Review both resources provided below in addition to the assigned readings for this week and reflect on 2 key differences between the UK and US Health systems.
1-What are key opportunities related to advocacy and politics interventions that can be taken by advanced practice nurses to improve our current health system?
Please refer to the resources identified below for details regarding the UK Health System. APA style. 350 words. 3 references
1. US and UK Health System Comparison- https://www.youtube.com/watch?v=R4Y0TKiwNgo
2. Peterson-Kaiser Health System Tracker- https://www.healthsystemtracker.org/chart-collection/quality-u-s-healthcare-system-compare-countries/#item-post-op-clots-better-u-s-comparable-countries
Summary of the American Health Care Act
This summary describes key provisions of H.R. 1628, the American Health Care Act, as approved by the House
of Representatives on May 4, 2017, as a plan to repeal and replace the Affordable Care Act (ACA) through the
Fiscal Year 2017 budget reconciliation process.
American Health Care Act
March 6, 2017; passed by the House of Representatives on May 4, 2017
Repeal ACA mandates (2016), standards for health plan actuarial values (2020),
and, premium and cost sharing subsidies (2020).
Modify ACA premium tax credits for 2018-2019 to increase amount for younger
adults and reduce for older adults; allow tax credits to apply to coverage sold outside
of exchanges and to catastrophic policies. In 2020, replace ACA income-based tax
credits with flat tax credits adjusted for age. Eligibility for new tax credits phases out
at income levels between $75,000 and $115,000
Retain private market rules, including requirement to guarantee issue coverage,
prohibition on pre-existing condition exclusions, requirement to extend dependent
coverage to age 26. Modify age rating limit to permit variation of 5:1, unless states
adopt different ratios, effective 2018. Retain essential health benefits requirement,
with state option to waive. Retain prohibition on health status rating with state
option to waive for individual market applicants who have not maintained continuous
Retain health insurance marketplaces, annual Open Enrollment periods (OE), and
special enrollment periods (SEPs).
Impose late enrollment penalty for people who don’t stay continuously covered.
Establish Patient and State Stability Fund with federal funding of $115 billion over
9 years available to all states, and additional funding of $8 billion over 5 years for
states that elect community rating waivers. States may use funds to provide financial
help to high-risk individuals, promote access to preventive services, provide cost
sharing subsidies, and for other purposes. In 2020, $15 billion of funds shall be used
only for services related to maternity coverage and newborn care, and mental health
and substance use disorders. [For 2018-2026, a further $15 billion is allocated
through the fund for Federal Invisible Risk Sharing Program (reinsurance). This
program is established as part of the fund, though administered by CMS to make
payments directly to health insurers.] In states that don’t successfully apply for
grants, funds will be used for reinsurance program.
Repeal funding for Prevention and Public Health Fund at the end of Fiscal Year
2018 and rescind any unobligated funds remaining at the end of FY 2018. Provide
supplemental funding for community health centers of $422 million for FY 2017
Encourage use of Health Savings Accounts by increasing annual tax free
contribution limit and through other changes
Limit enhanced FMAP for Medicaid expansion to states that adopted the
expansion as of March 1, 2017, and sunset enhanced FMAP for those states as of
January 1, 2020 except for beneficiaries enrolled as of December 31, 2019 who
do not have a break in eligibility of more than 1 month.
Summary of the American Health Care Act 2
Convert federal Medicaid funding to a per capita allotment and limit growth in
federal Medicaid spending beginning in 2020 using 2016 as a base year; provide
state option to receive a block grant for nonexpansion adults and children or only
Add state option to require work as a condition of eligibility for nondisabled,
nonelderly, nonpregnant Medicaid adults.
Prohibit federal Medicaid funding for Planned Parenthood clinics.
No change to Medicare benefit enhancements or provider/Medicare Advantage
plan payment savings.
Repeal Medicare HI tax increase and other ACA revenue provisions.
Tax penalty for not having minimum essential coverage is eliminated effective January
Late enrollment penalty (30% of otherwise applicable premium) applies for individuals
buying non-group coverage who have not maintained continuous creditable coverage.
Current law definition of creditable coverage includes group health plan, health
insurance coverage (including short-term non-renewable coverage), Medicare,
Medicaid, TriCare, Indian Health Service, state high risk pool, FEHBP, other public plan
coverage, and coverage for Peace Corps workers. Continuous coverage is assessed
during a 12-month look back period prior to the date of enrollment in new coverage.
If individual had a lapse in coverage of 63 consecutive days or longer during the look
back period, late enrollment penalty applies during the plan year in which the
individual enrolls in non-group coverage. (For SEP, penalty applies for the remainder
of the plan year). Late enrollment penalty is effective for special enrollments during
the 2018 plan year, for all other enrollments beginning with the 2019 plan year.
