-- Note: to the extent that annuitants without Part B coverage
decided to elect coverage through the alliances rather than
through Medicare, the estimated penalty and benefit payment costs
would be reduced.
OUTSTANDING ISSUES
-- Although for estimating purposes it was assumed OPM would
pay the penalty amount on an annual basis, no decision has been
made regarding whether the penalty would be paid annually or in a
lump sum.
-- Cost sharing arrangements for the U.S. Postal Service and
the Federal Government for penalty amounts for Postal Service
annuitants.
[Page 49]
BACKUP DOCUMENTATION
(savings negative, costs positive)
(outlays in $ billions)
BUDGET CATEGORY
Federal Employees Health -- coverage for the active workforce
(non-postal).
BUDGET PROJECTIONS
Fiscal Years 1995 1996 1997 1998 1999 2000 1995-00
0.0 0.0 0.0 -0.7 -1.1 -1.5 -3.3
POLICY DESCRIPTION
Federal employees receive coverage through the alliances.
Federal workers residing abroad receive coverage through a
residual FEHBP.
KEY TECHNICAL ASSUMPTIONS
-- Average annual employer-share of premiums under reform (1994
preliminary estimates): $1,546 single; $2,125 married couple
without children; and $2,479 family with children.
-- Government contribution rate for employees abroad at 80% of
a fee-for-service premium.
-- Current Federal workforce is reduced by approximately
252,000 active employees between 1994 and 1999 in accordance with
the President's September 11 memorandum on streamlining
bureaucracy.
OUTSTANDING ISSUES
-- Cost sharing and benefit assumptions for supplemental plans.
-- Assumptions and costs during the transition period (1996
through 1997) for coverage and premium contributions for Federal
workers not currently covered by FEHBP, but who reside in states
that become "participating states" prior to January 1998.
-- No assumption or allowance has been made regarding
disposition of any remaining FEHBP reserve funds.
[Page 50]
Pages 51 - 69
BACKUP DOCUMENTATION
BUDGET CATEGORY
Public Health Service
BUDGET PROJECTIONS: (billions of dollars)
Fiscal Years 1995 1996 1997 1998 1999 2000 1995-2000
Budget Authority 1.1 3.0 3.8 4.2 4.1 3.7 19.9
Total Outlays 0.4 1.5 2.6 3.3 3.7 3.8 15.3
Details of the Public Health Service initiatives planned as part of health reform are shown in the following tables in this section. These budget estimates are presented in terms of proposed Budget Authority. Actual outlays will differ somewhat from the BA because of differences of timing. Total outlays for the PHS initiatives are shown above.
[Page 51]
PUBLIC HEALTH SERVICE
Health Care Reform Budget
Public Health Initiative
(Dollars in Millions)
FY '95 FY '96 FY '97 FY '98
Incrmnt Incrmnt Incrmnt Incrmnt
Program/Activity
Capacity Expansion/Enabling
Community/Migrant Health Cntrs $100 $100 $100 $100
Capacity Expansion 200 500 600 700
Enabling Services 0 200 300 300
Subtotal 300 800 1,000 1,000
Workforce
National Health Service Corps 50 100 200 200
Health Professions 1/ 20 200 200 200
Academic Health Centers 3 4 5 5
Subtotal 73 304 405 405
School-Based Health
School Related Health Services 0 100 275 350
School Health Education 50 50 50 50
Subtotal 50 150 325 400
Health Research Initiatives
Prevention Research (Sect 3201) 400 500 500 500
Health Service Research 150 400 50 600
(Sect. 3202)
Subtotal 550 900 1,000 1,100
Indian Health Supplemental 40 180 200 200
Services
Mental Health & Substance Abuse 100 150 250 250
Public Health Services
Core 12 325 450 550
Priority 0 175 200 200
Subtotal 12 500 650 750
TOTAL $1,125 $2,984 $3,830 $4,205
----------------------- Continued
FY '99 FY 2000 Six Year
Incrmnt Incrmnt Total
Program/Activity
Capacity Expansion/Enabling
Community/Migrant Health Cntrs $100 $100 $600
Capacity Expansion 500 200 2,700
Enabling Services 300 100 1,200
Subtotal 900 400 4,500
Workforce
National Health Service Corps 200 200 950
Health Professions 1/ 100 100 820
Academic Health Centers 5 5 27
Subtotal 305 305 1,797
School-Based Health
School Related Health Services 400 400 1,525
School Health Education 50 50 300
Subtotal 450 450 1,825
Health Research Initiatives
Prevention Research (Sect 3201) 500 500 2,900
Health Service Research 150 600 600 2,850
(Sect. 3202)
Subtotal 1,100 1,100 5,750
Indian Health Supplemental 200 200 1,020
Services
Mental Health & Substance Abuse 250 250 1,250
Public Health Services
Core 650 750 2,737
Priority 200 200 975
Subtotal 850 950 3,712
TOTAL $4,055 $3,655 $19,854
[Page 52]
Health Security Act
Public Health Initiatives
The President's Health Security Act includes a $20 billion initiative over the next 6 years to expand Public Health Service activities that are essential to successful implementation. This initiative begins with $1.25 billion in FY 95, $2.98 billion in FY 1996, grows to $4.2 billion in FY 1998, and levels off at $3.6 billion in FY 2000. The additional resources in FY 1995 and FY 1996 represent an increase of 5 percent and 14 percent respectively over the resources available to PHS in appropriations bills (conference action) for FY 1994.
