A Changing Paradigm: Implications of the Affordable Care Act and the Medicaid 1115 Waiver Program J. Eric Evans: Sierra Providence Health Network Mano y Corazón Binational Conference of Multicultural Health Care Solutions, El Paso, Texas, September 27-28, 2013

1. A CHANGING
PARADIGM:
IMPLICATIONS OF THE
AFFORDABLE CARE
ACT AND THE
MEDICAID 1115
WAIVER PROGRAM
J. Eric Evans: Sierra Providence Health
Network

2. The Affordable Care Act
• The Patient Protection and Affordable Care
Act (ACA) became law on March 23, 2010
• The ACA makes health insurance coverage a
legal expectation on the part of U.S. citizens
and those who are legally present

3. The Affordable Care Act
• Strengthens existing forms of health
insurance coverage
• Builds a new, affordable health insurance
market for individuals and families who do not
have affordable employer coverage or
another form of “minimum essential coverage”
such as Medicare or Medicaid

4. The Affordable Care Act
In expanding existing coverage, the ACA
restructures Medicaid to cover all citizens and
legal U.S. residents with family incomes less
than 133% of the federal poverty level and to
streamline enrollment

5. The Affordable Care Act
Full implementation occurs on January 1, 2014
• Individual and employer responsibility
provisions take effect
• State health insurance Exchanges begin to
operate
• Medicaid expansions take effect
• Individual and small-employer group
subsidies begin to flow

6. The Affordable Care Act
• The ACA will cut the number of uninsured
Americans by more than half
• Will result in coverage for 94% of the
population
• reducing the uninsured by 31 million people
• increasing Medicaid enrollment by 15 million
• Approximately 24 million people expected to
remain without coverage

7. The Affordable Care Act
The ACA has five major aims:
• The first—and central—aim is to achieve near-
universal coverage and to do so through
shared responsibility among
government, individuals, and employers

8. The Affordable Care Act
• A second aim is to improve the
fairness, quality, and affordability of health
insurance coverage
• A third aim is to improve health-care
value, quality, and efficiency while reducing
wasteful spending and making the health-care
system more accountable to a diverse patient

9. The Affordable Care Act
• A fourth aim is to strengthen primary health-care
access while bringing about longer-term
changes in the availability of primary and
preventive health care
• A fifth aim is to make strategic investments in
the public's health, through both an expansion
of clinical preventive care and community

10. The Affordable Care Act
The Affordable Care Act begins to realign the
health-care system for long-term changes in
health-care quality, the organization and design
of health-care practice, and health information
transparency

11. The Affordable Care Act
• Introduces broad changes into Medicare and
Medicaid
• Empowers both the Secretary of the U.S.
Department of Health and Human Services
(HHS) and state Medicaid programs to test
new modes of payment and service delivery:
• medical homes, payments for episodes of
care, and bundled payments

12. The Affordable Care Act
Changes are intended to:
• Encourage the health-care system and health
professionals work in a more clinically
integrated fashion
• Measure the quality of their care and report on
their performance
• Improve quality outcomes for serious and
chronic health conditions that result in frequent
hospital admissions and readmissions

13. The Affordable Care Act
The law requires nonprofit hospitals to engage in
major community health planning
• Hospitals expected to demonstrate how
investment of resources into the communities
they serve reflects the priorities contained in
their plans
• Agencies and communities assure optimal
use of resources that will be invested in
community planning activities and the

14. Texas 1115 Waiver
Allows the state to expand Medicaid managed
care while preserving hospital funding, provides
incentive payments for health care
improvements, and directs more funding to
hospitals that serve large numbers of uninsured
patients

15. Texas 1115 Waiver Summary
The 1115 waiver provides flexibility for
Texas to expand risk-based managed care
statewide

16. Texas 1115 Waiver Goals
• Expand risk-based managed care statewide
• Support the development and maintenance of
a coordinated care delivery system
• Improve outcomes while containing cost
growth
• Protect and leverage financing to improve and
prepare the health care infrastructure to
increase access to services

17. Texas 1115 Waiver Goals (continued)
• Transition to quality based payment systems
in managed care and in hospital payments
• Provide a mechanism for investments in
delivery system reform including improved
coordination in the current indigent care
system in advance of health care reform

18. A Changing Paradigm
Improving the U.S. health care system requires
simultaneous pursuit of three aims:
• improving the experience of care
• improving the health of populations
• reducing per capita costs of health care

19. THE TRIPLE AIM
• Improving the
experience of care
• Improving the
health of
populations
• Reducing per
capita costs of
health care

20. A CHANGING
PARADIGM:
IMPLICATIONS OF THE
AFFORDABLE CARE
ACT AND THE
MEDICAID 1115 WAIVER
PROGRAM
J. Eric Evans: Sierra Providence Health
Network