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Health-reform’s near-death experiences

How health reform and medical costs affect Texas and the U.S. DFW Alliance for Healthcare Excellence September 12, 2013. Health-reform’s near-death experiences. Loss of super majority in the Senate Supreme Court challenge Presidential election. Delays, delays and more delays.

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Health-reform’s near-death experiences

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  1. How health reform and medical costs affect Texas and the U.S. DFW Alliance for Healthcare ExcellenceSeptember 12, 2013

  2. Health-reform’s near-death experiences • Loss of super majority in the Senate • Supreme Court challenge • Presidential election

  3. Delays, delays and more delays

  4. Other hurdles? Sloppy implementation • Exchanges: Who will run them? Will they open on time? • Individual mandate: Will it work? • Employer mandate: Will they hang in there? • Medicaid expansion: How many states opt out? • Lawsuits: contraception, employer mandate, subsidies

  5. Where health reform falls short • It became health “insurance” reform • What it does not do: Address the problems of cost and access (Price x Units = Costs)

  6. Health Care Reform in Texas What we’re up against

  7. Present and perennial Texas hurdles • State’s reluctance to expand Medicaid • Low-tax, low-service political culture: 47th in tax expenditures per capita • Budgetary pressures

  8. Full ACA implementation in Texas • Uninsured rate of 23.7% cut in half • 10% in rural counties; 11% in urban counties; 9.5% in suburban counties • If Medicaid is not expanded, uninsured rate would be cut by one-quarter

  9. Myth: It’s ‘Obamacare’ • Fact: Law was shaped and largely paid for by the health-care industry • Prediction: Health-care lobbyists won’t let the law die

  10. Cost shifting: Someone has to pay • Feds to the states • States to hospital districts (especially on ACA • Insurance companies (and providers) to employers • Employers to employees

  11. Unrelenting cost pressures

  12. The wild cards • High-deductible health plans • Accountable care

  13. What drives medical costs? • Overuse of technology • Market power • High prices

  14. Proton beam therapy

  15. Proton beam vs. radiation • Proton therapy: Average $63,511 • Radiation therapy: Average $36,808

  16. It’s the prices

  17. Fewer businesses offer health insurance High poverty: 1 out of 3 counties has at least 20% below the federal poverty line

  18. And in Texas …?

  19. The effect • 25% of Texans have unmet medical needs, which leads the nation

  20. Health Care Cost Growth Affects Living Standards • Family of four with employer coverage—income increased from $76,000-$99,000 (1999-2009) • Health care spending costs consumed almost all • Premiums $490-$1,115/mo. • Out of pockets $135-$235/mo. • If health care costs had increased at rate of inflation, family would have had additional $545/mo. (vs. $95) • Even $95 was “artificial”—tax collections insufficient to cover increases in Federal health care spending

  21. Access problems

  22. Too few doctors • 1 out of 4 are 60 years or older

  23. Primary care increase, 21%; overall increase, 36%

  24. 16,830 primary care physicians in active practice in 2009 68 per 100,000 pop 81:100 K is national average 118 of 254 counties are full HPSAs 26 counties had no primary care physicians in 2009 Texas’ Primary Care Shortage

  25. On track to boost PCPs by 80% … • …until the 82nd legislature gutted the programs

  26. Primary care and the 12-13 budget

  27. Access: The “state” of things • Texas MDs: 202/100K; U.S. 257/100K • Shortages in 36 out of 40 medical specialties

  28. The “state” of Texas GME • 45% of med students leave state • 38% of THOSE preferred not to • Most who leave do not return • $168,000 state investment in each is lost

  29. The “state” of funding healthcare • Hospitals: 8% Medicaid cut in 2011, 2% in 2009 • Hospitals: DSH payments going away, but state refuses to expand Medicaid • Hospitals: $19 billion in Medicare cuts over the next 10 years; Baylor takes $900 million hit • Physicians: 2% cut in Medicaid in 2011 • Physicians: SGR is up again in December 2012

  30. What we’re leaving on the table • $52 billion in federal funding this decade • Each $1 generates an additional $2 • Will cost Texas hospitals $25 billion • Penalties for Texas businesses: $299-$448 million annually • Net of $900 million per biennium savings from state-funded programs • Expansion = 231,000 new jobs by 2016

  31. Texas in 2020 • Number of insured grows 50%, if Perry relents • Waits for new patients could be 90 days

  32. Quality: No where to go but up! • AHRQ: Texas is dead last among the 50 states

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