These PHS initiatives are central to achieving the prevention, access, quality, and cost effectiveness goals articulated in the President's plan. These initiatives, included in Title III and Title VIII of the Health Security Act, are divided into seven major elements:
* Workforce Priorities - A new national council on graduate medical education (GME) is established to allocate specialty positions in a manner that: expands training capacity to support a shift to training 55 percent of new physicians in primary care; expands recruitment and financial assistance programs to increase the number of minority students in the health professions; and supports expansion of priority nurse training initiative including advanced practice nursing, faculty development, school nurse training, and development of data systems.
* Health Research Initiative are expanded to
-- Provide research on prevention and high cost/debilitating diseases (e.g. Alzheimer's disease) and areas such as children's health, breast cancer, and reproductive health and translate advancements into the health delivery system to help control health care costs and improve the quality of life.
-- To accelerate health services research including quality measurement and improvement, efficiency, and effectiveness of the health care delivery system.
* Core Functions of Public Health Programs and Preventive Health - support for public health agencies and community-based organizations to improve the health of populations and to control health care costs through:
[Page 53]
* Core Public Health - to reduce preventable disease and disability and their attendant costs to the personal health care delivery system by supporting states to strengthening their state and local health departments' capacity to carry out core public health functions that protect whole communities from infectious diseases, environmental hazards, and preventable injury and provide population-based prevention education and community mobilization regarding behavioral and environmental risks.
-- National Initiatives Regarding Preventive Health - to achieve measurable reductions in preventable disease, disability. and death by supporting public and private non-profit agencies at the community level to address priorities defined through the Health People 2000 process with community-based, innovative interventions affecting special population groups and involving regional and state variation in level of need.
* Health Services for Medically Underserved Populations - Capacity expansion and enabling initiatives are essential to ensure that underserved populations have access to the services to which they are entitled under the Health Security Act. Activities include support for:
-- the development of practice networks and community-based health plans;
-- information systems and telecommunications linkages;
-- acquisition, construction, or renovation of delivery sites; major equipment purchases; establishing financial reserves; and other capital needs of health care providers;
-- expansion of Community and Migrant Health Centers (C/MHCs); and
-- the provision of outreach and enabling services to ensure that low-income, hard-to-reach, and culturally diverse populations are able to use the health care system effectively;
-- expand from 1,600 to 8,000 by 2005 (when full effects are felt) the number of National Health Service Corps (NHSC) providers available to serve underserved populations;
* Mental Health and Substance Abuse - support is expanded for wrap-around services for the most vulnerable populations of our society, which includes over 2.5 million persons in poverty who are homeless, seriously mentally ill, or diagnosed to have mental health and/or substance abuse problems.
* Comprehensive School-related health activities - by FY 1999 provide health services to 3.2 million students in 3,500 schools with a high proportion of low-income populations. Also, a $50 billion health education program will be implemented for children in grades Kindergarten through 12.
* Indian Health - expand enabling services to help raise the health status of American Indians and Alaskan populations to that of the rest of the United States covered under teh Health Security Act.
[Page 54]
Health Security Act
Public Health Initiative
(Dollars in Millions)
Title III, Subtitle E - Health Services for Medically Underserved Populations
The Community and Migrant Health Center program is a successful program that currently provides a range of primary care, specialty care, and enabling services to 6.8 million American living in Federally-designated underserved areas. Twice as many projects are approved in this program than can currently be funded. An additional investment of $100 million annually over six years will expand the reach of this program to an additional 2 million individuals, meeting 7% of the current unmet capacity needs in underserved areas.
[Page 55]
Health Security Act
Public Health Initiative
(Dollars in Millions)
Title III, Subtitle E - Health Services for Medically Underserved Populations
This transitional program supports capacity expansion in underserved areas in ways that build on existing resources in each community and that are responsive to local circumstances and needs. With a $2.7 billion investment over six years, the program will fully address the estimated need for information system and telecommunications (exclusive of highway costs) in underserved areas; provide all federally-funded and other practitioners in underserved areas with the skills and support the need to form practice networks or health plans; meet most of the need for new practice sites in underserved areas; support renovations to improve the practice environment for 3800 practitioners working in C/MHCs and other existing sites in underserved areas; and address much of the capital needs of rural and public hospitals.
[Page 56]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle E - Health Services for Medically Underserved Populations
This program ensures that low income, hard to reach, culturally diverse populations have access to the services to which they are entitled under reform by providing them with the supplemental services they need to use the health care system effectively. With a $1.2 billion investment over six years, the program will support the provision of transportation, translation, outreach, follow-up, and child-care services to 6 million individuals not served by other programs.
