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National Policy Updates: Health Care Reform and Beyond

National Policy Updates: Health Care Reform and Beyond. Gabrielle de la Guéronnière, Legal Action Center 2012 Mid-Atlantic Behavioral Health Conference. Legal Action Center. Advocacy for people with addiction histories, criminal records, and HIV/AIDS

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National Policy Updates: Health Care Reform and Beyond

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  1. National Policy Updates: Health Care Reform and Beyond Gabrielle de la Guéronnière, Legal Action Center 2012 Mid-Atlantic Behavioral Health Conference

  2. Legal Action Center • Advocacy for people with addiction histories, criminal records, and HIV/AIDS • Federal policy work advocating for the expansion of services and resources for people with addiction histories, criminal records, and HIV/AIDS • Fighting discrimination: eliminating legal and policy barriers in place for people with addiction histories and criminal records

  3. What we’ll discuss today • Updates from DC • Implementation of the Affordable Care Act (ACA) • Work on the Essential Health Benefits • Federal funding for services • Huge need for our continued collective advocacy

  4. A Time of Tremendous Change and Uncertainty but also Huge Opportunity • Greater understanding of addiction and mental illness as treatable chronic health conditions • Recognition of the history of discrimination in private insurance coverage and passage of parity • Broader inclusion of SUD and MH prevention, treatment and recovery support services and providers by the health care system • Working toward a dramatic expansion of coverage of SUD and MH care through the new federal parity and health care reform laws

  5. We All Have Many Questions… • When will the U.S. Supreme Court make its ruling? How will the Court rule? How will the Court’s decision affect health reform work in my state? • Will coverage for SUD and MH services expand? Will access to care improve? • What decisions will this Congress make about federal funding? How will those decisions affect our ability to provide care? • How will the results of the upcoming election impact the MH and SUD fields? • With so many important activities going on, what should I be focusing on now?

  6. The Things We Do Know: The Work Goes On • Our current system of care must be fixed • Many reforms were being made before the ACA and will continue to be made regardless of the Court’s decision • Initiatives to expand coverage and access, improve quality of care and support integrated care • Although the ACA includes parity, the federal parity law is distinct from the ACA, not facing legal challenge, and is fully enforceable • There is greater understanding that SUD and MH services and providers must be a part of these reforms • There is a huge need for continued education, advocacy, and engagement by our field with other stakeholders and policy-makers at the local, state and federal levels.

  7. Ways the ACA Seeks to Increase Coverage: Expand Public Insurance • Medicaid expansion: • Expansion to everyone below 133% FPL, including childless adults for the first time in most states • Approximately 16 million new enrollees • States will also be deciding benefits for Medicaid expansion • Must provide MH and SUD benefits at parity • Federal government to pay enhanced match rate for expansion population

  8. Ways the ACA Seeks to Increase Coverage: Expand Private Insurance • Health Insurance Exchanges • Competitive State-based marketplaces for small employers and individuals to pool risk and purchase insurance • Plans will have to meet Essential Health Benefit and parity requirements and other consumer protections • Must offer MH and SUD benefits at parity • Plans will have to maintain a sufficient network of providers, including MH/SUD providers, to ensure all services are accessible without unreasonable delay

  9. Essential Health Benefits • The ACA will require certain health coverage to meet minimum requirements, including benefit requirements, beginning in 2014. • The 10 required categories of service: • While the SUD/MH category itself is important, SUD/MH touches, and must be addressed, in most of the 10 categories

  10. Essential Health Benefits (cont’d) • Essential Health Benefits (including SUD and MH) must be offered: • By private insurance plans participating in the health insurance exchanges • By non-grandfathered individual and small group plans outside the exchanges • To newly-eligible Medicaid enrollees, including childless adults • Large group plans and “traditional” Medicaid do not need to meet EHB requirements

  11. Essential Health Benefits (cont’d) • Where the EHB is required, parity is required • ACA improves on the federal parity law • SUD/MH benefits required and must be provided at parity • Extension to individual and small group plans • EHB expected to have a direct impact on over 70 million Americans

  12. Essential Health Benefits—Who decides the specifics? • The 10 EHB categories, including the MH/SUD category, are not defined in the ACA • Continuum of care for MH and SUD is not defined • In December, the federal Department of HHS set out a framework for defining the EHB • Strong State role, no federal definition of EHB

  13. Essential Health Benefits—What Choices Are States Facing? • States can to “benchmark” to one of ten options: • One of the three largest small group plans in the State • One of the three largest FEHBP plans • One of the three largest State-employee plans • The largest HMO in the State • For States that do not choose, largest small group is default • Deadline for EHB benchmark plan decisions is September

  14. Benchmarking Essential Health Benefits—What Does This All Mean? • States have lots of flexibility to define the EHB • Some range and variability in MH and SUD benefits available through typical employer plans • IOM and Milliman reports found relatively broad coverage of continuum of MH/SUD services in existing large plans

  15. Benchmarking Essential Health Benefits—What Does This All Mean? • EHB must be consistent with parity and nondiscrimination requirements • Hugely important—plan selected must have sufficient SUD and MH coverage as compared with other benefits provided by the plan; if the plan doesn’t, benefits must be added to meet parity requirements • MH/SUD benefits appear to be protected against being weakened by any substitutions that may be allowed • State-level advocates are in a strong position to influence EHB decisions; advocacy is extremely important!

