ACA Implementation

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National Councilfor Behavioral Health

• ACA Implementation UpdatesChuck Ingoglia,
  Senior Vice President, Public Policy Practice
  ImprovementSeptember 27, 2013

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Agenda

• Update on ACA Implementation
• Looking Ahead to 2014
• National Councils Legislative Agenda

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Medicaid Expansion Not Mandatory for States
But Federal Subsidy Amounts Depend on Whether
States Opt in
Supreme Court Ruling, June 28, 2012 Limits
Health and Human Services authority to enforce
Medicaid expansion if state chooses not to
implement expansion, HHS cannot withhold existing
federal program funds States left with choice
to opt in or out of Medicaid expansion

• Opt In to Expansion
• Individuals below 133 FPL eligible for Medicaid
• Federal government covers 100 of states cost of
  covering newly eligible beneficiaries from
  2014-2016
• Federal government phases down its contribution
  to 90 by 2020 (95 in 2017, 94 in 2018, 93 in
  2019, 90 in 2020 and each year after)

• Opt Out of Expansion
• Premium subsidies still available for those
  between 100-400 FPL
• In states that do not participate in expansion,
  many individuals below 100 FPL would be left
  without health insurance assistance

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201350th Anniversary of the 1963 Community
Mental Health Act

• Wrote in 1963 - mental illness among our most
  significant health problems, due to critical size
  and tragic impact deserving of whole new
  national approach

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Progress

• State hospital beds reduced from 530,000, (45
  institutionalized for over a decade) to about
  50,000
• Entitlements
• Array of community services
• Recovery movement
• Parity/ACA

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Work to be done

• Morbidity and mortality, little change compared
  to 50 drop for infectious disease,
  cardiovascular disease and some cancers
• Increasing Disability - Neuropsychiatric diseases
  30 of disability from all medical causes and
  growing
• No reduction in suicide rate
• Limited community impact of BHOs

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Whos Doing What With Medicaid Expansion?
MA
RI
CT
NJ
DE
MD
AK
HI

• Analysis
• The Supreme Courts ruling on the Affordable Care
  Act allows states to opt out of the laws
  Medicaid expansion, leaving this decision with
  state governors and legislatures
• Governors of states participating in Medicaid
  expansion cited support for increased coverage
  for residents as reason for opting in governors
  of non-participating states cited high cost of
  expansion as reason for opting out governors of
  undecided states weighing costs of expansion
  before opting in or out

Source Status of State Action on the Medicaid
Expansion Decision, Kaiser Foundation, June 20,
2013.
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Cost of Private Insurance Model May Limit
Feasibility

• Person Enrolled in Exchanges Costs Estimated 50
  More than Medicaid

Number of Individuals Covered by 360K in Federal
Spending in 2022, Insurance Exchanges vs.
Medicaid Expansion
For every two individuals covered through health
insurance exchanges, same cost would cover three
individuals under Medicaid
Individuals covered if funding goes towards
health insurance exchanges
Additional individuals covered if funding goes
towards Medicaid

• Analysis
• CBO estimates average person enrolled in
  insurance exchanges will cost 9K enrolled in
  Medicaid will cost 6K in 2022
• Private plans may cover fewer benefits than
  Medicaid states would be responsible for paying
  the difference
• HHS said plan must be shown to be comparable to
  Medicaid and cost-effective for federal
  government
• HHS said if states want to make private coverage
  a requirement rather than option, must apply for
  waiver

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Half of States Opted for Federal Exchanges in 2012

• State Exchange Second Most Popular Option

SC
Totals Federal 27 Partnership 7 State 17
FL
16 states and D.C.
Source Establishing Health Insurance
Marketplaces An Overview of State Efforts, The
Kaiser Foundation, May 28, 2013.
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• What can you do to help guarantee that everyone
  has access to quality health insurance?

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Get Your Clients Enrolled

• ACA requires simplified enrollment in Medicaid,
  CHIP, and Exchanges
• Potential for continued lack of insurance among
  eligible people
• Half of focus group participants in Mass. with
  MH/SUD conditions disenrolled from health
  insurance in past yr
• At MH/SUD treatment programs in Mass., 20-30 of
  patients seeking acute services are uninsured (in
  a state where 97 of population as a whole is
  insured)

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Strategies for reaching the eligible but
unenrolled

• Navigator support at key locationsfor the most
  vulnerable populations
• Outreach and enrollment efforts that target these
  populations
• Make things easy with clear, concise, simple
  instructions disseminated through multiple media
• Presumptive eligibility for acute and emergency
  episodes for those previously enrolled

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Reach the Uninsured by Using 4 Key Messages
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Use Your Resources!

