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Overview of Healthcare Reform & Behavioral Health. Jon T. Perez, Ph.D. Regional Administrator, Region IX. Behavioral Health: A National Priority. 2. Behavioral health is essential to health. Prevention works. Treatment is effective. People recover.

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overview of healthcare reform behavioral health

Overview of Healthcare Reform &Behavioral Health

Jon T. Perez, Ph.D.

Regional Administrator, Region IX

behavioral health a national priority
Behavioral Health: A National Priority


Behavioral health is essential to health

Prevention works

Treatment is effective

People recover

SAMHSA’s Mission: Reduce the impact of substance abuse and mental illness on America’s communities

samhsa core functions
SAMHSA Core Functions

Leadership and Voice


Practice Improvement -- Technical Assistance, Quality Measures, Evaluation/Services Research

Public Awareness and Education


Regulation and Standard Setting

division of regional and national policy liaison regional team
Division of Regional and National Policy Liaison – Regional Team
  • Represent SAMHSA leadership in the Regions
  • Provide SAMHSA staff with “eyes and ears” out in the Regions
  • Establish working relationships with:
    • Regional representatives of OPDIVS (HRSA, ACF, CMS) and internal staff divisions (e.g., ASFR and OASH.
    • State authorities for mental health and substance abuse, provider groups, city and county level health departments.
  • Coordinate support for State implementation of health reform.
  • Coordinate, as needed, implementation of SAMHSA Strategic Initiatives and technical assistance within the regions.
  • Help States to coordinate resources across SAMHSA to address emerging needs.
regional administrator roles
Regional Administrator Roles

Be a member of regional teams including federal, state, and local interests

the problem
The Problem
  • Pre-existing condition discrimination
  • Premiums had more than doubled over the last decade
  • Fifty million Americans were uninsured, tens of millions more were underinsured, and those who had coverage were often afraid of losing it
the health care law
The Health Care Law

In March 2010, President Obama signed into law the Patient Protection and Affordable Care Act

framework of health reform
Framework of Health Reform

Control Your Own Destiny

Importance of Federal AND State AND Local Involvement in ACA Implementation

Federal Framework AND State Implementation

framework of health reform1
Framework of Health Reform
  • 35 million more insured people by 2014 (92% of non-elderly population).

-- 29 million Americans covered via new Exchanges.

  • More than 546,000 insured in Nevada by 2014.

-- Potential for more than 198,000 individuals (non-group) covered via new Nevada Silver State Health Insurance Exchange.

what the law means for you 4 things to know
What the Law Means for You4 Things to Know:
  • Consumer protections are in force today
  • Better access to care
  • Makes health care more affordable
  • Stronger Medicare
these abuses used to be legal
These abuses used to be legal:

“Newborn Denied Health Insurance Coverage Days After Life Saving Heart Surgery”ABC News

“Low Health Insurance Caps Leave Patients Stranded”

-- USA Today

“WellPoint Routinely Targets Breast Cancer Victims for Rescission”

-- The Huffington Post

Now they are banned for good.

the law stops insurance companies from taking advantage of you
The Law Stops Insurance Companiesfrom Taking Advantage of You

It is now illegal for insurance companies to:

Deny coverage to children because of a pre-existing condition like asthma and diabetes.

Put a lifetime cap on how much care they will pay for if you get sick.

Cancel your coverage when you get sick by finding a mistake on your paperwork.

And more…

the law increases your access to affordable care
The Law Increases Your Access to Affordable Care

There are new plans in every state for people who have been locked out of the insurance market because of a pre-existing condition like cancer or heart disease. There are 579  people in Nevada on this program.

“When I was diagnosed, they told me I had a 60 percent chance of being cured. That's pretty good odds, but I was also terribly worried about finances. Now I don't feel like we can't afford the treatment."

--Gail O. in New Hampshire

For more, visit www.PCIP.gov.

the law increases your access to affordable care1
The Law Increases Your Access to Affordable Care

Young adults under the age of 26 can now stay on their parents’

health plans.