[Page 57]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle E - Health Services for Medically Underserved Populations
The National Health Service Corps assures the availability of physicians and other health professionals in severely underserved rural and urban communities. Of the 72 million Americans who live in underserved areas, 33 million currently lack a regular source of care. The NHSC provides scholarships and repayment of student loans to health professionals who agree to serve at least two years in these areas.
The NHSC would be expanded by increasing the number of NHSC scholarships and loan repayments from approximately 800 in 1994 to 1,800 in 1996 and to 2,800 in 1998 and subsequent years.
The NHSC field strength would grow from its level of 1,600 providers in 1993 to 5,300 providers serving over 8 million people in 1998. NHSC field strength would plateau at about 8,000 providers by the year 2005. Placements are prioritized by severity of need and these providers would serve the most difficult to reach one-third of underserved communities with providers distributed fairly evenly between rural and urban sites.
[Page 58]
Health Security Act
Pubic Health Initiatives
(Dollars in Millions)
Title III, Subtitle A - Workforce Priorities Under Federal Payments
Institutional Costs of Graduate Medical Education: Workforce Priorities
The nation currently trains far too many physicians in specialties and too few in primary care. This distortion of the workforce contributes to the high cost of care. There are also too few mid-level professionals trained and the workforce lacks diversity to assure adequate access to care for all groups in the population.
In a new system with more limited specialty training, the number of new medical school graduates who choose primary care training programs needs to increase from present level of 4,000 per year to 9,000 or 55 percent of all new graduates. Similarly, estimates indicate that the number of mid-level providers should increase from the current 2,500 per year to 5,000 per year. Finally an estimated 23,000 minority students could benefit from expanded recruitment programs, with about 8,500 students in such programs now.
Funds support the transition of physician training to primary care by increasing Federal assistance for primary care programs by 50%. These funds help meet the need for more graduates who choose primary care by supporting faculty and curricula development and expansion of 2,500 additional positions. Mid-level providers will increase to about 4,000 graduates per year to meet 80 percent of the projected need. Minority recruitment programs will expand to reach about 12,500 students each year, about 50% of the projected goal. Support for physician retraining programs will begin an effort to redirect physicians currently trained as specialists into primary care. Expanded support will be provided for a range of nursing programs, including school nurse training, geriatric nursing, development of innovative education and practice models, and other priority nursing projects. Public health training support will also increase.
The Health Security Act establishes formula payments to Academic Health Centers (AHCs) to assist eligible institutions with costs incurred by virtue of their training function. These funds will help cover such costs as: reduced rate of productivity of faculty due to teaching responsibilities; uncompensated costs of clinical research; and exceptional costs including treatment of rare diseases, treatment of unusually sever conditions, and providing other specialized health care.
The President's Health Security Act contemplates stronger ties between academic health centers and providers in urban and rural areas. The Act authorized grants to assist academic health centers establish referral networks and educational alliances in such areas.
* A new Academic Health Center account is established (outside the PHS initiative) to fund these activities as follows: 1996, $3,100 million; 1997 and 1998, $3,200 million; 1999, $3,700 million; and 2000, $3,800 million.
[Page 60]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle G - Comprehensive School Health Education; School Related Health Services
Only 500,000 children in America's middle and high schools have access to school based or school-linked clinics. Yet, according to a 1992 Department of Education survey, 5.4 million students age 10-19 in 9,411 middle and high schools with a high prevalence of poverty and other risk factors (schools where at least thirty percent of the student are eligible for subsidized meals) are estimated to be in need of these services. These young people, who frequently engage in high risk behaviors, experience multiple non-financial barriers to health care. These barriers included reluctance to seek help, lack of parental availability, and lack of knowledge about what help may be available and how to get it. This initiative will improve access to health and psycho-social services to up to 3.2 million children in over 3,500 schools (priority will be given to schools with the highest percentage of children in need) by providing health services where they spend most of their time. As a result of targeting services in high-need areas, there will be a reduction in the preventable morbidity and mortality that children and adolescents experience. Grants to states and local consortia will support the provision of services at sites throughout the country in areas of greatest need.
[Page 61]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle G - Comprehensive School Health Education; School Related Health Services
The health problems that plague our children and adolescents, and the adults they become, are cause primarily by behavioral patterns usually established during youth. Research has shown that initiation of these behaviors can be delayed, reduced, or prevented through school based health education programs. Yet U.S. Department of Education data show only 12 percent of 10th graders and 2 percent each of 11th and 12th graders received any health education credits in school. This initiative will provide grants to every state as well as 20 of the largest Local Education Agencies to enable them to implement comprehensive school health education programs. It contains waiver authority to leverage existing health education monies. State education and health agencies will be expected to collaborate in developing plans targeted to students at highest risk while integrating new funding with existing categorical funding to provide comprehensive health education services.
[Page 62]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle C: Health Research Initiatives
Prevention research is the foundation for clinical preventive services an public health interventions which are integral components of efforts to reduce the burden of avoidable disease, disability, and death. A renewed emphasis on prevention research is necessary to ensure the availability of effective preventive measures against existing disease, as well as new and emerging threats to the health of Americans. Progress in preventing disease will help to offset escalating acute health care costs and the disproportionate impact of disease and disability among women, minorities, and the elderly.