  16. Advocacy tools—Coalition for Whole Health Benefit Recommendations • Consensus document as tool for the MH/SUD fields to advocate for strong MH/SUD benefits in the EHB • Endorsed by over 100 national, state, and local organizations • Tool to evaluate benchmark plan benefits and advocate for services that may not be included in benchmark • Available at www.coalitionforwholehealth.org • EHBs need to address: • Long-term recovery and a chronic care approach • Include prevention, treatment, habilitation and rehabilitation • Prescribed medications when appropriate

  17. Coalition for Whole Health Benefit Recommendations (cont’d) • Consensus document includes specific minimum benefits recommendations for MH/SUD across the continuum, including: • Outpatient treatment & intensive outpatient treatment • Inpatient hospital services • Residential SUD treatment (corresponding to ASAM III) • Prescription drugs (all approved medications for MH/SUD) • Pediatric MH/SUD services • MH/SUD related prevention and wellness services • MH/SUD related chronic disease management services and supports

  18. Essential Health Benefit Work Around the Country : What Are We Hearing So Far? • Lots of variability—some states moving forward quickly, others are waiting • Overarching themes • Concern about coverage of certain modalities and levels of care • Residential treatment • Methadone treatment services • Need to ensure that prevention/wellness services adequately including MH and SUD • Need to identify services covered for other chronic diseases that are analogous to SUD and MH services that help people to get and stay well

  19. Essential Health Benefit Work: What Should We Be Doing Right Now? • Determine the status of work to analyze your state’s benchmark plan options and advocate for robust MH and SUD benefit coverage • Work by state MH and SUD directors; some states have retained consultants to do the analysis • Work together with your fellow SUD and MH advocates to get the results of the plan analysis, including each plan’s coverage of MH/SUD benefits, and then work to ensure that the selected plan has the strongest possible SUD and MH coverage • Use the federal parity law as a tool to ensure that there is good SUD and MH coverage

  20. Essential Health Benefit Work: What Should We Be Doing Right Now? • Identify where the levers are and how best to engage • Different processes, decision-makers and leverage points in each state • Develop new or strengthen existing relationships with your Insurance Commissioner, Medicaid Director, your federal HHS regional office, and other key decision-makers • Learn from the experiences of allies in your state and around the country

  21. Protecting Safety Net Funding • Recognition that ACA coverage provisions do not go into effect until 2014 and will take years to fully implement • We don’t yet know exactly which SUD and MH services will be included in the essential health benefit • Huge need for continued strong federal funding for prevention, treatment, recovery supports and research before the ACA is fully implemented and beyond • During this interim period before expansion has occurred • Through implementation of the ACA to cover the services not included and the people who remain uncovered or underinsured

  22. Update on the FY 2013 Funding Process • SAMHSA’s 2013 budget proposal • Similar to the 2012 budget, proposes to restructure a number of the agency’s programs • Under the proposal, SAMHSA would receive $3.15 billion • Represents an overall decrease of approximately $195.5 million from FY 2012—approximately a four percent cut • National field groups have analyzed SAMHSA’s budget and have crafted Field Funding Requests for our advocacy with Congress • Working jointly with our national partners to ensure strong funding for the field

  23. Our Advocacy on Strong Safety Net Funding • Advocacy by the national drug and alcohol community • Fighting for highest possible funding for SAMHSA and the continuum • Huge need for a continued push from around the country with Congress and the Obama Administration; www.lac.org • Need to ensure our system of care is strong now and beyond

  24. Our Advocacy: Now More Important Than Ever • Continued outreach and education—within and outside of our field • Connecting our work in Washington with implementation efforts around the country • Speaking with one cohesive voice • Finding the best ways to engage our champions and to cultivate new champions • Protecting safety net programming • Monitoring implementation and informing our federal partners about successes and non-compliance • Continued work to eliminate the barriers facing the people we serve

  25. Questions and Discussion? Gabrielle de la Guéronnière gdelagueronniere@lac-dc.org www.lac.org www.coalitionforwholehealth.org/resources-for-local-advocates/ www.hirenetwork.org

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