Private health plans continue to be required by law to provide certificates of creditable
coverage; however, no requirement for governmental programs (e.g., Medicaid, CHIP,
state high-risk pools) to provide such certificates.
For 2018-2019, modify premium tax credits as follows:
– Increase credit amounts for young adults with income above 150% FPL and
decrease amounts for adults 50 and older above that income level.
– For end of year reconciliation of advance credits, the cap on repayment of
excess advance payments does not apply.
– Tax credits cannot be used for plans that cover abortion.
– Premium tax credits can be used to purchase catastrophic plans.
– Premium tax credits can be used to purchase qualified health plans (i.e.,
covering essential health benefits) sold outside of the exchange, but are not
advance-payable for such plans. Premium tax credits cannot be used to
purchase short term policies or grandfathered or grandmothered individual
health insurance policies sold outside of the exchange.
Starting in 2020, replace ACA income-based tax credits with flat tax credit adjusted
for age. Credits are payable monthly; annual credit amounts are:
– $2,000 per individual up to age 29
– $2,500 per individual age 30-39
– $3,000 per individual age 40-49
– $3,500 per individual age 50-59
– $4,000 per individual age 60 and older
Families can claim credits for up to 5 oldest members, up to limit of $14,000 per
Amounts are indexed annually to CPI plus 1 percentage point.
U.S. citizens and legal immigrants who are not incarcerated and who are not eligible
for coverage through an employer plan, Medicare, Medicaid or CHIP, or TRICARE, are
eligible for tax credit. Married couples must file jointly to claim the credit. In
addition, eligibility for the tax credit phases out starting at income above $75,000
Summary of the American Health Care Act 3
(credit is reduced, but not below zero, by 10 cents for every dollar of income above
this threshold; tax credit reduced to zero at income of $95,000 for single individuals
up to age 29, $115,000 for individuals age 60 and older. For joint filers, credits begin
to phase out at income of $150,000; tax credit reduced to zero at income of
$190,000 for couples up to age 29; tax credit reduced to zero at income $230,000
for couples age 60 or older; tax credit reduced to zero at income of $290,000 for
couples claiming the maximum family credit amount.)
Taxpayers who are also enrolled in qualified small employer health reimbursement
arrangements (HRA) that apply to non-group coverage will have tax credit reduced,
but not below zero, by the amount of the HRA benefit.
Premium tax credit can be applied to any eligible individual health insurance policy
(but not grandfathered or grandmothered policies or short term policies) sold on or
off the exchange. Eligible policies do not include those for which substantially all
coverage is for excepted benefits; policies that cover abortion (with Hyde exceptions)
are not eligible policies. States shall certify plans eligible for the credit. The federal
government must establish a program for making advance payment of tax credits no
later than January 1, 2020; to the greatest extent practicable the program will use
methods and procedures used for the ACA advance payable premium tax credit.
ACA cost sharing subsidies are repealed effective January 1, 2020.
Require guaranteed issue of all non-group health plans during annual open
enrollment. Insurers also must offer 60-day special enrollment periods (SEP) for
individuals after qualifying events. Short-term non-renewable policies can continue to
be sold using medical underwriting.
Continue ACA rating rules, except age rating of 5:1 is permitted starting January 1,
2018, unless states adopt a different ratio. However, states that use Patient and State
Stability Fund grants for high risk pools or reinsurance, or that participate in the
Federal Invisible Risk Sharing Program, can apply to waive community rating (thus
permitting health status as a rating factor) for individual market participants who do
not maintain continuous coverage. Short-term non-renewable policies can continue to
set premiums based on health status.
Prohibition on pre-existing condition exclusion periods is not changed. Short term
non-renewable policies can continue to exclude pre-existing conditions
ACA requirement to cover 10 essential health benefit categories is not changed;
however, starting in 2020, states may apply for waivers to re-define essential health
benefits for health insurance coverage offered in the individual or small group
market. ACA requirement for maximum out-of-pocket limit on cost sharing is not
changed. ACA requirement for plans to be offered at specified actuarial values/metal
levels sunsets on 12/31/2019.
Prohibition on lifetime and annual dollar limits is not changed; however, the
prohibition applies to limits on essential health benefits, which can be changed under
state waiver authority
Requirement for individual and group plans to cover preventive benefits with no cost
sharing is not changed.