NIH is the Federal Government's lead agency for biomedical and behavioral research and has the expertise to plan, coordinate, and implement a prevention research agenda to support health care reform. Prevention research findings will be translated into, or appropriately integrated with personal health services and public health programs to maximize the impact of prevention research on disease reduction and improved health status.
The Prevention Initiative will contribute to more effective and efficient measures to prevent the onset of disease and disabilities that now affect tens of million of Americans. For example, delaying the onset of Alzheimer's disease by an average of five years would cut in half the costs associated with this disease, currently estimated at $90 billion annually.
[Page 63]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle C: Health Research Initiatives
The DHHS supports a broad based program of investigator-initiated and directed research on cost, quality, and access issues in health care delivery. This research will inform practitioners, managers, purchasers, providers, and consumers under the Health Security Act. The basic principle underlying the President's Health Security Act is that we can provide better quality of care to more people at less cost. To support the achievement of these objectives, DHHS will expand its research program to: 1) develop the science base on what works best in medical care to identify practice variations with unnecessarily high costs and no added clinical benefit; 2) develop quality and performance measures and related information to assist consumers, practitioners, and plans in making good health care decisions; 3) significantly expand medical effectiveness research and practice guidelines development, dissemination and evaluation to improve the treatment decisions made by physicians, thereby contributing to cost-containment by reducing unnecessary care; 4) design and test clinical and administrative data systems and technologies to expedite administrative simplification and lower administrative costs; 5) investigate and assess the organizational, clinical, and financial alternative adopted by states during initial reform to refine and improve subsequent implementation; 6) develop approaches for improving the efficiency and equity of reimbursement and provider payment systems; and 7)determine the impact of improved primary care on access to care.
The IHS provides comprehensive medical and public health services to the 1.3 million American Indians living on reservations. American Indians have among the poorest health status of all Americans: 40% reduction in years of productive life; tuberculosis rate 6 times higher than other Americans; and infant mortality 1.5 times higher than whites. Isolated living conditions, poverty, lack of available public health services, and inadequate access to care will contribute to poorer health status.
Historic legal and ethical obligations require that the Federal Government provide health care and public health services to American Indians and Alaskan Natives. These obligations continue under the Health Security Act. But, health insurance alone will not improve the health of American Indians. Given existing resources only 45% of American Indians receive the necessary personal, community and environmental-based public health services. Only about half of American Indians receive necessary enabling services such as outreach, transportation and translation services.
Additional funding will improve the health status of American Indians to a level closer to other Americans. Funds will increase enabling services by 2.7 million additional home and other visits, one-half million nursing visits and additional transportation and translation services to an additional 240,000 American Indians by FY 1998. Improved services will be targeted to lower rates of diabetes, alcoholism, injuries, and to improve immunization coverage.
[Page 65]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle F - Mental Health; Substance Abuse
While health insurance will cover most direct acute mental health and substance abuse treatment costs, it will not ensure access to services. Research clearly shows that enabling services, such as outreach, transportation, child care, and translation services are necessary to get persons with serious substance abuse and chronic mental health conditions into treatment. Beneficiaries will include 2.5 million persons in poverty who are homeless, seriously mentally ill, or diagnosed to have both mental health and substance abuse problems. This would meet approximately one-quarter of the need nationwide. Funds would be distributed to States using the existing formula for mental health and substance abuse block grants.
[Page 66]
Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle D - Core Functions of Public Health Programs;
National Initiatives Regarding Preventive Health
Part 2 - Core Functions of Public Health Programs
/* This section assesses the investment in prevention and includes projections of savings related to HIV prevention. */
The Health Security Act cannot meet its national cost containment targets if full advantage is not taken of opportunities to prevent unnecessary disease -- opportunities largely accessible through public health programs. These functions are necessary to protect whole communities from infectious disease, environmental hazards, and preventable injury and to provide population-based prevention education and community mobilization regarding behavioral and environmental health risks. Yet the resources available to support the core functions of public health are only about half the level necessary to meet basic responsibilities. Between 1981 and 1993, support for the basic public health functions fell from 1.2% to 0.9% of national health care expenditures. Concurrently, additional demands were imposed on public health agencies by problems such as HIV infection, childhood vaccine-preventable diseases, tuberculosis, violence, and the health and social service needs of young, single mothers and their children. There is a vital need to assist state and local health agencies to rebuild and strengthen their capacity to carry out their basic responsibilities for population-based programs, which have the potential to prevent diseases that otherwise drive up personal health care service utilization and cost billions of dollars to treat. Through this grant program, the Health Security Act will support states and communities to meet approximately 8% of estimated need to repair the eroded infrastructure by the year 2000. The returns to this program in terms of cost savings from reduced disease incidence - even using conservative assumptions -- will substantially exceed the investment.
