10/20/2017 2017 ObGyn Update: What Does the Evidence Tell Us? October 20, 2017 No commercial disclosures for this lecture Reproductive Health Policy in 2017: What’s Changed, What Hasn’t? Michael S. Policar, MD, MPH Clinical Professor of Ob, Gyn, & RS UCSF School of Medicine michael.policar@ucsf.edu Health Policy versus Health Politics Health Care Reform…Always a Tough Road • Health Policy : Which policies, structures, and financing lead to optimal clinical and economic health outcomes? – The Clinton Health Security Act • Health Politics : What is possible…winners and losers – Patient Protection and Affordable Care Act – Origins in conservative Heritage Foundation – Based on Massachusetts Health Connector program • Health Posturing – Legislation to “pay a debt to the base” – We need a win! 1
10/20/2017 7 Years into the ACA… P Has the Promise Been Kept? Women… • With commercial insurance have more women’s health benefits with lower or no out-of-pocket costs • Enrolled Medicaid now have comprehensive health insurance, including a PCP and an OBGYN • Women who have no insurance still have safety net coverage through state FP programs + Title X Something for everyone! “Patient Protection and ‘‘Patient Protection and Affordable Care Act ” (ACA) Affordable Care Act ” (ACA) March 23, 2010 • First step: Expand access to health insurance Everyone has coverage Fairer insurance practices Expand coverage to 32 million by 2019 • Second step: Improve quality of care Focused on prevention and primary care • Third step: Stabilize cost of health care Change incentives: shared risk, P4P Reduce waste and fraud 2
10/20/2017 ACA Step 1 : Expanding Access Phase 1 of ACA: 2010-2013 A Three Part Formula 1. Insurers must offer coverage to everyone • Coverage on parents plan until 26 years of age 2. Federal subsidies to help afford coverage • Improved Part C Medicare drug coverage – Share the cost of insurance premiums • Ban on lifetime benefit caps and rescissions – Tax credits for co-payments, deductibles • Insurance rate increase restrictions 3. Individual mandate: everyone must have health insurance • Plans must spend > 80% of premiums on health care – Risk pool must include healthy people • First dollar coverage of many preventive services (no- cost sharing…i.e., no deductible or co-payments) – Only way to cover pre-existing conditions – All of us need will coverage sooner or later Phase 2 of ACA: 2014-Present Little or no change Military Insured through Undocumented Veterans Admin employer individuals • Individual mandate to by insurance (or pay a tax penalty) • State health insurance exchanges opened Minor changes • State Medicaid expansion (now 2/3 of states) Medicare Medicaid • State essential health benefit (EHB) standards • Insurance market reforms – No restrictions for pre-existing conditions Major changes – No gender discrimination Uninsured Self employed Small business • Employer shared-responsibility penalties (now delayed) 3
10/20/2017 Major Changes State Health Insurance Exchanges • Uninsured • Self employed • Small business • SB <50 employees (50-100) • State regulated “insurance marketplaces” <50: business – “Travelocity” of health plans 5 5 1 pay can purchase 0 0 0 – Compare by quality and cost fine % % 0 <25: business – All offer same “essential health benefits” % tax credits Employer Medicaid – Optional participation by plans based HI • Subsidies for families 133-400% FPL (fed poverty level) State Health Insurance Exchanges OR – 399% FPL: $44,680 individual; $92,200 family of 4 Healthcare.gov • States without marketplace default to federal exchange State Health Insurance Marketplaces • Premiums are higher at Metal Level Plan covers each level Platinum 90% • Subsidy based on silver Gold 80% plan cost Silver 70% • Out-of-pocket costs are lower if subsidized Bronze 60% premium (cost-sharing Catastrophic < 30 yrs old subsidy…CSR) 4
