Health Care Reform: We’re Still Waiting for It

1. Health Care Reform: We’re Still Waiting for It Walter Tsou, MD, MPH PNHP Philadelphia August 2010

2. Outline of Talk • A Brief Health Policy 101 • Health Care Reform • Lessons for America

3. What is the health policy of the United States of America? How much will we spend this year (in dollars) on health care? Two Questions?

4. “Iron Triangle of Health Policy” Access to Care Cost Containment Quality of Care

5. Looking at Costs

6. Health Care Costs at $2.6 Tr in 2010 and almost doubles in 9 years. Total for Decade? $34 Trillion!! 2010 11 12 13 14 15 16 17 18 2019 Source: Projected from Health Spending Projections, Health Affairs, March 2010

7. US spends far more than other countries on health care per capita OECD, Health Expenditures per capita, 1998

8. Looking at Quality

9. 2009 National Healthcare Quality Report • “We find that health care quality in America is suboptimal” Agency for Healthcare Quality and Research, March 2010

10. Looking at Access

11. 50.7 MillionUninsured Source: US Census, 2010

12. Rex Morgan, MD on Personal Bankruptcy

13. 45,000 Adult Deaths Annually Due to Lack of health insurance NY Times, Sept. 18, 2009

14. Health Care Reform: Which Direction?

15. No domestic issue is more divided than health care

16. Democrats Signature Issue for Obama Republicans Plan is too big Government takeover It will influence the midterm election and maybe the presidency Major Stakes for Both Parties

17. Government is the answer Private insurance cannot be trusted Government is the problem Private insurance “works” for 160 million Americans Government or the “free market”?

18. Government Expand Medicare for everyone Private Require everyone to buy private insurance Insurers must be regulated Choosing a pathway for reform?

19. The greatest lobbying effort in history June 29, 2009

20. $1.2 Billion Spent on Health Care Lobbying! Center for Public Integrity, March 26, 2010

21. Health Care Reform: Which Direction?

22. What are the key elements of reform? • You will keep your insurance, whether you like it or not • You will be required to have private health insurance or pay a fine • There will be subsidies for the poor. • There will be a state insurance exchange which will be open to small businesses, self employed, and those not offered employer sponsored insurance starting in 2014 • Changes to Medicare • CLASS act - voluntary purchase long term care insurance? • New regulations on insurers • Immigrants are restricted or banned

23. You will be required to buy private health insurance or pay a fine • Bronze (60% of the cost of care) • Silver (70% of the cost of care) • Gold (80% of the cost of care) • Platinum (90% of the cost of care) • The better the plan, the more it costs • We don’t know the price (several thousand)

24. How much is the fine? • The greater of: • 2014 - $95 or 1% of income • 2015 - $350 or 2% of income • 2016 - $650 or 2.5% of income ($2,085 max)

25. “I am poor, how can I afford this?” • Medicaid up to 133% of poverty paid by the federal govt up to 2017 • Sliding scale cost sharing of 94 - 70% from 133% - 400% of poverty • Unclear what happens to subsidy if you gain or lose a job • $5 billion put in state run high risk pools for those with preexisting conditions

26. This is too confusing, who can help me? • Pick employer plan for those employed • Self employed, small businesses, uninsured can go to a state insurance exchange beginning in 2014 • Very poor get on Medicaid

28. Mass Connector, family of three, cheapest plan

29. Enormous Price Increases Marketwatch, Feb 19, 2010

30. LA Times, April 13, 2010

31. New insurance regulations • No exclusions for preexisting conditions • No medical underwriting • No recissions • No lifetime caps on claims • Children can stay on plan until age 26 • Must pay 80% of income toward claims if small plan, 85% if large plan • Insurers disclose payment policies, ratings

32. Some Republican ideas • Purchase of private insurance • Health Savings Accounts sold in exchanges • State demonstrations on malpractice reform • Restrictions on abortion

33. How to pay for it? • Employer sponsored insurance • Tax “Cadillac” insurance plans after 2018? • Medicare income tax increased to 2.35% • > $200K have to pay on investment income also (3.8%) • Employers > 50 workers fined if workers get insurance through the insurance exchange • Fees on drug and insurance industry • Cuts to Medicare and Medicare Advantage • Independent Payment Advisory Board

34. Source of Insurance Coverage Pre-Reform and Under Affordable Care Act, 2019 34 23 M (8%) Uninsured 24 M (9%) Exchanges (Private Plans) 54 M (19%) Uninsured 16 M (6%) Other 16 M (6%) Other 162 M (57%) ESI 159 M (56%) ESI 10 M (4%) Nongroup 15 M (5%) Nongroup 51 M (18%) Medicaid 35 M (12%) Medicaid Pre-Reform Affordable Care Act Among 282 million people under age 65 * Employees whose employers provide coverage through the exchange are shown as covered by their employers (5 million), thus about 29 million people would be enrolled through plans in the exchange. Note: ESI is Employer-Sponsored Insurance. Source: S. R. Collins, K. Davis, J. L. Nicholson, S. D. Rustgi, and R. Nuzum, The Health Insurance Provisions of the Affordable Care Act: Implications for Coverage, Affordability, and Costs, The Commonwealth Fund, (forthcoming).

35. Health Care Will Become Even More Expensive NY Times, April 23, 2010

36. Major Sources of Cost, Savings and Revenues Compared with Projected Spending, Net Cumulative Effect on Federal Deficit, 2010–2019 Dollars in billions Note: Totals do not reflect net impact on deficit due to rounding. Source: Congressional Budget Office, Letter to the Honorable Nancy Pelosi, Mar. 20, 2010.

38. We have the Most Expensive Health Care System in the World By far . . . Yet we have lower life expectancy than half of the world National Geographic, OECD Health Data 2009

39. Testimony on Why US is an Outlier http://www.c-spanvideo.org/program/294801-1 Go to 1:30 minutes and watch for 3 minutes Barry Anderson, Deputy Director of the CBO, Natl Commission on Fiscal Responsibility, July 28, 2010

40. Jobless Recovery in a Global Economy? • Why would we hire Americans when we have the most expensive health care per capita in the world? • Other countries that provide universal health care have either single payer or the insurers act as a single payer • A country that does not produce things will soon be a second class country

41. What Does It Mean When a Nation Stops Making Things Here?

42. Jobs, jobs, jobs . . . Health care are linked • Employer sponsored insurance is a cost for every employer • In a global economy, jobs follow manufacturing

44. Dramatic Loss of Jobs That May Never Return http://tipstrategies.com/archive/geography-of-jobs/ Move slider to 2007 and click start US Bureau of Labor Statistics

45. 2010 US Debt - $13.2 Trillion! 91% of GDP Gross Debt Debt as % GDP

46. Canada is First of G-7 Countries to Recover from Recession Bloomberg News, July 9, 2010

47. United States $7,300 per capita on health care in 2007 Administrative overhead 31% * Per capita income $46,000 Taiwan $800 per capita on health care in 2007 Administrative overhead 1.6% * Per capita income $30,100 Why US Manufacturers Move Overseas? * Sources: NEJM, August 21, 2003, Bureau of NHI, Taiwan

48. Information technology • Congress has $19 Billion in the economic stimulus bill • Can we do health IT with such a dysfunctional fragmented system?

49. Health IT works when the health system works (Taiwan) http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/view/ Start at 40:00 to 41:00 Frontline, April 2008

50. NY Times, Feb 26, 2010