Health Care Policy

Health Care PolicyEvelyn JARAMILLOJustine GONZALEZJoyce ALEXANDERLOUIS QUI

SLIDES 1-6: EvelynSLIDES 7- 17: LouisSLIDES 18 23: JustineSLIDES 24 25: JoyceSLIDE 26: EvelynSLIDES 27 30: JoyceSLIDE 31: EvelynSLIDE 32: Justine or Joyce1ObjectivesWhat is a PolicyWhat is Healthcare Policy How does Policy influence our healthcareEscape Fire Patient Protection and Affordable Care act (aka Obama care)King v. Burwell. Nurse practitioner as a care provider Case of Medicare Physician Fee Schedule Proposed RuleHow policy affects practice of APRN Get InvolvedWhat is a Policy?The Center for Disease Control and Prevention (CDC, 2014) defines policy as a law, regulation, procedure, administrative action, incentive, or voluntary practice of governments and other institutions.

Healthcare Policyaka Healthcare reformThe health of our nation can be influenced by public health policies, such as a tobacco control policy, and by policies in many other sectors. For example, transportation policies can encourage increased physical activity and school nutrition policies can ensure healthier meals are provided in schools. (CDC,2014)

Health care policy targets the organization, financing and delivery of health care services. For example, health care may be delivered through a managed care provider or a preferred provider network. It may be financed through employer-sponsored health insurance, individual policy, or Medicare. And the care you get may be pegged to federally funded research that has identified the most effective treatments.

3 types of Universal HealthThis system is completely government run. In at least one country, the government places its citizens into one of two categories. The medical services available to an individual are then based on their category. If they need services that are not included in their category, they must petition their government.

The government provides or mandates a minimum amount of insurance coverage for every citizen.

The government mandates that all citizens purchase insurance, whether from private, public, or non-profit insurers. In this case, insurance companies must accept all applicant, regardless of health. Single Payer2-TieredInsuranceMandate (IM)Movie is 1:40:00 If by 10:40 we have not finished the movie, just stop it.5Escape FireMovie

Patient Protection and Affordable Care Act (PPACA)Affordable Care Act(ACA) or Obama CareInsurance Mandate type of universal health careSigned into law in March 2010.ACA requires all citizens to purchase an acceptable health insurance policy or pay a penalty. Some changes started immediately while others would be phased in over the next 5 years

- ACA falls under the Insurance Mandate type of universal health careSigned into law in March 2010, the new law provides a complex series of changes in healthcare delivery, payment, coverage, and education.

7Affordable Care Act (ACA) cont. Individuals can purchase competitively-priced health insurance on American Health Benefit Exchanges (exchanges) that may be run by either the States or the federal government. Authorizes a federal tax credit for low- and middle-income individualsAccording to the U.S. Department of Health and Human Services, by 2014 ACA will expand coverage to nearly 32 million uninsured citizens. Starting in 2011, the law began to focus on preventative services: This includes immunizations, diabetes and cancer screenings, counseling for smoking and alcohol abuse, and more.Other parts outlined that went into effect in 2011 were: no annual or lifetime limits on essential health benefitsChildren stay on a parents plan until 26y/oChildren with pre-existing health problems can be covered

- The ACA provides that individuals can purchase competitively-priced health insurance on American Health Benefit Exchanges (exchanges) that may be run by either the States or the federal government. - The ACA also authorizes a federal tax credit for low- and middle-income individuals who purchase insurance on the Exchanges - According to the U.S. Department of Health and Human Services, by 2014 ACA will expand coverage to 32 million uninsured citizens.

8Who This has AffectedInsured by employerMany health care reform changes that affects your health plan may already be in place. If there are additional changes that will affect your plan, you should have receive details under the current enrollment period.

Insured on their own Some plans are being updated to include certain protections healthcare reform requires

Not insured As of January 2012, U.S. citizens can no longer be denied coverage. Financial help may also be available if you qualify.

