Accomplishments to Date: Laying the Foundation for Earlier, More Effective Treatment

Bonnie Preston MSPHNational Alliance for Mental Illness – CaliforniaNewport Beach, CaliforniaAugust 1, 2014

The Affordable Care Act (ACA)The Affordable Care Act (ACA)

Goals for Today:Goals for Today:

1. Review the basics of the Affordable Care Act, its accomplishments and next steps

2. Learn about Federal Priorities & Resources in Mental Health Services

3. Be Inspired about your role to get people enrolled & to reform health care towards improving health•To improve people’s health•Help save a family/business from financial ruin •Help improve country’s economic future

HEALTH & HUMAN SERVICES (HHS) HAS TEN REGIONS

HEALTH & HUMAN SERVICES (HHS) HAS TEN REGIONS

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• Our office serves as the public interface with federal health programs

• Represents Regional Issues to Influence Operation of Federal Programs

• Shares Best Practices Across Region

Office of the HHS Regional DirectorOffice of the HHS Regional Director

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SAMHSA’s Mission: Reduce the impact of substance abuse and mental illness on communities by helping people with mental and substance use disorders, supporting their families and promoting better health for all Americans.

Behavioral Health: A National PriorityBehavioral Health: A National Priority

Behavioral health is essential to health

Treatment is effective

Prevention works

People recover

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Pre-ACA Health Care SystemPre-ACA Health Care System

49 Million Americans lacked coverage• Uncoordinated – Fragmented delivery systems

with variable quality• Unsupportive – of patients and healthcare

providers• Unsustainable – Costs rising at twice the inflation

rate

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• 17.6% of economic output tied up in health care system

• Without reform– by 2040, 1/3 of economic output tied up

in health care– 15% of GDP devoted to Medicare and

Medicaid–Number of uninsured would grow to 58

million in 2020*

*Source: Urban Institute: “The Cost of Failure to Enact Health Reform: 2010-2020” March 15, 2010

Pre-ACA Health Care System Pre-ACA Health Care System

Health Disparities Health Disparities

• 1 in 5 Children affected by mental illness are not getting treatment

• 61% of Adults with mental illness do not receive any mental health services

• 39% of Adults with serious mental illness are not receiving any mental health treatment

Disproportionate number of people with mental illness are in the custody of the correctional system

People with M/SUDs are nearly 2x as likely as general population to die prematurely, often of preventable or treatable causes

Health DisparitiesHealth Disparities

Factors Shaping Health Outcomes:

• Stigma of Mental Illness and Substance Abuse

• Lack of access to timely treatment

• Lack of health insurance

March 23, 2010: A New Day For Health Care

March 23, 2010: A New Day For Health Care

After a year of striving, after a year of debate, after a historic vote, Health Care Reform is no longer an unmet promise. It is the law of the land.”

- President Barack Obama

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Three Aims Of the Affordable Care ActThree Aims Of the Affordable Care Act

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Better Care

Patient-Centered Care Coordination

Quality

Better Insurance

Accessibility Affordability

Staying Healthy

Prevention Public Health

January 1, 2014

Exemptions include:• Financial hardship;• Religious objections;• Native Americans• Without coverage for less than 3 months;• Incarcerated individuals; and• Cost exceeds 8% of individual’s income.

Individual RequirementIndividual Requirement

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• No Employer Requirement until 2015

• Less than 50 full-time equivalents – exempt from any requirement

Employer Requirement (Shared Responsibility)Employer Requirement (Shared Responsibility)

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New Coverage Options for Millions of Americans

New Coverage Options for Millions of Americans

Medicaid$16,000/Indiv.;$31,000/Family

Marketplace with Tax Credits

$45,000/Indiv.;$92,000/Family

Market-place or Private

Plan

0%FPL 133%FPL 400%FPL

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Medicaid ExpansionMedicaid Expansion

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• California Expanded Medi-Cal eligibility to adults ages 19 – 64 with incomes up to $16,000 per year for an individual. • 100% federal funding for newly Medicaid eligible• No longer only disabled or pregnant young

