Elizabeth R. Rosenthal, MD Assistant Clinical Professor, AECOM

1. Can We Bring Single Payer toNew York?Gottfried’s New York Health Bill:The Single Payer Plan for New York State Elizabeth R. Rosenthal, MD Assistant Clinical Professor, AECOM Health Caucus for NYS League of Women Voters June 1, 2013

2. Disclosures • Dr. Rosenthal has no relevant financial relationships with commerial interests. • She has recently retired from the private practice of Dermatology. She is a Board member of Physicians for a National Health Program, a non-profit educational and advocacy organization. She receives no financial compensation from PNHP.

3. Acknowledgments • Most of these slides are from a lecture created by Leonard Rodberg, PhD, a founding member of PNHP and the Research director of our NYMetro chapter. You can find the original at: www.pnhpnymetro.org

4. Why Health Care Was On the Agenda: Escalating Cost Average Annual Premiums for Single and Family Coverage, 1999-2011 * Estimate is statistically different from estimate for the previous year shown (p<.05). Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2011.

5. How is private health insurance like a hospital gown? Chances are, your ass isn’t covered!

7. RISE IN PERSONAL BANKRUPTCIES 62% of personal bankruptcies are due to medical expensesand over 75% had health insurance at the outset of their bankrupting illness.* * Himmelstein, et.al. Am J Med, August, 2009

9. The President’s Fateful Choice In creating a reform plan, the President could have chosen to -- build on the public sector, especially Medicare, or -- expand the private sector. He chose to build his program on private insurance: -- leave the basic structure unchanged -- attempt to achieve the goals of health reform by changing the behavior of private insurance companies through regulation.

10. Starting in 2014, state-based insurance “exchanges” offer private insurance to individuals and employers Citizens and legal immigrants required to be insured. Subsidies up to 400% Federal poverty level Medicaid for all below 133% poverty level Affordable Care Act:Now the Health Reform Law of the Land

11. ACA will be implemented over ten years.Beginning now: • Insurance companies required to cover dependent children up to age 26 • No lifetime limits on coverage • Begin closing the Medicare drug benefit “donut hole”, finally closed in 2020 • Government review of insurance premiums • Experimental programs in Medicare to reduce costs (e.g. primary care medical home, accountable care organizations)

12. Starting in 2014:The Insurance Mandate • Citizens and legal immigrants required to be insured. Penalties up to 2.5% of income. • Insurers required to take everyone. • State-based insurance “exchanges” for individuals and small employers • Subsidies up to 400% Federal poverty level so premium is less than 9.5% of income • “Hardship waiver” if premium greater than 8% of income  Can remain uninsured! • Medicaid for all below 133% poverty level

13. Millions Will Remain Uninsured… Millions Note: The uninsured include about 5 million undocumented immigrants. Source: Congressional Budget Office

14. …while Underinsurance becomes the Norm (Average Employer Plan: 87% coverage) 60% 70% 80%

15. Numbers of NYS Uninsured Reduced by 37% -- Still 1.7 million Population figures in thousands of people Source: The Coverage and Cost Effects of Implementation of the Affordable Care Act in New York State, Urban Institute, March 2012

16. More than Half of NYS Funds Will Come from Government Employers 19% Federal Government ( Medicare, Medicaid, ACA subsidies, other) 43% Federal tax subsidy 9% Individual 19% ACA subsidy 2% State and Local Govt (Medicaid, other) 11% Source: Urban Institute

17. There is more “cost sharing”

18. Overall Consequences of ACA • Continued reliance on private insurance • Employment-based insurance largely unchanged • Market competition will determine what health care costs (insurance premiums, co-pays, deductibles) and how it works (payment and denial practices) • Experimental pilot programs to try and reduce system costs Result: The program will make very little difference in the lives of most people. Why? Because there’s no change in the way we will be paying for health care.

19. The Bottom Line The world’s most expensive system will become even more costly Millions will remain uninsured and underinsured Premiums and co-pays will keep climbing Why? Because ACA doesn’t change the way we pay for health care.

20. We Can’t Wait Another 13 Years! We Need Health Reform 2.0 Before the Premium Takes All our Income! Today Source: American Family Physician, November 15, 2005

21. “Kids, your mother and I have spent so much money on health insurance this year that instead of vacation, we’re all going in for elective surgery.”

