Susan Dentzer Editor-in-Chief

1. Moving Forward on Health Reform Susan Dentzer Editor-in-Chief

2. How Health Care Reform Must Bend The Cost Curve David M. Cutler Harvard University

3. The Drivers of Productive Industries Move from pay-for-volume to pay-for-value [PPACA, 2010] Engaging employees and consumers in continuous quality improvement IT and its use [ARRA, 2009]

4. Bundled payment

5. Performance-based payment

6. Forecast of Cost Savings Total savings = $9.0 trillion

7. What It Will Take Administrative Implementation Shorten demonstration time Openness to new approaches Provider response Changing existing operations New organizational forms

8. Health Reform And Federal Budget Deficits: Likely to Broaden The Gap, Not Reduce It Michael Ramlet Analyst, The Advisory Board Company Douglas Holtz-Eakin President, American Action Forum

9. It Was Ugly Before Reform Federal Revenues and Noninterest Spending, by Category Congressional Budget Office’s Alternative Fiscal Scenario Percentage (%) of Gross Domestic Product (GDP) Source: Congressional Budget Office. The long-term budget outlook. Washington (DC): CBO; 2009 Jun.

10. Modest Deficit Reduction Projected ^ Really Congressional Budget Office (CBO) Score – H.R. 4872, Reconciliation Act of 2010 $ Billions Notes: Components may not sum to totals because of rounding. aPositive numbers indicate increases in the deficit, and negative numbers indicate reductions in the deficit. bExtrapolations for 2020-2029 calculated using CBO estimated compounded annual growth rates (CAGR). cThe CBO pegs tax revenues to the rate of general inflation. U.S. Breakeven 20-Year Inflation rate between normal bonds and inflationary bonds was 2.51 percent (accessed via Bloomberg, 9 April 2010). Source: Congressional Budget Office. The long-term budget outlook. Washington (DC): CBO; 2009 Jun.

11. Substantial Deficits More Likely ^ A Lot Scenario Analysis Summary – H.R. 4872, Reconciliation Act of 2010 $ Billions Notes: Components may not sum to totals because of rounding. aPositive numbers indicate increases in the deficit, and negative numbers indicate reductions in the deficit. bExtrapolations for 2020-2029 calculated using CBO estimated compounded annual growth rates (CAGR). cThe CBO pegs tax revenues to the rate of general inflation. U.S. Breakeven 20-Year Inflation rate between normal bonds and inflationary bonds was 2.51 percent (accessed via Bloomberg, 9 April 2010). Source: Congressional Budget Office. The long-term budget outlook. Washington (DC): CBO; 2009 Jun.

12. Hello Greece? In light of the fiscal threat from growing spending, the budgetary impacts of the Patient Protection and Affordable Care Act are central to any discussion of its merits Even with the budgetary gimmicks, if everything goes well there is only a modest projected decline in the deficit of $124 billion in the first 10 years and $681 billion in the second 10 years If one accounts for the dubious budgetary provisions related to unachievable cost savings, unscored budget effects, uncollectible revenue, and already reserved premiums, the act would raise, not lower, federal deficits by $554 billion in the first ten years and $1.4 trillion over the succeeding 10 years

13. Bruce H. Hamory Executive Vice President, Chief Medical Officer Emeritus Geisinger Health System

14. Delivery System Reform and Bending the Cost Curve Rich Umbdenstock American Hospital Association

15. A Framework for Health Reform

16. 32 million more people with health coverage • Shared responsibility • Insurance reforms • Medicaid expansions • Tax credits • $12.9 billion prevention fund • Increases coverage of preventive services • No cost sharing for recommended preventive services • Annual Medicare wellness visits • Grants for workplace wellness programs • Creates a national public health council with advisory groups • HIT Medicare/ Medicaid Incentive programs • Expansion of broadband technology • Funding for HIT infrastructure • Pilot programs on payment bundling • Accountable Care Organizations • Center for Medicare and Medicaid Innovation (CMI) • Independent Payment Advisory Board (IPAB) • Administrative Simplification • Comparative effectiveness • Hospital Value-Based Purchasing (VBP) • Enhanced public reporting • Numerous provisions to reduce health disparities • National quality center

17. Assisting with Health Reform National Framework for System Reform Key Health Reform Quality Issues Education, Tools, Leadership Development and National Projects to Support Implementation

20. National Projects Comprehensive Unit-based Patient Safety Program (CUSP) to reduce Central Line Associated Blood Stream Infections (CLABSI) and Catheter Associated Urinary Tract Infections (CAUTI) CLABSI: 28 states, over 600 hospitals and growing

21. Work To Be Done Policy Adjustments Readmissions Hospital acquired conditions DSH Additional Issues Campaigns GME slots 340B expansions Medicaid hospital payments Liability reform Coverage (undocumented immigrants)

22. The New Health Reform Law and Private Insurance Scott Keefer America’s Health Insurance Plans

23. Laying the Foundation Building Up to Successful Implementation

24. 2010 Market Reforms and Impact Impact on Costs and Premiums; Provider Capacity?