• Enroll Americawww.enrollamerica.org
• HHS/CMS enrollment
• SSI/SSDI Outreach, Access and Recovery (SOAR)
  http//www.prainc.com/soar/
• Apply to become a Certified Application Counselor
  Organization http//marketplace.cms.gov/help-us/c
  ac-apply.html

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What to Focus on in 2014

• Enrollment
• Revenue Shifts
• Clinical Accountability New Approaches to
  Treatment

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Public Policy Agenda

• Establishing federal status for community
  behavioral health organizations, as outlined in
  the Excellence in Mental Health Act (S.264/H.R.
  1263)
• Promoting federal initiatives that support public
  education on mental illness and addiction such as
  the Mental Health First Aid Act (S.153/H.R. 274)
• Working to ensure that behavioral health
  providers are eligible for health information
  technology incentives, as in the Behavioral
  Health IT Act
• Ensuring behavioral healths full inclusion in
  health reform implementation
• Protecting federal funding for Medicaid and
  protecting beneficiaries and providers
• Preserving funding for other important behavioral
  health programs such as those funded by the
  Substance Abuse and Mental Health Services
  Administration

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Mental Health First Aid Act

• 20 million in grants for MHFA training programs
• Eligible entities states, political subdivisions
  of states, tribes, tribal organizations,
  nonprofits
• Grants will be distributed across geographical
  regions, with a focus on rural areas
• Elements of MHFA Act included in S. 689

Rep. Ron Barber, D-AZ
Sen. Mark Begich, D-AK
Rep. Lynn Jenkins, R-KS
Sen. Kelly Ayotte, R-NH
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Excellence in Mental Health Act

• Creates federal definition/criteria for Certified
  Community Behavioral Health Centers (CBHCs)
• Improves Medicaid reimbursement for CBHC services
• Makes CBHC services mandatory in Medicaid
• Supports modernization/construction of CBHCs.

Sen. Debbie Stabenow, D-MI
Sen. Roy Blunt, R-MO
Rep. Doris Matsui, D-CA
Rep. Leonard Lance, R-NJ
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Behavioral Health IT Act

• Extends federal health IT incentive payments to
  community mental health and addiction treatment
  facilities
• Last congressional session, introduced in both
  chambers with strong bipartisan support
• Will be reintroduced in 2013

Sen. Sheldon Whitehouse, D-RI
Rep. Tim Murphy, R-PA
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Tax Reform

• Future of the charitable deduction?
• Also Entitlement reform?

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Tax Reform Loses Steam in 2013
Tax Reform Momentum in 2013
Corporate coalitions form to advocate for tax
code overhaul
Senate Finance Cmte. shifts focus to IRS scandal
House Ways and Means Cmte. Chairman Dave Camp
(R-Mich.) flirts with but decides against Senate
run
Sequester diverts lawmakers attention
Congressional momentum on tax reform
Fiscal cliff deal meets some Democrats aim of
raising taxes on wealthy eases widespread push
for reform
Senate Finance Cmte. Chairman Sen. Max Baucus
(D-Mont.) announces retirement
Senators asked to submit confidential proposals
on which tax breaks to keep
Congress resumes budget is top priority

• Analysis
• House Ways and Means Cmte. Chairman Dave Camp
  (R-Mich.) announced in 2012 that his panel would
  pass tax reform legislation in 2013, but
  sequestration, the IRS scandal, and budget
  negotiations have waylaid progress
• Lawmakers and Washington insiders dont expect
  movement on tax reform in 2013 due to other
  legislative priorities, sharp ideological divides
  on revenue, and little support from leadership on
  either side of the aisle

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Influencing Legislators Decisions

• Who has influence on lawmakers decisions?
• Who is talking to them about health policy?

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How influential are?(Numbers represent of
staff responding very influential.)
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In the past year, have you?
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As Thomas Jefferson said

• We do not have a democracy of the majority. We
  have a democracy of the majority who participate.

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Most importantly

• Always say thank you
• Dont get discouraged
• VOTE!

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Exercise

• Tell a compelling story
• Explain the human and district impact
• Include a clear call to action

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Questions?

• Chuck Ingoglia, MSW
• Senior Vice President, Public Policy Practice
  Improvement ChuckI_at_thenationalcouncil.org
• 202-684-7457, ext. 249