Requirement for all plans to apply in-network level of cost sharing for out-of-network
emergency services is not changed
Prohibit abortion coverage from being required. Federal premium tax credits cannot
be applied to plans that cover abortion services, beyond those for saving the life of
the woman or in cases of rape or incest (Hyde amendment). Nothing prevents an
insurer from offering or an individual from buying separate policies to cover abortion
as long as no premium tax credits are applied.
ACA essential health benefit requirement for individual and small group health
insurance policies is not changed, including requirement to cover maternity care as an
essential health benefit; however, EHB can be changed under state waiver authority.
Requirement for individual and group plans to cover preventive benefits, such as
contraception and cancer screenings, with no cost sharing is not changed.
Summary of the American Health Care Act 4
Prohibition on gender rating is not changed
Prohibition on pre-existing conditions exclusions, including for pregnancy, prior C-
section, and history of domestic violence, is not changed.
Prohibit federal Medicaid funding for Planned Parenthood clinics for one year,
effective upon date of enactment. Specifies that federal funds to states including
those used by managed care organizations under state contract are prohibited from
going to such entity.
In states electing Medicaid block grant, family planning would no longer be a
mandatory covered service.
Redefine qualified health plan to exclude any plan that covers abortion services,
beyond those for saving the life of the woman or in cases of rape or incest (Hyde
amendment), effective in 2018
Prohibit federal premium tax credits from being applied to plans that cover abortion
services, beyond Hyde limitations. Disqualify small employers from receiving tax
credits if their plans include abortion coverage beyond Hyde limitations, effective in
2018. Does not prevent an insurer from offering or an individual from buying
separate policies to cover abortion as long as no tax credits are applied.
Modify certain rules for HSAs, changes take effect January 1, 2018 unless otherwise
– Increase annual tax free contribution limit to equal the limit on out-of-pocket
cost sharing under qualified high deductible health plans ($6,550 for self only
coverage, $13,100 for family coverage in 2017, indexed for inflation).
– Additional catch up contribution of up to $1,000 may be made by persons
over age 55. Both spouses can make catch up contributions to the same HSA.
– Amounts withdrawn for qualified medical expenses are not subject to income
tax. Qualified medical expense definition expanded to include over-the-
counter medications and expenses incurred up to 60 days prior to date HSA
– Tax penalty for HSA withdrawals used for non-qualified expenses is reduced
from 20% to 10%, effective January 1, 2017.
States may use Patient and State Stability Fund grants to fund high-risk pools, and for
As part of the Patient and State Stability Fund, establish a new “Federal Invisible Risk
Sharing Program,” (FIRSP), a reinsurance program, which CMS will establish to offset
claims costs of certain high-risk individuals covered by participating individual health
insurance companies. CMS will establish a process for states to operate the program
beginning in 2020.
FIRSP is funded at $15 billion over 9 years (2018 through 2026), plus any other
unallocated funds under the Patient and State Stability Fund (see below). FIRSP will be
administered by CMS and will make direct payments to health insurers in all states.
Neither State application nor matching funding appear to be required for FIRSP. No
later than 60 days after date of enactment, CMS will establish parameters for FIRSP to
operate starting in 2018. Parameters shall include:
– Health status statements will be developed to identify eligible individuals
– In addition, a list of health conditions will be developed; individuals diagnosed
with listed conditions will be automatically eligible individuals
– Health insurers in the individual market may voluntarily qualify other
individuals for the program
– Health insurers will pay a percentage (to be determined by CMS) of the
premium for eligible individuals to FIRSP
– CMS will designate a dollar threshold for claims for eligible individuals, and a
proportion of claims above that threshold, that FIRSP will pay to health
– CMS will also designate a process states can use to take over operation of
FIRSP within their states starting in 2020
Summary of the American Health Care Act 5
FIRSP funds cannot be used to pay for any abortion or to assist in the purchase, in
whole or in part, of health benefit coverage that includes coverage of abortion, except
if the abortion is needed to save the life of the woman or if the pregnancy resulted
from rape or incest.
State exchanges continue, though premium tax credits can be used for eligible non-
group policies regardless of whether they are sold through an exchange. Through
2019, tax credits are only advance payable for policies purchased through an
Single risk pool rating requirement for plans first sold on or after January 1, 2014 is
Requirement to provide dependent coverage for children up to age 26 for all
individual and group policies is not changed.
Minimum medical loss ratio standards for all health plans are not changed.
Requirement for all health plans to offer independent external review is not changed.
Requirements for all plans to report transparency data, and to provide standard, easy-
to-read summary of benefits and coverage are not changed.