[Page 67]
The Health Security Act
Public Health Initiatives
(Dollars in Millions)
Title III, Subtitle D - Core Functions of Public Health Programs;
National Initiatives Regarding Preventive Health
Part 3 - National Initiatives Regarding Health Promotion and Disease Prevention
Prevention opportunities related to behavioral risks, physical and social environment, and appropriate use of clinical preventive services have been defined and quantified in the national prevention agenda contained in Healthy People 2000. Through community-based prevention approaches, it is possible to dramatically reduce premature mortality and chronic disease and disability. The need is to support public and not-for-profit agencies in devising approaches that mobilize communities to improve health of whole populations, thus effecting savings to the overall health care system. A competitive grants program will support large-scale, multi-site community-based prevention innovations, with findings from these projects disseminated through public health information network to other communities across the nation. Examples of priorities of this program and prevention of the initiative of Smoking by Children and Youth, prevention and violence, and reduction of behavioral risks contributing to chronic diseases such as heart disease, cancer, stroke, and adult-onset diabetes.
[Page 68]
Public Health Service Off-sets
Many current Public Health Service (PHS) programs provide 'gap-filler' health service to uninsured individuals. Some PHS programs provide direct health services to selected uninsured populations, while others support disease-specific or treatment-specific medical services. For example, PHS grants support State immunization programs.
The Health Security Act assurance of univeral coverage and a comprehensive benefits package directly addresses many of the 'gaps' that PHS fills. The services currently provided piece-meal through public health programs will be covered uniformly under the comprehensive benefits package, such as immunizations. Preventive, mental health and substance abuse services, and many disease-specific services, are covered under the benfits package.
As health reform progresses, there will be an opportunity to redirect PHS resources to higher priority programs
PHS Off-sets
(outlays in $ billions)
FY95 FY96 FY97 FY98 FY99 FY00 FY95-00
Offset/ 0.0 (0.3) (0.9) (1.8) (2.4) (2.6) (8.0)
Redirection OL
[Page 69]
Pages 70 - Glossary
BUDGET CATEGORY
Special Supplememental Food Program for Women, Infants, and Children (WIC)
BUDGET PROJECTIONS (OUTLAYS IN BILLIONS)
Fiscal Years 1995 1996 1997 1998 1999 2000 20001
Increase in 0 .2 .2 .2 .3 .3 .3
regular appropriations
Special fund 0 .2 .4 .4 .4 .4 .4
Total 0 .5* .6 .6 .7 .7 .7
* Total does not add to rounding.
POLICY DESCRIPTION
The Special Supplemental Food Program for Women, Infants, and Chilldren (WIC) has been proven to play a key role in health promotion by providing nutritional supplements to pregnant women and young chiledren. WIC services to pregnant women have been found to reduce medical costs the first 60 days after birth. WIC also increases micronutrient intake among infants and children, thus reducing conditions such as iron deficiency anemia. Fully funding WIC is a strong priority of the President's and builds on our commitment to preventative and primary care. The bill seeks to guarantee full funding for WIC by the end of FY 1996 by creating a special fund to supplement annual appropriations. The amounts in the fund will automatically become available for WIC if appropriations bills include the amounts shown in the first line in the table below.
The cost estimate for the WIC provision in the bill is the difference between current services and full funding.
[Page 71]
BACKUP DOCUMENTATION
(savings negative, costs positive)
(Outlays in $ billions)
BUDGET CATEGORY
Academic Health Centers and Graduate Medical Education
BUDGET PROJECTIONS
FY 1995 1996 1997 1998 1999 2000 '95-00
Gross 5.93 6.3 6.75 8.0 9.5 9.6 46.08
Medicare
Offset -5.9 -3.6 -3.6 -3.6 -4.0 -3.9 -24.6
Net New
Spending 0.03 2.7 3.15 4.4 5.5 5.7 21.48
POLICY DESCRIPTION
The "Gross" spending line represents the policy commitment to Academic Health Centers and Graduate Medical Education support for physicians, nurses, and other health professionals. The Medicare Offset represents proposed law IME and current law DME payments for physicians (DME for nonphysicians is assumed to continue to flow to Academic Health Centers).
KEY TECHNICAL ASSUMPTIONS
The projections of IME/DME dollars are made by OACT consistent with their appraisal of overall health reform and the Medicare savings package in general.
[Page 72]
BACKUP DOCUMENTATION
(savings negative, costs positive)
(outlays in $ millions)
BUDGET CATEGORY
Program for Poverty-Level Children with Special Needs
BUDGET PROJECTIONS
Fiscal Years 1995 1996 1997 1998 1999 2000 1995-2000
0 264 869 2,453 3,025 3,157 9,768
POLICY DESCRIPTION
A new Federally-funded program will provide certain medically necessary and appropriate items and services (that are not in the comprehensive benefit package and are not Medicaid long-term care services) to qualified low-income children.
KEY TECHNICAL ASSUMPTIONS
The estimate assumes that Federal expenditures would be limited to total (Federal and State) Medicaid spending for these services in FY 1993 in participating States, trended forward through the year of implementation for each State by the appropriate growth rates in 9003(a). Thereafter, the annual Federal expenditure limit is trended forward by the growth rates in 9003 (b).