• Simplified income calculation • Promotes More Primary Care Provider Participation in

Medi-Cal

Opportunity for Supported Employment

Medi-Cal Expansion & ImprovementsMedi-Cal Expansion & Improvements

State Health Insurance Marketplace Decisions, 2014State Health Insurance Marketplace Decisions, 2014

Partnership Marketplace (7 states)State-based Marketplace (16 states and DC)

Federally-facilitated Marketplace (27 states)

WA

OR

WY

UT*

TX

SD

OK

ND

NM

NV NE

MT

LA

KS

ID

HI

CO CA

ARAZ

AK

WI

WV VA

TN SC

OH

NCMO

MS

MN

MI

KY

IA

IN IL

GA

FL

AL

VT

PA

NY

NJ

NHMA

ME

CT

DE

RI

MD

DC

* In Utah, the federal government will run the marketplace for individuals while the state will run the small business, or SHOP, marketplace.SOURCE: State Decisions For Creating Health Insurance Marketplaces, 2014, KFF State Health Facts: http://kff.org/health-reform/state-indicator/health-insurance-exchanges/.

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• It’s an easier way for individuals and small businesses to shop for health insurance

• Most people are able to get a break on costs

• Provides clearer options with more straight forward comparisons

Covered CaliforniaCovered California

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Who’s eligible?• 2014 /2015 – Covered California set the upper limit at 50• 2016 – Marketplaces must accommodate 100 FTE and below• 2017 and Beyond – States can decide their upper limit

When can businesses enroll?• Throughout the year

How can businesses enroll?• Directly through Covered California SHOP • Through a broker registered with Covered California SHOP

Enrolling in SHOP:Who, When & How?

Enrolling in SHOP:Who, When & How?

The Small Business Health Care Tax Credit Is available to those employers :

With fewer than 25 “full time equivalent” employees‐ Whose employees’ wages average less than $50,000 per year Who contribute at least 50% of employees’ premium costs Who buy health insurance through the SHOP

Discounts are worth: Up to 50% of employer’s premium contribution (up to 35% for tax

exempt employers)

Removing the Obstacles:Tax Credits

Removing the Obstacles:Tax Credits

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6. Prescription drugs

7. Rehabilitative and habilitative services and devices

8. Laboratory services

9. Preventive and wellness services and chronic disease management

10. Pediatric services, including oral and vision care

1. Ambulatory patient services

2. Emergency services

3. Hospitalization

4. Maternity and newborn care

5. Mental health and substance use disorder services, including behavioral health treatment

All Qualified Health Plans Will Cover These Essential Health Benefits

All Qualified Health Plans Will Cover These Essential Health Benefits

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• Ends Spending Limits• No more artificial treatment cut offs• Move to support outcome based plans

• Ends Pre-existing Conditions Exclusions• Allows Young Adults to be Covered till 26• 19-25 yr olds at risk of first episode of mental illness

Financial Protections for Families and Providers

Consumer Protections w/ ParityConsumer Protections w/ Parity

• Medicare – Improves Care and Lowers CostsPreventive care with no copays, Improves drug coverage,Strict anti-fraud measures andBetter care coordination

Duals Project Medical Homes Accountable Care Organizations

Strengthens Other Public ProgramsStrengthens Other Public Programs

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• Nationally, more than 8 million people have enrolled in private insurance through the Marketplace

• An additional 6 million additional people enrolled Medicaid

• 3 million young adults were able to stay on their parents’ plans

Affordable Care Act Accomplishments – Expanding Coverage

Affordable Care Act Accomplishments – Expanding Coverage

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• 1.2 million Californians have enrolled for health insurance and selected plans through the Marketplace through the end of March and over 1.9 million have been found likely eligible and enrolled for expanded Medi- Cal coverage through March

• 435,000 young adults have gained insurance through their parents’ plans

Affordable Care Act – Expanding Coverage in California

Affordable Care Act – Expanding Coverage in California

• 71 million privately insured people gained improved coverage for preventive services