“I honestly don’t know what we would have done…. There was no way we could have afforded it. I might not be here right now.”

--Kylie L., 23, in Illinois, who credits the health care

law for enabling a life-saving heart transplant

two years later the benefits of the aca for nevada
Two Years Later: The Benefits of the ACA for Nevada

Providing new coverage options for young adults

Health plans are now required to allow parents to keep their children under age 26, without job-based coverage, on their family’s coverage, and, thanks to this provision, 2.5 million young people have gained coverage nationwide.

As of June 2011, 22,640 young adults in Nevada gained insurance coverage as a result of the new health care law.

promoting prevention and improving public health
Promoting Prevention and Improving Public Health

Prevention and Public Health Fund used for prevention-related activities and to expand primary care workforce.

Promotes prevention and wellness for Seniors and older Americans.

Removes financial barriers to preventive care and encourage prevention.

Awards grants that promote community health.

Provides individual wellness and worksite wellness initiatives.

Requires nutrition labeling.

prevention and behavioral health
Prevention and Behavioral Health
  • No-cost preventive services for new plans or plans started after September 23, 2010
    • Includes including behavioral health services such as depression screening, alcohol misuse, alcohol and drug screenings for adolescents, and behavioral assessments for children of all ages
  • Community Transformation Grants
    • Focus on chronic disease prevention
    • 35 grants to implement proven interventions to help improve health and wellness
    • 26 grantees to build capacity by laying a solid foundation for sustainable community prevention efforts
  • National Prevention Strategy
    • Report Published June 2011 - http://www.healthcare.gov/center/councils/nphpphc/strategy/report.pdf
    • 4 Strategic Directions
      • Healthy and Safe Community Environments
      • Clinical and Community Preventive Services
      • Empowered People
      • Elimination of Health Disparities
    • 7 Priorities – Aimed at Addressing the Leading Causes of Death
      • Tobacco Free Living
      • Alcohol and Other Drug Abuse
      • Mental and Emotional Wellbeing
      • Injury and Violence Free Living
      • Sexual Health
      • Healthy Eating
      • Active Living
    • Need Partners in Prevention to Make this Successful
The Law Increases Your Access to Affordable CareIn many cases, you can get preventive services for free:
  • Cancer screenings such as mammograms & colonoscopies
  • Vaccinations such as flu, mumps & measles
  • Blood pressure screening
  • Cholesterol screening
  • Tobacco cessation counseling and interventions
  • Birth control
  • Depression screening
  • And more…

Visit www.healthcare.gov/prevention for a full list.

the law keeps women healthy
The Law Keeps Women Healthy

Preventive care services are free for many Americans with private health insurance. For women, this includes:

  • Well Woman Visits
  • All FDA-approved contraception methods and contraceptive counseling
  • Mammograms
  • Pap smears
  • HIV and other sexually transmitted infection screening and counseling
  • Breastfeeding support, supplies, and counseling
  • Domestic violence screening and counseling

Visit www.healthcare.gov/prevention for a full

list and implementation dates.

two years later the benefits of the aca for nevada1
Two Years Later: The Benefits of the ACA for Nevada

Covering preventive services with no deductible or co-pay

In 2011, 230,891 people with Medicare in Nevada received free preventive services – such as mammograms and colonoscopies – or a free annual wellness visit with their doctor.

And 54 million Americans with private health insurance gained preventive service coverage with no cost-sharing, including 477,000 in Nevada.

did you know
Did You Know…
  • The law does not add to the deficit. According to the independent Congressional Budget Office, reform is paid for in the next 10 years.
  • The CBO estimates that the legislation will reduce federal deficits by $124 billion the next 10 years.
  • And 1 trillion over the second decade.
the law makes health care more affordable
The Law Makes Health Care More Affordable

60% / 40%

80% / 20%

BEFORE, insurance companies spent as much as 40 cents of every premium dollar on overhead, marketing, and CEO salaries.