ACA Definitions:Subsidies: a sum of money granted by the government or a public body to assist an industry or business so that the price of a commodity or service (mandated health insurance) may remain low or competitive.Exchange: A health market place where bargains and sales take place. A negotiation by which one person transfers to another funds that he has in a certain place, either at a price agreed upon or which is fixed by commercial usage State exchanges: Health care policy program market places offered by a state that a person lives in (ex. Covered California). Federal Exchanges: Health care programs offered by the federal government (ex. Medicare, Medicaid)

ACA Section 1311A State shall use amounts awarded under this subsection for activities related to establishing an American Health Benefit Exchange.

ACA Section 1321If a State elects not to establish its own exchange or will not be ready to operate its exchange in 2014, the Secretary [federal government] shall establish and operate such Exchange within the State

11ACA Section 36B of Internal Revenue CodeRefers to all federal exchanges in requiring all exchanges to report to the federal government on the amount of advance payments of premium credits that taxpayers receive.

Section 1401 authorizes subsidies (nominally, tax credits) for exchange enrollees whose household income falls between 100 and 400% of the federal poverty level, who are not eligible for qualified employer coverage or other government programs, and who enroll in coverage through an Exchange established by the State.

12King v BurwellCan the IRS issue Affordable Care Actsubsidies through federal exchanges?

The Supreme Court is going to take up Obamacare again. And it could prove disastrous for the administration and for millions of individuals and families who have found affordable coverage under the law. Without subsidies, health reform starts to fall apart.13King v Burwell

Federal governments ability to distribute tax credits Discounted health coverageSome people live in States that made their own exchangesCalifornia, Kentucky, and MarylandMajority live in states like Florida, Pennsylvania, and Texas, Federally-run exchangesThe central issue is the federal governments ability to distribute tax credits, which allows people buying coverage through Obamacares new marketplaces to pay less than full price.Some of these people live in states like California, Kentucky, and Maryland, where officials decided to build and operate their own marketplaces.The majority live in states like Florida, Pennsylvania, and Texas, where officials handed that work off to the federal government.

Louis, I omitted the last 2 points you had here because they are explained on a different slide.16If the justices uphold the latest Obamacare lawsuit, here's the average increase in premiums for people who now receive tax credits.Halbig v burwell Letter of the law should be implemented as it is written DC Circuit judges ruled that is was ILLEGAL for IRS to extend subsidies to federally-run exchangesDoes not take context into considerationCurrently reviewing appeal en banc for reconsideration in December

King v burwellThe language of the ACA is ambiguous and subject to multiple interpretationsChevron DeferenceUpheld the rule as a permissible exercise of the agencys (IRS) discretionFourth Circuit judges said they could not confidently conclude which was the correct interpretation

Whether the Internal Revenue Service may permissibly extend tax-credit subsidies to coverage purchased through exchanges established by the federal government under Section 1321 of the Affordable Care Act.

Earlier this year, DC Courts ruled in favor of the Plaintiff Haliburg that subsidies for federally-run health exchanges were illegal. Then in the summer, US Court of Appeals for 4th Circuit ruled in favor of govt in King v Burwell.

KING: Under the legal principle of Chevron Deference, the appropriate way to deal with ambiguous text is to allow the agency responsible for implementing a law to interpret it, as long as the interpretation is reasonable.

HALBiG: DC Circuit judges are currently reviewing the appeal en banc [for Haliburg v Burwell], meaning that the ruling has been vacated and a larger panel of active DC Circuit Judges will reconsider the case on its merits in December.

18Why is this case such a big deal?

According to challengers, the PLAIN TEXT of the ACA limits the federal subsidies to states that actively established their own exchanges. In Obamacares first year, only 14 states set up their own exchanges. The other 36 defaulted to federally-operated exchanges through Healthcare.gov

36 states defaulted to federally-run exchanges.~87% of these individuals enrolled through the govt are receiving subsidies.Without the subsidies, private insurance becomes unaffordable for many who have already enrolled7.3 million people are expected to receive subsidies in 2016

