurance
companies from denying
coverage to children with
pre-existing conditions
September 23, 2010
What happens in the first year
Insurance companies
will be banned from
dropping people when
they get sick and
imposing lifetime limits
on coverage
-
September 23, 2010
What happens in the first year
Holds insurance
companies accountable
for unreasonable rate
hikes
What happens in the first year
Youth can stay on
their parents’ plans up
to age of 26
September 23, 2010
What happens in the first year
Small business tax credits to help provide health insurance to
employees - right away
A high risk pool is created for people with pre-existing conditions,
this will be in place until the exchanges are up in 2014 - June 21,
2010
Investments to increase the number of primary care doctors and
nurses - October 1, 2010
New consumer assistance offices - September 23, 2010
New plans will have free preventative care and an independent
appeals process for insurance company decisions to deny care September 23, 2010
What is your current health care situation?
Are you insured through work? Through
Medicare? Medicaid?
Are you uninsured?
Insured through Employer
2010
No canceling policies when you
get sick or setting lifetime limits.
Children up to age 26 can stay
on your plan.
Insurance companies will have
to cover children with preexisting conditions.
New plans must provide free
preventative services & allow
you to appeal denials of
coverage.
2011 – 2013
Insurance companies
required to spend
80-85% of premium
dollars on medical
services or else
provide rebates to
their policyholders.
2014
Insurers will have to
cover adults with
pre-existing
conditions.
States can require
insurance companies
to submit justification
for premium
increases.
Qualified individuals
can begin buying
subsidized coverage
in the Exchange.
No annual limits on
coverage.
2018
Insurers will have
to pay a 40%
excise tax on
high cost
insurance plans.
The tax is on the
cost of coverage
in excess of
$27,500 (family
coverage) and
$10,200
(individual
coverage).
Insured through Medicare
2010
Seniors on traditional
Medicare will have no
losses in coverage and
will add important
benefits.
2011
Seniors in the “donut
hole” will receive a 50%
discount on brand name
drugs. The “donut hole”
will be closed slowly
through 2020.
Seniors that reach the
“donut hole” will
receive a $250 rebate
for prescription drugs.
Annual checkups and
most preventative care
and screenings are at no
cost.
2013
Government begins to cut
subsidies to Medicare
Advantage, which costs the
government more than
traditional Medicare.
Seniors on these plans may
face reduced benefits or
higher costs. Seniors have
the option of transitioning
to traditional Medicare
during the first 45 days of
the year.
2020
The donut
hole will
fully close.
Uninsured
2010
Temporary high-risk pool for people
with pre-existing conditions
uninsured for at least 6 months
For early retirees, age 55-64, a
temporary re-insurance program is
created until the Exchange is
running.
A large expansion in funds to
Community Health Centers. This is
expected to double the number of
patients that clinics serve. This will
help millions of undocumented
immigrants.
If you are under age 26, you can
join your parent’s plan.
2014
Individuals and families will be able to purchase health insurance in
state-based Exchanges. Those earning up to 400% FPL ($88,200
for a family of 4) will have access to subsidies on a sliding scale.
Cap on out-of-pocket costs of $5,950 for individuals and $11,900
for families, with lower caps for lower-income families.
Individuals and families under 133% FPL will be eligible for
Medicaid.
Most Americans will be required to buy health insurance or pay a
penalty. Undocumented immigrants will not be able to purchase
insurance in the Exchange.
Those who are exempt, or under 30, can buy a catastrophic policy
(must also allow for 3 primary care visits a year).
Members of Congress will get their health insurance through the
Exchange.
Insured through Medicaid or CHIP
2010
All children currently receiving Medicaid
and CHIP can continue to receive coverage.
States cannot cut children from Medicaid or
CHIP until 2019, at which point some
children may transition into the Exchange.
All adults under 133% of the Federal
Poverty Level can continue to receive
coverage. States cannot cut adults that
make under 133% FPL from Medicaid.
Many preventive services will be offered
without cost.
2014
Medicaid’s physician reimbursement levels
for specific primary care services will be
increased, leading more doctors to accept
Medicaid.
Anyone with an income below 133% FPL,
about $29,327 in 2009 for a family of
four, will be eligible for Medicaid.
When the Exchange is operating, states can
decide to keep adults on Medicaid that are
over 133% FPL or transition them into the
Exchange.
What did you learn today that
was meaningful for you?
Next Steps
Share this info and materials with family and friends
Local opportunities to get involved in “bringing
health reform home”, making sure health reform is
implemented well on the state and local level
www.piconetwork.org
Acknowledgements
Many thanks to Community Catalyst and
Georgetown Center for Children and Families
for their assistance in creating this presentation
WHAT DOES HEALTH CARE REFORM MEAN FOR
YOU AND YOUR FAMILY?
April 2010