TODAY, we have the new 80/20 rule: insurance companies must spend at least 80 cents of your premium dollar on your health care or improvements to care.

If they don’t, they must repay the money.

the law makes health care more affordable1
The Law Makes Health Care More Affordable

“Anthem Withdraws Rate Increases”

-- San Francisco Chronicle

“Blue Shield Cancels Insurance Rate Increase”

-- Los Angeles Times

“Connecticut Rejects Insurance Rate Increase”

-- The New York Times

the law makes health care more affordable2
The Law Makes Health Care More Affordable

BEFORE, insurance companies could raise your premiums by double digits without justification.

TODAY, insurance companies must publicly justify their actions if they want to raise premiums by 10 percent or more. And states have more power to block them.


The Law Makes Health Care More Affordable

BEFORE, small businesses paid an average of 18 percent more for health insurance than large companies.

TODAY, small businesses can get tax credits to help pay for coverage for their employees.

“In 2010, we paid close to $11,000 for employees’ health insurance. The tax credit cut our costs by over $2,000. For a small business struggling to keep health coverage, that makes all the difference. We were actually considering dropping our insurance, but the tax credit tipped thebalance and helped us maintain coverage.”

--Matt H. in Montana


The Law Saves Small Businesses Money

The New Small Business Tax Credit

Who qualifies?

Businesses and non-profits with 25 or fewer full-time employees and average wages of $50,000 or less.

What’s the maximum tax credit?

The maximum tax credit is 35% of the cost of coverage, rising to 50% in 2014.

How is it calculated?

The tax credit is available on a sliding scale – businesses with 10 or fewer full-time employees and average wages below $25,000 receive the full credit.

the law strengthens medicare
The Law Strengthens Medicare
  • Many free preventive services such as mammograms and colonoscopies and a free annual wellness visit.
  • A 50% discount on covered brand-name medications for those in the prescription drug donut hole – an average savings of nearly $600 per person in 2011. The donut hole will be closed in 2020.
  • Strong anti-fraud measures, including tougher penalties for criminals.
  • Makes sure your doctors can spend more time with you and improve care coordination – just like they do at hospitals such as the Mayo Clinic and Cleveland Clinic.
two years later the benefits of the aca for nevada2
Two Years Later: The Benefits of the ACA for Nevada

Making prescription drugs affordable for seniors

Thanks to the new health care law, 24,892 people with Medicare in Nevada received a $250 rebate to help cover the cost of their prescription drugs when they hit the donut hole in 2010.

In 2011, 22,193 people with Medicare received a 50 percent discount on their covered brand - name prescription drugs when they hit the donut hole.

This discount resulted in an average savings of $553 per person, and a total savings of $12,274,764 in Nevada. By 2020, the law will close the donut hole.


The Law Increases Your Access to Affordable Care There are thousands of new doctors and nurses in communities around the country and millions more patients getting care.

new community health centers
New Community Health Centers
  • The Affordable Care Act provides $11 billion over the next 5 years for health centers throughout the nation
    • $9.5 billion is designated for building new health centers in underserved areas or expanding primary care services at existing health centers
    • An additional $1.5 billion will support major construction and renovation projects at health centers nationwide
    • These changes will nearly double the 19 million patients receive treatment today, regardless of their insurance status or ability to pay
two years later the benefits of the aca for nevada3
Two Years Later: The Benefits of the ACA for Nevada

Increasing support for community health centers

The Affordable Care Act increases the funding available to community health centers in all 50 states, including the 28 existing community health centers in Nevada.

Health centers in Nevada have received $4.2 million to create new health center sites in medically underserved areas, enable health centers to increase the number of patients served, expand preventive and primary health care services, and support major construction and renovation projects. 

community health centers
Community Health Centers

Capital Development - Immediate Facility Improvement Program

  • Announced Two Weeks Ago:

Nevada Rural Health Centers (Carson City), Inc. –$499,788

individual mandate
Individual Mandate
  • 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.
more improvements to come
More Improvements to Come

In Less Than Two Years:

  • Discriminating against anyone because of a pre-existing condition will be illegal.
    • There will be new State-based marketplaces – called Affordable Insurance Exchanges – where private insurers will compete for your business. Members of Congress will have to buy insurance there, too.
  • Tax credits will make buying insurance more affordable.

