Transcript Health Care Reform: What is it and What Does it Mean for Us

Medicare: a Single Payer system in “crisis”?
A Comparison to other U.S. Health Insurance
Systems
Oliver Fein, M.D.
Chair, New York Metro Chapter
Physicians for a National Health Program
Professor of Clinical Medicine and Health Policy
Associate Dean (Affiliations)
Weill Cornell Medical College
([email protected])
Workshop
PNHP National Meeting
New Orleans, LA
November 15, 2014
DISCLOSURES
Dr. Oliver Fein has no relevant financial
relationships with commercial interests
Dr. Oliver Fein is Chair of the NY-Metro Chapter
and past President of Physicians for a National
Health Program (PNHP), a non-profit
educational and advocacy organization. He
receives no financial compensation from PNHP.
PRESENTATION OUTLINE
1. Macroeconomics of Health Care
2. Medicare in Comparison to other
U.S. Health Insurance Programs
3. Comparing Traditional Medicare
to Medicare Advantage
NATIONAL HEALTH
CARE EXPENDITURES
Billions of dollars (% total for year)
Category
1960
2012*
• Personal Health Care
$ 23.3 (85%)
$ 2,360.4
(84%)
• Public Health Activities
$ 0.4
(1%)
$
75.0
(3%)
• Research and Construction
$ 2.6
(10%)
$
160.0
(6%)
• Other
$ 1.2
(4%)
$
198.0
(7%)
TOTAL NHE
$ 27.5 (100%)
$ 2,793.4 (100%)
Per Capita NHE
$ 147
$ 8, 915
NHE as percent of GDP
5.2%
17.2%
* Data for 2012 from Health Affairs: January, 2014;33:67-77
PERSONAL HEALTH CARE
EXPENDITURES
Billions of dollars (% total for year)
Category
1960
2012*
• Hospital care
$ 9.2 (39%)
$ 882.3 (37%)
• Physician services
$ 5.4 (23%)
$ 565.0 (24%)
• Dental
$ 2.0 (9%)
$ 110.9
(5%)
• Other professional services
$ 0.4 (2%)
$ 76.4
(3%)
• Prescription drugs
$ 2.7 (12%)
$ 263.3 (12%)
• Other medical products
$ 2.3 (9%)
$ 95.0
• Nursing home and home health
$ 0.9 (4%)
$ 367.5 (15%)
• Other
$ 0.4 (2%)
$
Total Personal Health Care
$ 23.3 (100%)
$2,360.4 (100%)
* Data for 2012 from Health Affairs: January, 2014;33:67-77
0
(4%)
(0%)
WHO PAYS FOR1 HEALTH
CARE?
Category
Billions of Dollars
% of Total
NHE (minus investments - $160B)
$ 2,633.4
(100%)
Private Funds
$
882.1
(34%)
Private health insurance
$
553.9
(12%)
 Out of pocket payments
$
328.2
(13%)
$ 1,751.4
(66%)
 Medicare
$
572.5
(22%)
 Medicaid
$
421.2
(16%)
 Other Federal**
$
103.8
(4%)
 Other Federal and State***
$
290.8
(11%)
Public Employee health benefits
$
167.6
(6%)
Tax Subsidies
$
195.5
(7%)
Public Funds
Tax-Financed ($ per capita)
$ 5,590
*Data for 2012 from Health Affairs: January, 2014, using the methodology described in Health Affairs 2002;21:88-98
**Includes VA, DOD, CHIP
*** Includes IHS, federal public health, Worker’s Comp., SAMSA, School health, etc.
1
Woolhandler S, Himmelstein, DU. Paying for National Health Insurance—and Not Getting It. Health Affairs. 2002:21;8898
CONCLUSION #1
We are more than half way to a
government financed health care
system!