[Page 73]
This estimate includes administrative costs, which are not explicitly accounted for in the legislation. The estimate also differs from the legislation in the calculation of the annual Federal expenditure limit: (1) The estimate trends FY1993 expenditures for wrap-around services by projected spending growth for these services for children; (2)1934 (d)(2)(A)(i) requires that FY1993 spending also be adjusted to take into account annual increases or decreases in the number of qualified children; (3) the legislation requires that FY93 spending for these wrap-around services be trended forward according to a schedule that does not take into account when States become participating States. This estimate applies the trend factors noted in 9003(b) for spending in each State in the year following the year in which it becomes a participating State.
[Page 74]
BACKUP DOCUMENTATION
(savings negative, costs positive)
(outlays in $ millions)
BUDGET CATEGORY
Long-term care: New Federal spending for community-based program
BUDGET PROJECTIONS
Fiscal Years 1995 1996 1997 1998 1999 2000 1995-2000
community 0 4,500 7,800 11,000 14,700 18,700 56,700
LTC program
POLICY DESCRIPTION
The new community-based LTC program is a capped entitlement to States to finance community-based care for the severely disabled (i.e., disability with at least 3 ADLs). The program is not means-tested but includes an income-scaled coinsurance schedule. The Federal matching rate for the program is a approximately 28% higher than current Medicaid FMAP in each State.
KEY TECHNICAL ASSUMPTIONS
Estimates are from ASPE/Lewin-VHI long-term care model, the key components of which are outlined in the attached document. Figures reflect phased-in funding of total program costs according to the following schedule: 20% in 1996, 30% in 1997, 40% in 1998, 50% in 1999, 60% in 2000, 80% in 2001, and 100% in 2002. Thereafter, the capped amounts are trended forward by CPI and the percentage change in the severely disabled population. Absolute capped amounts are derived from the following assumptions (per Lewin-VHI): 3.1 million individuals are eligible for the program; 80% of eligibles participate in the program; elderly participants receive approximately 120 visits per year; physically disabled adults and children receive approximately 122 visits per year; mentally retarded participants receive care 365 days per year. Costs per visit are assumed to be $56 for elderly and physically disabled patients, $85 for mentally retarded (in 1993 dollars). Per ASPE, the capped amounts now include the Federal share of
[Page 75]
administrative costs. No Medicaid offset dollars are included in these capped amounts.
[Page 76]
KEY COMPONENTS OF HOME AND COMMUNITY-BASED CARE PROPOSAL
NUMBER OF ELIGIBLES
1993 estimates in thousands
total -- 3,090
children -- 150
adult physical -- 420
MR/DD -- 270
elderly -- 2,250
The estimates are based on a number of different data
sources used for different age groups in an attempt to use the
best available data source.
* Children -- For persons under age 18, both the 1989
National Health Interview Survey (NHIS) and the 1987
National Medical Expenditure Survey (NMES) were used to
estimate the number of children with at least three of
five ADLs.
* Working-Age Adults -- For persons age 18 to 64, the
1990 Survey of Income and Program Participation (SIPP)
was relied upon to estimate the number of persons who
required help with at least three of five ADLs. SIPP
was also used to estimate the number of persons who
have severe or profound mental retardation or
developmental disabilities (MR/DD). Because SIPP does
not have data on levels of MR/DD, we used data from
Charles Lakin at the University of Minnesota to
estimate the total number of community-dwelling persons
with severe or profound MR/DD (approximately 220,000 in
1990).
* Elderly -- The 1989 National Long Term Care Survey
(NLTCS) was used to estimate the number of elderly who
would be eligible. The NLTCS provides a large sample
of elderly Medicare beneficiaries with disabilities
that have or are expected to last at least three
months. The data were used to estimate the number of
persons with at least three of five ADLs or a similar
level of cognitive impairment. A similar level of
cognitive impairment was defined as: 1) missing four
of ten questions on the Short Portable Mini-Mental
Status Questionnaire (SPMSQ); and 2) demonstrating one
of the following: disability in at least one of the
cognitive Instrumental Activities of Daily Living
(IADLs) of medication management, money management, or
telephoning; evidence of a behavior problem; or
disability in one or more ADLs.
[Page 77]
PARTICIPATION RATE
total -- 77%
children -- 60%
adult physical -- 65%
MR/DD -- 77%
elderly -- 80%
AVERAGE EXPENDITURES
1993 estimates of average expenditures under fully phased-in
program
Average Annual Average Annual
Total Expenditures Public Expenditures
Per Per User Per Per User
Eligible Eligible
TOTAL $9,320 $12,150 $8,415 $10,970
Children $4,100 $6,830 $4,100 $6,830
Adult
Physical $4,440 $6,830 $3,900 $6,000
MR/DD $24,095 $31,290 $24,095 $31,290
Elderly $8,840 $11,100 $7,950 $9,940
CURRENT LAW PROGRAMS AFTER REFORM
Medicare -- assumed unchanged
Other Federal Sources (OAA & VA) -- assumed unchanged
State Supported Programs --
expenditures estimated for severely disabled are
incorporated into match rate on an aggregate basis
$1.7 billion current law state-only spending in 1993
for the eligible population has been distributed among
the states according to the estimated distribution of
MR/DD state-only spending by state
state spending for other populations assumed to remain
unchanged
Medicaid --
In 1993, we estimate $7.1 billion for Medicaid home
and community-based care expenditures; this is less
than HCFA actuaries $8.8 billion and more than the
annualized first three
[Page 78]
quarters of HCFA 64 data at $6.5 billion
One-half of current Medicaid home and community-based
care spending ($3.55 billion) is assumed to be for
persons eligible for the program.