Tax penalty for large employers that do not provide health benefits is reduced to
zero, retroactive to January 1, 2016
Wellness incentives permitted under the ACA are not changed
Repeal tax credits for low-wage small employers, effective January 1, 2020. Prohibit
small business tax credits from being used to purchase plans that cover abortions
beyond Hyde limitations, effective in 2018
Codify that the Medicaid expansion is a state option as of January 1, 2020 consisting
of “expansion enrollees” and “grandfathered enrollees”; eliminate option to extend
coverage to adults above 133% FPL effective December 31, 2017; limit the enhanced
match for the Medicaid expansion to 133% FPL to states that adopted expansion as of
March 1, 2017, and sunset enhanced FMAP for those states as of January 1, 2020
(except for grandfathered enrollees who were enrolled through the Medicaid
expansion as of December 31, 2019 and who do not have a break in eligibility of
more than one month).
– Limit the “expansion state” enhanced match rate transition percentage to CY
2017 levels of 80% (instead of phasing up the match to equal the ACA
enhanced match rate by 2020).
Convert federal Medicaid financing to a per capita cap beginning in FY 2020.
– Per enrollee caps for five enrollment groups—elderly, blind and disabled,
children, expansion adults, and other adults—are based on 2016 expenditures
(excluding administrative costs, DSH, Medicare cost-sharing, and safety net
provider payment adjustments in non-expansion states, and certain categories
of individuals, including CHIP, those receiving services through Indian Health
Services, those eligible for Breast and Cervical Cancer services, and partial-
benefit enrollees) divided by full-year equivalent enrollees in each category
and trended forward to 2019 by medical CPI.
– For states opting to adopt the Medicaid expansion after 2016, the per enrollee
amount for this group would be the same as the other adult group under the
per capita cap.
– Per enrollee amounts are adjusted to exclude non-DSH supplemental
– The target expenditures in 2020 are calculated based on the 2019 per
enrollee amounts for each enrollment group adjusted for non-DSH
Summary of the American Health Care Act 6
supplemental payments and increased by an inflationary factor multiplied by
the number of enrollees in each group. In 2021 and beyond, per enrollee
amounts are based on the prior year amounts increased by an inflationary
factor. The inflationary factor for the elderly and blind/disabled groups is
medical CPI plus 1 percentage point. The inflationary factor for children,
expansion adults, and other adults is medical CPI.
– States with medical assistance expenditures exceeding the target amount for a
fiscal year will have payments in the following fiscal year reduced by the
amount of the excess payments.
Decrease per capita cap target medical assistance expenditures by the amount of
certain expenditures required by political subdivisions of certain states that are
unreimbursed by the state beginning in FY 2020 – as written appears to apply only to
New York. 1
Add state option to elect Medicaid block grant instead of per capita cap for certain
populations for a period of 10 fiscal years, beginning in FY 2020 – if option is not
extended at the end of 10 FY period, per capita cap provisions apply.
– States may elect block grant for children and nonexpansion adults or only for
nonexpansion adults. States can set conditions of eligibility (except that
states must cover mandatory pregnant women and children and infants born
to eligible pregnant woman for1 year, depending on the category elected),
– Block grant payments shall only be used for “block grant health care
assistance” instead of “medical assistance” under Title XIX (Medicaid). States
must provide hospital care, surgical care and treatment, medical care and
treatment, obstetrical and prenatal care and treatment, prescribed drugs,
medicines, and prosthetic devices, other medical supplies and services, and
for children under 18, health care (but not Early, Periodic, Screening,
Diagnosis and Treatment services). States determine cost sharing and delivery
system. Federal Medicaid requirements for statewideness, amount, duration,
and scope, reasonable standards for determining eligibility for and the extent
of medical assistance, and free choice of provider do not apply.
– The total block grant amount for the initial FY is based on the state’s target
per capita medical assistance expenditures for the FY multiplied by the
number of enrollees in the category(ies) elected and the federal average
medical assistance matching rate for the state for FY 2019. In subsequent
FYs, the total block grant amount for the prior FY is increased by annual CPI
for urban consumers. The federal portion of block grant funds payable to
states is based on the CHIP enhanced FMAP, with the state funding the
difference. States can rollover unused block grant funds into the next FY as
long as they continue to elect the block grant option. States must contract
with an independent entity to audit its expenditures for each FY to ensure
spending is consistent with these provisions.
– State must submit plan to Secretary, which is deemed approved unless
Secretary determines within 30 days that plan is incomplete or actuarially
Provide 100% FMAP for MMIS and eligibility systems for FY 2018 and FY 2019 and
increase other administrative matching to 60% for expenses related to implementing
new data requirements.