If plaintiffs prevail and subsidies are withdrawn, Private insurance would become extremely unaffordablehealthy people would drop their coverageOnly the very sick (and very expensive to insure) would keep their plansdeath spiral undermining the purpose of the ACA19Potential ImplicationsPrivate Insurance becomes extremely unaffordableHealthy people dropOnly very sick keep coverageDeath SpiralOver 7 million people will be subject to individual mandate penalties, 57 million subject to employer mandate.Individual Mandate Exemptions Some people may have to pay back the governmentThe IRS is given power to interpret the law as they see fitRuling will set a precedent for authority an agency such as the IRS has to rewrite the law or execute laws as they interpret them

If plaintiffs prevail and subsidies are withdrawn, Private insurance would become extremely unaffordablehealthy people would drop their coverageOnly the very sick (and very expensive to insure) would keep their plansdeath spiral undermining the purpose of the ACA

Over 7 million people will be subject to individual mandate penalties, 57 million subject to employer mandate.Individual Mandate Exemptions the lowest priced coverage available to you costs >8% household income among many others

The IRS is given power to interpret the law as they see fitpeople werent predicting that money wouldnt apply to those states who did not make an exchange.

Ruling will set a precedent for authority an agency such as the IRS has to rewrite the law or execute laws as they interpret themPossibly gives too much power to Congress to be ambiguous in law-making toward agendas

http://www.commonwealthfund.org/publications/blog/2014/nov/the-supreme-court-decides-to-hear-king

http://www.washingtonpost.com/news/volokh-conspiracy/wp/2014/11/12/the-test-to-textualism-in-king-v-burwell-a-reply-to-abbe-gluck/

20Lets hear from both sidesAffirming Congress intended to include federal exchanges under the broad term of Exchanges Federal exchange is the State Exchange in states not establishing their own exchange ACA was intended to give all people access to affordable care no matter where they live Tax credits are available to all taxpayers who obtain coverage in an exchange, according to section 36B of ACA Chevron Deference allows for executing agencies to interpret the law and carry it out as such opposing The wording of the sections in the law explicitly state that subsidies and tax credits would be extended to State-run exchanges There is no mistake in the way the law was written. Congressional intent is the legislation the Congress enacted. Congress planned to draft the law in such a way that left federally-run exchanges without access to subsidies The part of the law that calculates subsidies specifies that those subsidies are only available to people enrolled in through an Exchange established by the State under 1311 It does not reference section 1321, which sets up the federal and partnership marketplaces the subsidies were supposed to act as a carrot, encouraging states to set up own exchangesIf a state didnt set up their own exchange, they wouldnt receive the subsidies for themselves or their residents. According to the plaintiff, this was a political decision to win over moderate Democrats opposed to federal control of insurance marketplaces.

Issue is not about legislative intent. If the statute said what the Congress wanted it to say, they wouldnt have to rely on intentCongressional intent is not the law, the words that congress enacted and the bill that the president signed into legislation is the law. There is no ambiguity in the wording of the law.

21DISCUSSION

Which way do you sway?Whose responsibility is it to change the law: Congress or Courts?Should the term exchanges includeFederal exchanges as well?Should the law be followed as it is written?Should the law be subject to interpretation of intent of congress?Did the IRS act illegally when it gave money to federally-run exchanges?What incentives do states have to set up their own exchanges?Why havent those states made exchanges?Can Congress force states to comply?What if states dont buy in?22How should healthcare work?

Nurse PractitionersFightTo gain autonomy

Advanced Practice Nurse (APN) A registered nurse with a masters or doctoral degree in nursing who demonstrates expert knowledge, skills, and attitudes in the practice of nursing.

Comparison of Old Sick Care Paradigm with New Healthcare Paradigm Old paradigmHospital-based acute care

Physician in chargeNurse as subordinatePhysician as primary decision maker

Segmented care focused on separate body parts/systemsPrimary care physicians and specialist separated

Paper records; some electronic health records (EHRs)

Free-for-service

Hierarchical organizations

Positivist, linear thinking

New paradigmShort-tem hospital, outpatient surgery, mobile/satellite clinics, telehealth/telemedicine

Team approachNurse as full team memberRelevant professionals and patient make treatment decisions

Seamless, coordinated, holistic carePatient-centered home health

HER system that generate data used for change packagesValue-based organizations

Complexity science: patterns noted in chaos, networks essential, quantum principles.