The estimate of one-half of current Medicaid home and
community-based care expenditures for the eligible
population is based on NMES data and HCFA form 64 and
372 data. For Home Health, Personal Care, and Home and
Community-Based Waivers, the distribution among all
elderly, adult disabled and children who are Medicaid
home and community-based care recipients and the subset
that would be eligible for the program is based on 1987
NMES data. These data indicate that approximately 50
percent of Medicaid expenditures are for those meeting
the severely disabled criteria. The split between
MR/DD Medicaid Home and Community-Based Waiver
recipients and others is based on a Congressional
Research Service paper by Richard Price ("Medicaid Home
and Community-Based Care Program," 92-902 EPW). This
report indicated that approximately 65 percent of Home
and Community-Based Care Waiver expenditures in 1991
were for persons with MR/DD. Based on data from the
1987 NMES Institutional sample for residents of small
(beds less than 16) MR facilities, we assumed that 47
percent of these expenditures were for persons with
severe or profound MR/DD (those eligible for the
program).
[Page 79]
BACKUP DOCUMENTATION
(savings negative, costs positive)
(outlays in $ billions)
BUDGET CATEGORY
Net Federal Discount Payments to Alliances (Capped Entitlement)
BUDGET PROJECTIONS
FY 1995 1996 1997 1998 1999 2000 '95-00
Gross
Discounts 0 12.8 35.7 96.3 100.6 103.6 349.0
State
Maintenance
of Effort 0 -2.5 -7.4 -20.6 -21.7 -22.6 -74.9
Net
Discounts 0 10.3 28.3 75.7 78.9 81.0 274.1
POLICY DESCRIPTION
Although all Americans will be asked to contribute to the cost of
their health care, there are some groups that will not be able to
meet their full contribution: low income families, individuals
who have lost their jobs, and small businesses. Low income
households and all firms in regional alliances are eligible for
premium discounts. Low income households without access to low
cost-sharing plans are also eligible for discounts on their
out-of-pocket expenses. There are special discounts for early
retirees as well. No firm in the regional alliance will pay more
than 7.9% of payroll, and small, low-wage firms will pay less,
according to a specified schedule. These numbers also reflect a
direct grant program for state and local governments as employers
($2B over the period). State maintenance of effort payments
(detailed documentation follows this page) to alliances offset
Federal discount payments. The Federal liability is capped at
the Net Discounts amount, to ensure fiscal responsibility.
[Page 80]
Discount eligibility summary:
20% share: households with AGI less than 150%
of poverty, no household pays more
than 3.9% of AGI for this portion;
80% share: households with less than at least
one full-time worker which have AGI
- wages - unemployment compensation
+ tax exempt interest less than
250% of poverty;
out-of-pocket: households with AGI less than 150%
of poverty without access to an
HMO;
7.9% payroll cap: all firms in the regional alliance;
small-firm schedule: firms with fewer than 75 employees
and average wages less than
$24,000. The self-employed are
treated as a firm of size one for
the 80% share.
KEY TECHNICAL ASSUMPTIONS
Discount estimates came from a collaborative estimation process
involving HCFA/OACT, AHCPR, Treasury, and the Urban Institute
models. The actual numbers used were from the HCFA/OACT model.
An additional 15% contingency was added to the point estimate of
the premium discounts. This 15% is an allowance or "cushion" to
cover potential behavioral responses that are difficult to model.
[Page 81]
BACKUP DOCUMENTATION
(savings negative, costs positive)
(outlays in $ millions)
BUDGET CATEGORY
Medicaid: State maintenance-of-effort payments to alliances.
BUDGET PROJECTIONS
Fiscal Years 1995 1996 1997 1998 1999 2000 1995-2000
Each State contributes a maintenance-of-effort (MOE) payment to alliances that is equal to the level previously spent for services in the standard benefit package for non-cash Medicaid recipients and for wrap-around services for children who receive AFDC or SSI benefits. Medicaid will continue to provide emergency services to undocumented persons and current State spending for these services is netted out of the MOE computation.
KEY TECHNICAL ASSUMPTIONS
State phase-in schedule assumes States with 15% of Medicaid spending implement 10/1/95; States with 25% implement 10/1/96; and States with the remaining 60% of spending implement 10/1/97.
[Page 82]
KEY TECHNICAL ASSUMPTIONS (cont.)