• 105 million Americans have had lifetime limits removed from their insurance

• 7.1 million people with Medicare saved over $8.3 billion on drugs since law’s enactment

• 37.2 million people with Medicare received a free preventive service

Affordable Care Act Accomplishments– Improving Coverage

Affordable Care Act Accomplishments– Improving Coverage

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• 358,862 people with Medicare through 2013 received $333 million in prescription drug discounts

• 3.6 million people with Medicare received a free preventive service

• 8 million privately insured people gained improved coverage for preventive services

• 12 million California residents have had lifetime limits removed from their insurance

ACA Accomplishments in CaliforniaCost, Quality & Consumer Protections

ACA Accomplishments in CaliforniaCost, Quality & Consumer Protections

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Slowest sustained national health spending growth in 50 years• Low growth continued in 2013 for Medicare and

Medicaid• Resulting in No Increase in 2014 Medicare Premiums

Covering Physician Charges $500 million returned to consumers in 2012• Plans must spend 80% of premium on healthcare

Over $19.2 billion recovered from anti-fraud efforts – a record level which added years to Medicare Trust Fund

Affordable Care Act Accomplishments– Quality and Cost

Affordable Care Act Accomplishments– Quality and Cost

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• Medicare Payment reform led to 8% decrease in readmit rate between 1/2012 and 12/2013

• 360 Medicare ACOs developed • Strengthening Primary Care Workforce• Primary Care providers in NHSC doubled since 2008

• 1,200 Community Health Centers are providing primary care to >21 million annually

• Small business tax credit provided >$1billion to small employers

Affordable Care Act Accomplishments– Quality, Cost and Access

Affordable Care Act Accomplishments– Quality, Cost and Access

Partner w/national organizations to create and implement enrollment campaigns

• Provide marketing materials

• Provide T/TA

• Provide training to design and

implement enrollment assistance

• Channel feedback

• Evaluate success

What’s Next?SAMHSA ENROLLMENT STRATEGY

What’s Next?SAMHSA ENROLLMENT STRATEGY

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Coverage to Care• Department of Education report showed 1 in 10

Americans have proficient level of “health literacy”• Language and cultural barriers add to confusion• IOM found that low health literacy are more likely to be

hospitalized and have more ER visits

http://marketplace.cms.gov/c2c• to help those with new health care coverage make the

most of their coverage, and raise awareness about the importance of getting routine primary care and regular preventive care

What’s Next? What’s Next?

• Providers Sufficient to Deliver Services• “Including mental health & substance use disorders

services”

• MH Providers More Likely to be Experienced in Billing/Being Part of Networks than SA Providers

• Community MH/SA Providers Heavily Dependent on Declining Fund Sources• Non-insurance based federal, state, local, private pay

QUALIFIED HEALTH PLANS (QHPs)QUALIFIED HEALTH PLANS (QHPs)

California Summary FY 2013/2014

Formula Funding FY 2013 /2014

Substance Abuse Prevention and Treatment Block Grant $235,684,407

Community Mental Health Services Block Grant $55,061,609

Projects for Assistance in Transition from Homelessness $8,483,000

Protection & Advocacy for Individuals with Mental Illness $2,986,452

Subtotal of formula funding: $302,215,468

Discretionary Funding

Mental Health $26,317,822

Substance Abuse Prevention $12,931,978

Substance Abuse Treatment $29,486,934

Subtotal of discretionary funding: $68,736,734

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• Nationally $54.6 million to support 221 health centers to establish or expand behavioral health services for over

450,000 people.

• $7,990,619 will support 32 health centers in California to establish or expand behavioral health services for

111,127 Californians.

• Hire new mental health professionals, add mental health and substance use disorder health services; employing integrated models of primary care.