I rented this movie and it is all about insurance and how healthcare is reactive and not proactive and they are just worried about if the patients have coverage. It goes with the ACA providing coverage so that the doctors cannot turn patients away as well as insurance companies not being able to cover patients due to pre-existing conditions.

For the NP part it can be a point of discussion where not just the doctors opinion is taken into consideration but the nurse who is an APRN who is part of the healthcare team!!

26

Just as a picture of what is stated It can be placed on the previous slide too273 Levels of PracticeState practice and licensure law provides for nurse practitioners to evaluate patients, diagnose, order and interpret diagnostic tests, initiate and manage treatments- including prescribe medications- under the exclusive licensure authority of the state board of nursing.

State practice and licensure law reduces the ability of nurse practitioners to engage in at least one element of NP practice. State requires a regulated collaborative agreement with an outside health discipline in order for the NP to provide patient care.

State practice and licensure law restricts the ability of a nurse practitioner to engage in at least one element of NP practice. State requires supervision, delegation, or team-management by an outside discipline in order for the NP to provide patient care.

FullReducedRestricted28

Full practice rights

Reduced Practice rights

Restricted Practice Rights

NOTE THAT IN THE STATE OF CALIFORNIA RIGHTS ARE RESTRICTED

Do nurses want to be doctors?

Nurse Practitioners can help

Case Study

Maybe change it to just case(without the S).32Medicare Physician Fee Schedule Proposed RuleOn August 24, 2010, ANA submitted comments to the Centers for Medicare and Medicaid Reimbursement (CMS) regarding the 2011 Physician Fee Schedule proposed rule. Under recent legislation, reimbursement to all Medicare Part B providers, including APRNs, has increased by 2.2%. Under the Affordable Care Act (ACA), Medicare reimbursement for certified nurse-midwives (CNMs) is on par with that of physicians, just as it is for certified registered nurse anesthetists. Nurse practitioners and clinical nurse specialists continue to be compensated at 85% of what physicians receive for providing the same services. Discuss why NPs and CNs are not reimbursed at 100%What could be done to change this?What players/stakeholders would you involve in trying to change this?What implementation variables should be addressed?

ACTIVITY:Split into 2 groups: Doctors & NursesDiscussion: question on the green side

33Get Involved! Learn and understand the issues regarding healthcare policies Join professional nursing organizations American Nurses Association California Association for Nurse Practitioners Write to your legislative representative31st District Gary Miller Rancho Cucamonga, Redlands, Colton, Loma Linda34th District Xavier Becerra El Sereno, Boyle Heights, Montecito Heights, Cypress Park, Glassell Park, Mt Washington, Highland Park 35th District Gloria Negrete McLeod Ontario, Chino, Pomona, Bloomington, Montclair39th District Ed Royce Diamond Bar, Fullerton, La Habra, Yorba Linda, Chino Hills, Hacienda Heights Organizations often have templates for letters and emails specific to your area of interest Become a Legal Nurse Consultant

There are >3.1 million practicing nurses in US, yet we are often referred to as the silent majorityJust imagine if we used out collective voice to influence change we could really do something good for the public that we serve

A legal nurse consultant (LNC) is a registered nurse who uses expertise as a health care provider and specialized training to consult on medical-related legal cases.minimum 5 years clinical experienceLNC license is not required but usually a plus

9255734ReferencesVox http://www.vox.com/2014/11/7/7148215/obamacare-supreme-court-subsidies-kingACA Health Reform Navigator https://sites.google.com/site/healthreformnavigator/ system/app/pages/search?scope=search-site&q=internal+revenue+codeThe three types of universal healthcare: http://www.forbes.com/sites/mikepatton/2013/10/21/the-facts-on-obamacare-will-it-make-america-sick/http://obamacarefacts.com/obamacare-individual-mandate/What is a policy: http://www.cdc.gov/stltpublichealth/policy/