22. So the Question Is: Can we reform our system so as to achieve what every other advanced country has already accomplished?

23. PNHP’s National Program for Health Care Reform: Conyers’ Expanded and Improved Medicare for All/Single PayerHR 676 Universal - Extend Medicare to everyone Comprehensivebenefits Choice of doctor and hospital No co-pays or deductibles Funded through progressive taxes Cost-effective – Costs less than we now spend and contains future costs

24. Health Care Reform in New York State:Gottfried’s New York Health BillA7860/S5425 Universal coverage Comprehensivebenefits Coordination of care No cost sharing No private insurance Funding by progressive taxes

25. New York Health Eligibility • Every resident of NYS eligible to enroll • No barriers due to age, sex, income, wealth, employment, or health status • No regressive premiums • No co-pays or deductibles

26. New York Health Comprehensive Benefits • Inpatient and Outpatient Hospital Care • Physician Care • Primary & Preventive Care • Prescription Drugs • Dental, Vision, & Hearing Care • Choice of Doctor, including primary care physician (PCP) and specialists, and Hospital

27. New York Health Care Coordination • Innovative measure to achieve higher quality, less costly care • Choice of care coordinator, could be PCP • Assistance in navigating the system, receiving necessary care and follow-up • No gatekeeping or other barriers to care, referral not required • Care coordinator paid by capitation (per capita per month)

28. New York Health Funding • Progressive, graduated payroll tax, 80% employer-paid, 20% employee-paid • Self-employed pay full payroll tax • Surcharge on unearned (non-wage) income • Existing premiums eliminated • Federal funds from Medicare, Medicaid, Family & Child Health Plus – Federal waiver necessary • All funds placed in New York Health Trust Fund

29. New York Health Provider Reimbursement • All providers paid in full byNew York Health, with no copays or other charges to patients • New reimbursement methods will be developed to replace wasteful fee-for-service payments • Rates negotiated with health care provider organizations by New York Health

30. New York Health Administration • New York Health administered within the Department of Health by Commissioner of Health • Commissioner assisted by broadly- representative Board of Trustees

31. New York Health Further Work Needed • Incorporate long-term care, including nursing home care • Develop hospital, physician, nurse practitioner, physician assistant payment methods

32. Vermont is using its Exchange to facilitate transition to Single Payer: New York can, too

33. Building a Forward-looking Insurance Exchange in New York State(statement endorsed by NY Metro Chapter of PNHP, Community Service Society, and 27 other organizations) New York’s Exchange should • encourage the highest quality, most affordable coverage • facilitate movement toward a simplified, more efficient, more broadly inclusive health care system. Administrative Streamlining • Create a single application process for all types of coverage. • Unify and simplify the administration of health care benefits. Create a unified, simplified administrative process for all insurers, patients, and providers. • Integrate private insurance and public programs within the exchange. Improve the transition among existing programs, including the subsidized private insurance and Medicaid

34. Building a Forward-looking Insurance Exchange in New York State (cont.) High Quality, Affordable Care • Promoting comprehensive, standardized benefits with the widest possible provider networks and lowest possible deductibles and co-pays. • Spread risk as widely as possible, incorporating as many plans and users as possible. Require, through new legislation, that all individual and small group insurance be sold through the exchange • Offera true state-run public plan. Start with the Basic Health Plan provided under the ACA for low-income residents, and then incorporate other public plans to compete with inefficient, profit-oriented, private insurers.

35. Building a Forward-looking Insurance Exchange in New York State (cont.) Meet the Needs of All New Yorkers • Make the exchange as immigrant-friendly as possible. Provide support for immigrants that Federal law, so far, does not provide. • Facilitate consumer engagement through the exchange. Help consumers deal with the complexity of the multi-payer health insurance market. Invest in a robust network of community-based Navigators and a strong independent Consumer Assistance Program. • Position New York State to move forward toward the simplified, efficient, high quality health care system that its residents deserve.

36. Recommended Reading • O’Brien ME, Livingston M (editors), 10 Excellent Reasons for National Health Care. New Press, 2008 • Potter W, Deadly Spin: An Insurance Company Insider Speaks Out on How Corporate PR Is Killing Health Care and Deceiving Americans. Bloomsbury Press, 2010 • Reid T.R., The Healing of America. The Penguin Press, 2009 • Angell M, The Truth About The Drug Companies. Random House, 2004