Wellness and Prevention in Health Reform

1. Wellness and Prevention in Health Reform Concerns with wellness plans and examples of consumer-friendly prevention provisions Claire McAndrew Families USA February 16, 2010

2. Wellness Plans Today • Individual market wellness plans are not federally regulated; some states have passed relevant laws • Group market (workplace) wellness plans are regulated by HIPAA rules • Rules divide employer wellness plans into two groups:

3. Wellness Plans Today: EmployerPlan Design • Plans based on participation goals: • Example: Employees who participate in a nutrition seminar will have a lower deductible for their health insurance • Incentive size restriction: none

4. Wellness Plans Today: Employer Plan Design • Plans based on health factors/ outcomes: • Example: An employer charges a higher deductible to workers who do not have a BMI under 35 • Incentive size restriction: 20% of the value of total health insurance premium (including the employer’s and the worker’s share) • Average worker premium for ESI in 2009: $4,824 (Kaiser/HRET 2009 Annual Health Benefits Survey) • 20%= $965

5. Concerns with wellness plans today • Access to coverage and care: Surcharges could make health coverage unaffordable altogether • Lack of evidence-base • Lack of comprehensive supports in programs • Inequities: may place a disproportionate burden on individuals with low-incomes, racial and ethnic minorities, and individuals with chronic health problems or disabilities

6. Concerns with wellness plans today • Privacy issues • Alternative standards • Verifying compliance/ measuring achievement • Lack of appeal rights

7. Wellness Plans and Health Reform: Senate Bill • Increases allowable incentive from 20% of premium value to 30%, with the option to go up to 50% • This would increase allowable surcharges from $965 to $1,447 for an average worker, with the possibility of a $2,412 surcharge (using 2009 average values as an example)

8. Wellness Plans and Health Reform: Senate Bill • Provides incentives for 10 states to start incentive-based wellness plans in their individual markets/ exchanges • Expands to more states in 2017 at the Secretary’s discretion • Major concern: Bill language appears to allow wellness surcharges to be tacked-on after people receive premium credits, undermining affordability protections

9. Wellness Plans and Health Reform: Medicaid • Grants for states to do Medicaid wellness programs • Protections • Evidence-based • Take into account unique needs of Medicaid population • Incentives cannot affect eligibility or benefits • Issue to watch

10. Wellness Plans and Health Reform: House Bill • No change to incentive limit (20% for outcome-based plans still stands) • Grant program for small businesses to start wellness plans, but only those that do NOT vary premiums or cost-sharing • To receive grants, programs must also be comprehensive and provide an array of supports • Note: Final Senate bill adopted some of these provisions— created a small business grant program with some standards, but doesn’t prohibit insurance-linked incentives.

11. Wellness Plans and Health Reform: Talking About It • House provisions reflect broader health reform goals: evidence-based, comprehensive supports for improving health • Senate provisions contradict broader goals of health reform, which seek to eliminate: • Pre-existing condition and health status discrimination • Unaffordable health coverage and care • Concerns with today’s plans still stand

12. Wellness and Prevention that Works for Consumers: Senate Bill • Comprehensive coverage for and increased access to preventive and health promotion services • Private Market: Essential benefits package • Medicare: wellness visit, no preventive cost-sharing • Medicaid: smoking cessation for pregnant women • Grant program for states to increase adult vaccination rates; Medicare study of beneficiary vaccine access

13. Wellness and Prevention that Works for Consumers: Senate Bill • Targeted prevention and health promotion efforts based on where people spend their time: • Grants for school-based health centers • Grants to states, local governments, and community organizations to implement evidence-based, community prevention activities • Specific grants for community health prevention and health promotion activities targeted to individuals ages 55-64, including screenings and referrals

14. Wellness and Prevention that Works for Consumers: Senate Bill • Support for a preventive and public health infrastructure • Creates a preventive medicine and public health training grant program • Establishes a Community Health Center fund to increase investments in centers

15. Wellness and Prevention that Works for Consumers: Senate Bill • Public awareness and education • New fund for national prevention and health promotion strategies • New campaign to make Americans aware of new access to preventive services • Oral health prevention campaign • Breast cancer awareness campaign targeted at young women • New national diabetes prevention campaign and CDC National diabetes “report card”

16. Wellness and Prevention in Health Reform: Takeaway Wellness and prevention= GOOD! Underwriting and insurance discrimination disguised as wellness= BAD!

17. Wellness and Prevention in Health Reform: Resources Families USA Talking Points: “Senate Amendment on Wellness Program Surcharges Jeopardizes Access to Affordable Coverage and Care” http://www.familiesusa.org/assets/pdfs/wellness-amendment-in-senate-bill.pdf Families USA Blog Post: “The Wellness Plan Discrimination Loophole”http://www.standupforhealthcare.org/blog/archives/the_wellness_plan_discrimination_loophole/ HIPAA Rules on Wellness Plans: “Nondiscrimination and Wellness Programs in Health Coverage in the Group Market; Final Rules,’ Federal Register 71, no. 239 (December 13, 2006): 75014-75055. http://www.dol.gov/ebsa/regs/fedreg/final/2006009557.htm