SAMHSA Primary and Behavioral Health Care Integration Grants

SAMHSA Primary and Behavioral Health Care Integration Grants

AHRQ Center for Integration Models: Developing models of integrated BH care in primary care settings

CMS/CMMI Innovative Financing Models for Integration: Grants to test models

SAMHSA’S Primary/BH Integration (PBHCI) Grants: Physical health of adults w/ SMI and TA for bi-directional integration

HRSA FQHCs: Integrating BH screening, brief intervention and treatment

Medicare Accountable Care Organizations: Payment for integrated care and outcomes

CMS Health Homes: Whole person care for persons with specific characteristics or health conditions

CMS Partnership for Patients: Reducing hospital readmissions; increasing quality

SAMHSA’s WORK WITH OTHER FEDERAL PROGRAMS

SAMHSA’s WORK WITH OTHER FEDERAL PROGRAMS

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• Supports the ongoing development of new models of payment and delivery.

• Invests $10 billion in this Center over 10 years to test

payment and delivery innovations that can improve the quality of care and/or increase cost efficiency, identifying successes that could be expanded by the Secretary of Health and Human Services (either regionally or nationally).

• These funds will produce returns on investment and reduce Medicare and Medicaid spending over the long-term.

CMS Center for Medicare & Medicaid Innovation

CMS Center for Medicare & Medicaid Innovation

OutcomeAccountable Care

OutcomeAccountable Care

Coordinated SeamlessHealthcare System 2.0

• Patient/Person Centered• Transparent Cost and Quality Performance

• Accountable Provider Networks Designed Around the patient

• Shared Financial Risk

• HIT integrated

• Focus on care management and preventive care

CommunityIntegratedHealthcare

● Healthy Population Centered● Population Health Focused Strategies

● Integrated networks linked to community resources capable of addressing psycho social/economic needs

●Population based reimbursement ●Learning Organization: capable of rapid deployment of best practices ●Community Health Integrated●E-health and telehealth capable

• Episodic Health Care

• Lack integrated care networks• Lack quality & cost performance transparency

• Poorly Coordinate Chronic Care Management

Acute Care System 1.0

US Health Care Delivery System Evolution

Neal Halfon, UCLA Center for Healthier Children, Families & Communities

Community Integrated Healthcare System 3.0

Health Delivery System Transformation Critical Path

Episodic Non-Integrated Care

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Bonnie PrestonRegional Outreach & Policy Specialist415-437-8503 – Direct NumberBonnie.Preston@hhs.gov

Thank you!Thank you!

California Summary FY 2013/2014

Formula Funding FY 2013 /2014

Substance Abuse Prevention and Treatment Block Grant $235,684,407

Community Mental Health Services Block Grant $55,061,609

Projects for Assistance in Transition from Homelessness $8,483,000

Protection & Advocacy for Individuals with Mental Illness $2,986,452

Subtotal of formula funding: $302,215,468

Discretionary Funding

Mental Health $26,317,822

Substance Abuse Prevention $12,931,978

Substance Abuse Treatment $29,486,934

Subtotal of discretionary funding: $68,736,734

SA TREATMENT FACILITIES ACCEPTANCE OF INSURANCE PAYMENTS *

PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS

PROVIDERS ACCEPTING HEALTH INSURANCE PAYMENTS

*Source: NSATSS **Source: 2011 NCCBH BH Salary Survey

SOURCE OF FUNDS FOR CMHCS**

National Prevention StrategyStrategic Directions and Priorities

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ACA /Parity Projected ReachIndividuals who

will gain MH, SUD, or both benefits under the ACA

including federal parity protections

Individuals with existing MH and

SUD benefits who will benefit from

federal parity protections

Total individuals who will benefit

from federal parity protections as a

result of the ACA

Individuals currently in individual plans

3.9 million 7.1 million 11 million

Individuals currently in small group plans

1.2 million 23.3 million 24.5 million

Individuals currently uninsured

27 million n/a 27 million

Total 32.1 million 30.4 million 62.5 million

NOTE: These estimates include individuals and families who are currently enrolled in grandfathered coverage

Source: ASPE Research Brief, February 2013