The State contribution is based on the State share of spending for non-cash recipients (comprehensive benefits package only); cash children (wrap-around services only); and DSH spending attributable to non-cash recipients in FY 93, trended forward according to national projected growth rates for Medicaid through the first year of implementation. Projected annual growth rates will be those included in section 9003 of the Health Security Act. Following the first year of implementation, the MOE is trended forward according to the 1 + general health care inflation factor (section 6001) multiplied by 1 + the annual percentage increase in the US population that is under age 65. States assumed to phase-in on fiscal year basis.
BACKUP DOCUMENTATION (savings negative, costs positive) (outlays in $ millions)
BUDGET CATEGORY Information Systems and Quality Assurance
The Health Security Act specifies that the Federal government would help develop and maintain the new health information systems and would perform quality assurance activities in the new system.
KEY TECHNICAL ASSUMPTIONS
The estimate includes pricing for the following major administrative functions: support of information systems , support of the National Quality Management Program, and technical assistance to alliances, plans and states. The estimate assumes that, in addition to new resources, existing resources could be used to help support the quality assurance and information collection activities of the National Quality Management Program.
[Page 84]
BACKUP DOCUMENTATION (savings negative, costs positive) (outlays in $ millions)
BUDGET CATEGORY
Monitoring of Alliances and States ADMINISTRATIVE COST BUDGET PROJECTIONS FY1995 FY1996 FY1997 FY1998 FY1999 FY2000 Total FY95-00
Est. Cost 63 120 205 240 250 262 1,140
POLICY DESCRIPTION
The Health Security Act specifies that the Federal government would be responsible for overseeing certain state and alliance functions. Major monitoring activities would include: overseeing the financial operations of alliances, ensuring that plans and alliances adhere to applicable regulatory requirements, and overseeing the premium targets. KEY TECHNICAL ASSUMPTIONS
The estimate assumes a number of Federal auditing functions, and includes costs associated with the hiring and contracting of auditors needed to carry out these activities.
[Page 85]
BACKUP DOCUMENTATION (savings negative, costs positive) (outlays in $ millions)
BUDGET CATEGORY
Program Oversight and Financial Management ADMINISTRATIVE COST BUDGET PROJECTIONS FY1995 FY1996 FY1997 FY1998 FY1999 FY2000 Total FY95-00 Estimated
Cost 301 218 242 293 300 300 1,654
POLICY DESCRIPTION
As reflected in the Health Security Act, the Federal government would be responsible for developing rules/standards for the new system, and managing existing Federal programs within the new system.
KEY TECHNICAL ASSUMPTIONS
The estimate includes several oversight functions of the National Health Board, including: updating the comprehensive benefits package, monitoring new drug prices for consumers, development of enrollment rules for plans, monitoring of alliance grievance procedures, development and management of a risk adjustment factor for premiums in the alliances. The estimate also includes the cost of Federal support for antitrust reform, and fraud and abuse activities.
[Page 86]
BACKUP DOCUMENTATION (savings negative, costs positive) (outlays in $ millions)
BUDGET CATEGORY
Transition to the New System ADMINISTRATIVE COST BUDGET PROJECTIONS FY1995 FY1996 FY1997 FY1998 FY1999 FY2000 Total FY95-00
Estimated
Cost 419 360 393 783 39 39 2,033
POLICY DESCRIPTION
As reflected in the Health Security Act, the Federal government would be responsible for helping states make the transition to the new sytem. The Federal government would help administer planning and implementation grants, issue standards, provide technical assistance and approve state plans. The Federal government would also administer a national risk pool for the uninsured during the period before universal coverage fully phased-in.
KEY TECHNICAL ASSUMPTIONS
The estimate reflects the costs of organizing and maintaining a new National Transitional Health Insurance Risk Pool for uninsured individuals. The cost of administering the risk pool would phase-down as universal coverage is phased-in. The estimate also reflects the administrative costs of processing approvals of state plans and waivers for states opting to implement single payer systems, as well as the cost of state planning and start up grants.
[Page 87]
Glossary of Acronyms
AAPCC Average Adjusted Per Capita Cost
ADL Activities of Daily Living
AFDC Aid to Families with Dependent Children
AHCPR Agency for Health Care Policy and Research
ASPE Assistant Secretary for Planning and Evaluation (HHS)
CABG Coronary Artery Bypass Graft
CBO Congressional Budget Office CEA Council of Economic Advisers
C/MHC Community/Migrant Health Centers
CPI-U Consumer Price Index -- Urban Area
CY Calendar Year
DME Durable Medical Equipment
DoD Department of Defense
DSH Disproportionate Share Payments to Hospitals
ESRD End Stage Renal Disease
FEHBP Federal Employees Health Benefits Program
FMAP Federal Matching Percentage (Medicaid)
FY Fiscal Year
GDP Gross Domestic Product
GME Graduate Medical Education
HCFA Health Care Financing Administration
HCR Health Care Reform
HHS Department of Health and Human Services
HI Hospital Insurance
HIV Human Immuno-Deficiency Virus
HMO Health Maintenance Organization
IADL Instrumental Activities of Daily Living
ICF/MR Intermediate Care Facility/Mentally Retarded (facilities)
(.txt)