25. Reforms & Reflection through 2015 Changes in Coverage and Cost Impact?

26. Broader Reforms and Key Challenges

27. Sustainability: Driving Value in Delivery

28. Implementing Insurance Market Reforms Under the Federal Health Reform Law Len M. Nichols, Ph.D. Director, Center For Health Policy Research and Ethics College of Health And Human Services George Mason University

29. Jon Kingsdale Executive Director Commonwealth Health Insurance Connector Authority

30. PPACAis NOT a Federal Takeover Takeover not 2000 pages, rather, 2 lines Federalism: Federal Goals – State Implementation McCarran-Ferguson HIPAA Patient Protection and Affordable Care Act

31. Examples of Federalism in PPACA Grants to states for Ombudsmen Reporting and regulation of MLRs Setting up an exchange, with federal start-up funds, and flexibility in key areas high-risk Pools Annual review of premium increases State insurance departments and regulation of immediate and 2014 reforms

32. Successful Implementation Self-Interest Capacity Authority

33. Major Challenges Coordinating Medicaid and Exchange subsidy eligibility in the dynamic real world Politics of non-cooperation

34. Playing for Time: The Federal high-risk Program Deborah Chollet Mathematica Policy Research

35. Why focus on high-risk individuals? Unlike groups, individuals who apply for coverage now can be: Denied coverage Offered coverage that excludes care broadly related to their condition Charged a much higher premium Even minor conditions can trigger denial, exclusions, or a “rate up”

36. Where do high-risk individuals find coverage now? In 35 states, a state high-risk pool funded by premiums, assessments on insurers, state funds In 5 states, the insurance market An insurer of last resort No option if not transferring from group coverage

37. State high-risk pools High premiums Rarely, enrollment limits High cost sharing Annual/lifetime benefit limits Waiting periods for coverage of preexisting conditions

38. The Federal High-Risk Program Temporary, pending 2014 market reforms Premiums equal to market rates No waiting periods, lower cost sharing Eligible if Qualifying condition, denied coverage or offered exclusion or higher premium Uninsured 6 months or more

39. Ready, Set, Plan, Implement: Executing the Expansion of Medicaid Leighton Ku George Washington University

40. Medicaid Eligibility in a Typical State: Now and 2014

41. Countdown for Key Changes Now • States must retain Medicaid & CHIP eligibility (limited exceptions) • States may begin expansions for adults early Soon • CMS & states begin planning & systems development Jan. 2014 • Expand eligibility for non-elderly adults • Narrower benefit packages for newly covered • Coordinated applications for Medicaid, CHIP & health insurance exchanges

42. Big Challenges Ahead • Will the health care system be ready? • How much will this cost? • Will the states be ready?

43. States Opposing Health Reform Have More to Gain % of Medicaid-Eligible Adults Uninsured Source: Author’s analysis of March 2009 Current Population Survey data Notes: Opposing states include Alabama, Alaska, Arizona, Colorado, Florida, Georgia, Idaho, Indiana, Louisiana, Michigan, Mississippi, Nebraska, Nevada, North Dakota, Pennsylvania, South Carolina, South Dakota, Texas, Utah, Virginia and Washington state. Estimates are for people 19 to 64 with income below 138 percent of poverty, adjusted for immigrant status.

44. New Roles For States In Health Reform Implementation Alan Weil National Academy for State Health Policy Raymond Scheppach National Governors Association

45. The State To-Do List Medicaid Eligibility Expansion Commercial Health Insurance Regulation Insurance Exchanges Many Other Provisions

46. What States Need Knowledge Executive-Branch Leadership Strategic Plan Operational Plan Needs Assessment Short-Term Plan

47. Conditions For Success Federal Cooperation Stakeholder Engagement State-to-State Learning Vision, Leadership, Commitment and Willingness to Take Risks

48. Health Reform’s Late-Term Delivery: Struggling with Political Birth Defects Thomas P. Miller American Enterprise Institute

49. Political Strategies Budget Extenders Beat the Clock Smoke Screens All or Nothing Health Reform Stooges

50. Rough Road Ahead?