10/20/2017 State Medicaid Expansion • Medicaid eligibility for adults with income <138% FPL – Before: “Broke plus something else” – Now: men + women with incomes below • $15,867 individual; $32,500 for a family of 4 • Feds cover 100% costs until 2017, then 90% by 2020 – Reason for rejection of expansion by many states… Reproductive Cancer Healthy Pregnancy Immunizations Chronic Health Behaviors related conditions • Alcohol • TdaP, Td STI and HIV Breast Cancer Alcohol S&C CV: HTN, • Mammography • MMR, varicella counseling S&C lipids • Preventive services with no cost-sharing (in blue) • Genetic S&C • Tobacco Ct, GC, Syphilis Tobacco C&I Influenza T2DM screening C&I screen – USPSTF grade [A] or [B] • Preventive • Folic acid • Hepatitis A, B HIV screening Diet Depression • Meningococcal (adults at HR; all medication counseling if supplement screen sexually active F) counseling CVD risk – AAP Bright Futures • GDM • HPV Contraception Cervix: Interpersonal Osteo- • Cytology – CDC ACIP vaccination recommendations (women w/repro and DV S&C screen (women 19-26) porosis • HPV + cytology • Rh, anemia capacity screen screen • 8 additional women’s prevention benefits not • STI screen • Pneumococcal Colorectal: Well-woman Obesity • • Bacteruria • Zoster addressed by USPSTF…intended to “close the gaps” FOBT, visits screen; C&I • Colonoscopy, screen if obese • Sigmoid – (In red) • Lactation Supports S&C: screening and counseling C&I: counseling and interventions 5
10/20/2017 Women's Preventive Services Women's Preventive Services HHS Guideline for Frequency Insurance Coverage HHS Guideline for Insurance Coverage Frequency • Several visits may be Well-woman visits All FDA approved contraceptive methods, As annually including needed to obtain all sterilization procedures, and patient education & prescribed preconception and recommended services, counseling for women with reproductive capacity prenatal care depending on health status, health needs, and • All methods must be covered, but not all products other risks • Limited exemption for religious institutions (e.g., churches) • National direct access to Ob-Gyn’s from providing contraceptive coverage for insured employees • Includes visits to PCP, ObGyn, or both 7 Years of the ACA… Obama B. US Health Has the Promise Been Kept? Care Reform Progress to Date and Yes, but… Next Steps 25% • There are major variations, depending upon your JAMA online July 11, 2016 state of residence 15% • Women in the poorest states (those with no Medicaid expansion) have the least improvement 9.8% in coverage…“the coverage gap” Uninsured: 49 million in 2010 29 million in 2015 20 million more covered by ACA 6
10/20/2017 19-64 years old Obama B. Uninsured: (Medicare excluded) US Health 19% 11% Care Reform Progress to Date and Next Steps Medicaid: JAMA online 13% 17% July 11, 2016 Commercial: 65% 67% 7
10/20/2017 2017: What’s Changed State Of Birth Control Coverage • Multiple attempts to “repeal and replace” the ACA • 55 million women have accessed birth control without • Efforts to weaken the ACA by the Executive Branch cost-sharing • Entry and exit of Tom Price, MD, as Secretary of DHHS • 2/3 OC and 3/4 CVR users are not paying out-of-pocket • Proposed DHHS regulations • In 2013, women saved more than $483 million in out- – Exemptions to contraceptives as a preventive service of-pocket costs for birth control, or $269 per woman • Loosening of EHB standards: association health plans • 70% of Americans support this requirement • New restrictions in OPA/Title X: mainly failure to renew research projects…more on the way NWLC, 2015 “Repeal and Replace” 5 Attempts to “Repeal and Replace” • Long-standing campaign promise of Republicans • Similarities • Objections to the ACA – Repeal individual and employer mandate – Minimizes “free market” in health care economics – Repeal subsidies for out-of-pocket costs – Government take over of health care – Keep “dependent coverage until 26 years old” – Medicaid expansion: too many “free riders” • Differences – Too expensive for federal government and states – Degree of state control over insurance rules – In some markets Few or no health plan options – What to do with Medicaid expansion Expensive, and rising, premiums for >400% FPL – What to do with all Medicaid funding Very high deductibles in bronze + silver plans 8
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