Note: Nevada has been awarded three grants totaling more than $5 million to support the Nevada Silver State Health Insurance Exchange.

affordable insurance exchanges
Affordable Insurance Exchanges

State-based health insurance Exchanges will be established to provide families and employers/employees with the same private insurance choices that the President and Members of Congress have, to foster competition and increase consumer choice.

  • Must be operational by Jan. 1, 2014; Certification, at least Conditional = January 1, 2013
  • Coordination between Exchange, Medicaid, and CHIP coverage
  • Grants for Navigators: entities that have relations with consumers and can provide information and facilitate enrollment
  • Four benefits categories: bronze, silver, gold, platinum
essential benefits
Essential Benefits
  • Two statutory goals that frame EHBs
    • Essential Benefits Package shall be based on the typical employer plan and
    • Ensure that there is no discrimination by age, disability or lifespan
  • Essential Health Benefits Bulletin released by HHS December 2011
    • Gives flexibility to States in choosing a benchmark plan
    • Can be found at : http://cciio.cms.gov/resources/files/Files2/12162011/essential_health_benefits_bulletin.pdf
    • FAQs found at : http://cciio.cms.gov/resources/files/Files2/02172012/ehb-faq-508.pdf
affordable insurance exchanges1
Affordable Insurance Exchanges
  • Essential Benefits Package: Take into account the health care needs of diverse segments of the population, including women, children, persons with disabilities, and others.
  • Essential Benefits Package Required Categories:
    • Ambulatory patient services
    • Emergency services
    • Hospitalization
    • Maternity and newborn care
    • Mental health/substance use disorder services/BH treatment
    • Prescription drugs
    • Rehabilitative and habilitative services/devices
    • Laboratory services
    • Preventive/wellness services and chronic disease mgt
    • Pediatric services, including oral/vision care
importance of integration bh impact on physical health
Importance of Integration: BH Impact on Physical Health


  • MH problems increase risk for physical health problems & SUDs increase risk for chronic disease, sexually transmitted diseases, HIV/AIDS, and mental illness
  • People with M/SUDs are nearly 2x as likely as general population to die prematurely, often of preventable or treatable causes
  • Cost of treating common diseases higher when a patient has untreated BH problems
    • Hypertension – 2x the cost
    • Coronary heart disease – 3x the cost
    • Diabetes – 4x the cost
  • M/SUDs rank among top 5 diagnoses associated with 30-day readmission; one in five of all Medicaid readmissions
    • 12.4 percent for MD
    • 9.3 percent for SUD
affordable insurance exchanges more improvements to come
Affordable Insurance ExchangesMore Improvements to Come
  • In 2014, refundable tax credits for people with income from 134 percent to 400 percent of the poverty level
    • Maximum annual income of:
        • $43,560 for 1 person;
        • $89,400 for family of 4
          • These tax credits level the playing field for middle class families, the self-employed and people who work more than one part-time job
more changes ahead
More Changes Ahead
  • Increases Medicaid payment rates for primary care to 100% of Medicare rates in 2013 and 2014.
  • The federal government will pay 100% of the cost of covering newly-eligible individuals for the first three years of expansion.
more changes ahead1
More Changes Ahead
  • In 2014 , the Affordable Care Act takes full effect:
    • Medicaid will expand to cover families with income up to 133 percent of the poverty level
        • Maximum annual income of:
        • $14,484 for 1 person
        • $29,726 for a family of 4
    • Mandatory income eligibility levels for children ages 6 to 18 will also change from 100 percent to 133 percent of the poverty level
learn more
Learn More



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