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The 2009/2010 health reform debate Underlying Philosophical argumentsGoals for Health ReformContinuous, Affordable, Universal, Sustainable Effective (CAUSE)PPAC ( Reconciliation): Short-term changesPPAC ( Reconciliation): Middle-term changesLow-income/uninsuredMedicare Privately insuredAssessing PPAC using the CAUSE goalsNext Steps/ The
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1. National Health Policy: CAUSE Goals and the 2010 ReformsApril 27, 2010Osher Lifelong Learning Institute John Amson Capitman, PhD.
Nickerson Professor of Health Policy
Central Valley Health Policy Institute
California State University, Fresno
2. The 2009/2010 health reform debate
Underlying Philosophical arguments
Goals for Health Reform
Continuous, Affordable, Universal, Sustainable Effective (CAUSE)
PPAC (+ Reconciliation): Short-term changes
PPAC (+ Reconciliation): Middle-term changes
Low-income/uninsured
Medicare
Privately insured
Assessing PPAC using the CAUSE goals
Next Steps/ The “devil” in implementation detail
Questions
Health Reform: CAUSE Perspective
3. “Private sector dominant”/ Massachusetts model—approach from outset
No serious debate of Universal/single payer plans
No serious debate of goals for reform
“Card not care” : “health reform” vs “health insurance reform”
Successful lobbying by insurance and pharmaceutical industries
August tea parties---astro-turf and manufactured rage
House and Senate bills passed
Reconciliation after presidential intervention The 2009/2010 Health Reform
4. Health care as:
RIGHT
PRIVILEDGE
RESPONSIBILITY
US historic compromise: All of the above
US compromise: International comparisons
Underlying Political Philosophy Debate
5. IOM Report as basis
Approach based on “real US health system” rather than political philosophy
CAUSE and the goals for reform
Continuous,
Affordable,
Universal,
Sustainable
Effective Health Care CAUSE
6. Failure of prevention adherence
Most spending for chronic disease
Unnecessary burden of poor management of chronic disease
Unnecessary burden of preventable disease
No breaks in coverage/primary care access
Patient centered medical home
Reimburse “cognitive services”
Improved transition management
Continuous
7. About 50 million uninsured and about same number find it unaffordable/inadequate---about ¼ find health care unaffordable
Health care costs biggest source of bankruptcy
Employer coverage has decreased –unaffordable to many small businesses—limits mobility
Keep total health care expense to 10% or less of pre-tax income for those within 500% of poverty
Break link between employment and coverage Affordable
8. Uninsured and inadequately insured have worse health outcomes, increase costs of care for all, increase unequal healthcare burden on low-income communities
Exclusion of demographic (e.g. “undocumented”, young adults) and need (e.g. behavioral health, community long-term care) groups increases overall system costs
Universal access promotes efficiency and public health
Remove demographic and need barriers to care Universal
9. Under current law and practice, Medicare goes broke next decade
AND: health care grows ½ of economy reducing US global position
Establish budget discipline for health care at national, state, and local levels
Change reimbursement systems to promote prevention and efficiency
Use financial transactions tax or FAT (financial activity tax) to finance health care Sustainable
10. Despite spending more, US has poorer health outcomes across life span
Regional, race/ethnic, rural/urban, condition inequalities in care and outcomes
Over-use of high cost/low efficacy services
Low adherence to prevention recommendations
Change reimbursement and tort laws to promote evidence-based and safe practice
Change reimbursement and regulation to promote prevention and “cognitive” services
Address health inequities through financing and regulatory changes Effective
11. Persons 23-26 remain on parents’ plan
New federally-funded high risk pool
Tax credit for small employers to purchase coverage
Private insurance reforms (lifetime cap, cancellations, pre-existing conditions for children, preventive services with no co-pay, reporting on loss ratio and cost increase)
PPAC+ Reconciliation: Short-Term
12. Medicaid expanded to 133% of FPL.
Establish state exchange (uninsured/insured but unaffordable 133-400 %FPL, small business employees) for legal residents.
Subsidized coverage with total exposure less than 10% of pre-tax for 133-200% FPL, but less affordable.
Increased Medicaid rates
Demonstrations, start-up funds, training funds to improve safety-net capacity and effectiveness
PPAC: middle-term changesuninsured/low-income
13. Reduced subsidy for Medicare Advantage plans—Medicare solvent for 15 years
Donut hole in Part D closed by 2020—short-term asssistance
Immediate benefit improvements
Annual physical
No co-pay for preventive services
Improves primary care reimbursement
Transitional care benefits
Bundled payments and other reimbursement reform demonstrations
Comparative effectiveness and payment review commissions
PPAC: middle-term changesMedicare
14. Individual mandate to hold qualifying insurance
Phased-in reforms (guaranteed issue, community rating, maximum out-of-pocket) apply to employer and individual markets
Establishes level of exposure, loss ratios, minimum benefits etc. for qualifying plans
Tort reforms
Medical home demonstration
Comparative effectiveness research
Oversight for premium increases PPAC: middle-term changesprivate insurance
15. PPAC: CAUSE Assessment
16. 1) PPAC leaves health care profit motive intact.
Insurers will seek to limit (unprofitable) enrollment and coverage
Pharmaceutical and other private health care will seek cost increases
Ineffective, high-technology procedures will be pushed
How will CA ensure that abuses actually stop?
Can CA develop public options?
Can CA institute additional practice and payment changes?
2) PPAC leaves undocumented uninsured (at least 200,000 in SJV) a state and local responsibility.
How will CA and local government respond?
Next Stepsthe “devil” in (implementation) detail
17. 3) PPAC increases MediCal eligibility, expands Healthy Families, and creates Exchange but leaves much flexibility in benefits design and administrative process.
How will CA manage new beneficiaries?
How will CA expand safety net services to meet new demand?
4) PPAC will slow but not limit premium rate hikes.
What else can CA do to keep health care affordable?
5) PPAC will promote comparative effectiveness knowledge but not require practice change.
How can CA promote adoption of evidence-based practice?
How can CA promote patient-centered medical home and disease management?
Next Stepsthe “devil” in (implementation) detail