Repeal Medicaid DSH cuts for FY2020 – FY2025; exempt non-expansion states from
DSH cuts for FY2018 – FY 2019
Provide $10 billion over 5 years (FY2018 – FY 2022) to non-expansion states for
safety-net funding (applies to states not adopting the expansion by July 1 of the
previous year). Allotments based on the number of individuals in the State with
income below 138% of FPL in 2015 relative to the total number of individuals with
income below 138% of FPL for all the non-expansion States in 2015. Payments 100%
funded by the federal government in FY 2018-2021 and 95% in FY 2022. Payments to
providers may not exceed providers’ costs in providing health care services to
Summary of the American Health Care Act 7
Medicaid and uninsured patients. States receiving these funds in a year in which they
also adopt expansion shall no longer be eligible to receive these funds in any
Create state option to require work as a condition of eligibility for nondisabled,
nonelderly, nonpregnant Medicaid enrollees as of October 1, 2017, by participating in
work activities as defined in the TANF program 2
for a period of time as determined by
the state and as directed and administered by the state.
– Exempts pregnant women through 60-days post-partum, children under 19,
individuals who are only parent/caretaker relative in family of child under age
6 or child with disability, and individuals under age 20 who are married or
head of household and maintain satisfactory attendance at secondary school
or equivalent or participate in education directly related to employment.
– Provides 5% enhanced federal matching funds for activities carried out by the
state and approved by the Secretary to implement work requirement.
Repeal the essential health benefits requirement for those receiving alternative
benefit packages, including the expansion group, as of December 31, 2019.
Repeal increase in Medicaid eligibility to 138% FPL for children ages 6-19 as of
December 31, 2019. The minimum federal income eligibility limit for these children
will revert to 100% FPL.
Repeal hospital presumptive eligibility provisions and presumptive eligibility for
expansion adults, effective January 1, 2020
Repeal enhanced FMAP for the Community First Choice Option to provide attendant
care services effective January 1, 2020
Prohibit federal Medicaid funding for Planned Parenthood for one year, effective upon
date of enactment
Require states to consider lottery winnings (and other lump sum payments including
gambling winnings and liquid assets from an estate) as income over a period of
months in determining Medicaid ineligibility for individual and spouse beginning,
January 1, 2020. Secretary can establish hardship criteria and state can intercept
lottery winnings for Medicaid recoupment.
Eliminate 3-month retroactive coverage requirement (start eligibility “in or after” the
month of application) beginning October 1, 2017.
Require states to limit home equity to federal minimum (removes the option to
expand the limit from $500,000 to $750,000 (adjusted for CPI), effective six months
after the bill is enacted or longer if states must pass legislation to change.
Require eligibility redeterminations every 6 months for expansion enrollees beginning
October 1, 2017. Expands civil monetary penalties up to $20,000 per individual for
intentionally claiming Medicaid matching funds for an individual not eligible for
expansion. Provide a temporary (10/1/17 through 12/31/19) five percentage point
FMAP increase for expenditures directly related to complying with this provision.
Repeal the HI payroll tax on high earners, beginning after December 31, 2022
Repeal the annual fee paid by branded prescription drug manufacturers, beginning
after December 31, 2016
Reinstate the tax deduction for employers who receive Part D retiree drug subsidy
(RDS) payments to provide creditable prescription drug coverage to Medicare
beneficiaries, beginning after December 31, 2016.
Summary of the American Health Care Act 8
ACA benefit enhancements (no-cost preventive benefits; phased-in coverage in the
Part D coverage gap) are not changed
Reductions to provider and plan payments
ACA reductions to Medicare provider payments and Medicare Advantage payments
are not changed
Other ACA provisions related to Medicare are not changed, including:
Increase Medicare premiums (Parts B and D) for higher income beneficiaries (those
with incomes above $85,000/individual and $170,000/couple).
Authorize an Independent Payment Advisory Board to recommend ways to reduce
Medicare spending if the rate of growth in Medicare spending exceeds a target
Establish various quality, payment and delivery system changes, including a new
Center for Medicare and Medicaid Innovation to test, evaluate, and expand methods
to control costs and promote quality of care; Medicare Shared Savings Accountable
Care Organizations; and penalty programs for hospital readmissions and hospital-
State role States may determine age rating ratio; otherwise federal standard of 5:1 applies.
Establish new Patient and State Stability Fund. Funds can be used by states for
financial help for high-risk individuals, to stabilize private insurance premiums,
promote access to preventive services, provide cost sharing subsidies, for maternity
coverage and newborn care, for mental health and substance use disorder services,
and for other purposes. In states that do not successfully apply for grants, funds will
be used for a default reinsurance program, administered by CMS, that will pay 75% of
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