2011 healthcare spending per capita
US Public Spending for Health Exceeds
Total Spending in Other Nations
$8,950
Data are for 2011
Sources: OECD 2013; Health Affairs 2002 21(4)88
COMPARISON OF US HEALTH INSURANCE PROGRAMS
Medicare
Number enrolled
Eligibility
Means-based
Comprehensive
Coverage
1. Benefits
2. Deductibles
(annual)
3. Co-payments
Actuarial Value
Type of Financing
Progressiveness of
Financing
Administrative
Costs
Type of MD
Payment
Network
Narrowness
Medicaid
Private HI
Employer-based
Private HI
Exchange-based
2014 Federal Poverty Guidelines
Federally facilitated marketplaces will use the 2014 guidelines to determine
eligibility for Medicaid and CHIP (this is effective February 10, 2014).
Household
Size
100%
133%
150%
200%
1
$11,670
$15,521
$17,505
$23,340
2
15,730
20,921
23,595
31,460
3
19,790
26,321
29,685
39,580
4
23,850
31,721
35,775
47,700
5
27,910
37,120
41,865
55,820
6
31,970
42,520
47,955
63,940
7
36,030
47,920
54,045
72,060
8
40,090
53,320
60,135
80,180
250%
$29,175
39,325
49,475
59,625
69,775
79,925
90,075
100,225
300%
400%
$35,010
$46,680
47,190
62,920
59,370
79,160
71,550
95,400
83,730
111,640
95,910
127,880
108,090
144,120
120,270
160,360
Subsidization of Cost Sharing Amounts (for copayments and deductibles): will be made for
parties or below 250% of poverty (currently less than $28,725 for a single adults and $58,875
for a family of four).
It is not clear how any provider will be in a position to know any member’s cost share obligations
at the time of service.
TABLE 4: HOSPITAL COST SHARE AMOUNTS
Metal Product
Deductible
Inpatient
Cost
Share
Outpatient
Cost Share
ED
Cost
Share
Max Annual
Out of
Pocket
$0
$500
$100
$100
$2,000
$600
$1,000
$100
$150
$4,000
Silver
Full Pay
FPL 200% - 250%
FPL 150% - 200%
FPL 100% - 150%
$2,000
$1,750
250
0
$1,500
$1,500
250
100
$100
$100
75
25
$150
$150
75
50
$5,500
$4,000
$2,000
$1,000
Bronze
$3,000
50%
50%
50%
$6,350
Catastrophic*
$6,400
100%
100%
100%
$6,400
Platinum
Gold
*Catastrophic policies cover 3 primary care visits per year at no cost. Catastrophic policies also cover the free
preventive benefits (https://www.healthcare.gov/what-are-my-preventive-care-benefits/)
TABLE 4A: PHYSICIAN SERVICES COST SHARE AMOUNTS
Primary
Care MD
Specialist
MD
Surgeon
MD
Platinum
$15
$35
$100
Gold
$25
$40
$100
Silver
Full Pay
FPL 200% - 250%
FPL 150% - 200%
FPL 100% - 150%
$30
$30
$15
$10
$50
$50
$35
$20
$100
$100
$ 75
$ 25
Bronze
50%
50%
50%
Catastrophic
100%
100%
100%
Metal Product
CONCLUSION #2
U.S. Health Insurance system
is very complex
COMPARISON
• Traditional Medicare
• Medicare Advantage
CONTACTS AND REFERENCES
•
PNHP National: www.pnhp.org
•
PNHP-NY Metro: www.pnhpnymetro.org
•
Bodenheimer TS, Grumbach K. Understanding Health Policy: A Clinical
Approach. McGraw-Hill (2012)
Fein O, Birn AE. (editors). Comparative Health Systems. Am Jour Public Health
(2003) 93: 1-176
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
(2010)
Geyman, J. Health Care Wars: How Market Ideology and Corporate Power are
Killing Americans. Copernicus Healthcare, Friday Harbor, Washington (2012)
Himmelstein, DU, et. al. A Comparison of Hospital Administrative Costs in Eight
Nations: US Costs Exceed All Others by Far. Health Aff (2014) 33:1586-1594.
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