Transcript Health Policy and Politics

US Health Care System:
Its impact on your future practice
and patients
Nancy Cooper
Coordinator, Health Policy Fellowship
February 21, 2014
1
 Medicine
is the #1 industry in the US
 We have the best
• Technology
• Infrastructure
• Medical schools
• Physicians
2
3
“ We are trying to fill
infinite need with finite
resources”
Richard Lamm
Former Governor of Colorado
4
 $2.6 Trillion
in 2010 –
over $8,400 per
person
 5%
of patients
account for half total
spending
Cohen and Uberoi. Differentials in the Concentration
in the Level of Health Expenditures across Population
Subgroups in the U.S., 2010. AHRQ/HHS. August 2013
CMS Office of the Actuary 2011 & Kaiser Family
Foundation report, Health Care
5
White House Office of Management and Budget 2010
6
Half of all children born after 2000
will live to be 100
One in three will develop Type II
diabetes
The Lancet Oct 1, 2009 and National Diabetes Fact Sheet,
Jan 26, 2011
7




Emphasize acute care over
wellness and prevention
Fee for service payment
encourages quantity over
quality
Health disparities among
racial and ethnic minorities
Outcomes are poorer than
countries which spend much
less
8
"In the United States today, we give you all
the care you can afford, whether or not
you need it, as opposed to all the care
you need, whether or not you can afford
it."
Arthur Kellerman, MD, MPH, Emory Medical School
9
Understanding the
US Health Care
System(s):
Evolution or
Intelligent Design?
10
50%
Private Insurance
Employer-based group insurance
or
Single policy
or
Out of Pocket
11
50% State and Federal
Government Insurance
Medicare (elderly)
Medicaid (destitute)
Children’s Health Insurance Program (CHIP)
Veterans Affairs
Indian Health Service
Federal Employees Health Benefit Program




Emergency rooms
Public hospitals
Federally Qualified Health Centers (FQHCs) 145 OR
Migrant worker health centers
$61 B per year in uncompensated care
Urban Institute: Health Care Spending Under Reform: Less Uncompensated Care
and Lower Costs to Small Employers 1/2010
http://findahealthcenter.hrsa.gov/Search_HCC.aspx
13
Employer-sponsored benefits cover 59%


Ave. cost around $15,745 family of four
• Employee pays about $4,316
• Tax-free benefit
Down side?
 Lose your job, lose your insurance
 Health care costs impact profits
 Costs
years
have risen 97% over the past ten
Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2002–2012
14
 Individual
employers
policies for self and small
• $15,000 for individual – after tax dollars
• Harder to get: exclusions and higher prices for pre-existing
conditions
 States control insurance regulations
• Mandates impact cost
• Wide variation in benefits covered: 13 in ID and 70 in VA)
 28 services mandated in Oregon
• Guaranteed issue – no exclusions in NY, NJ, ME, MA, VT
• Community rated – everyone pays same rate in NY, NJ, ME,
MA, VT
Kaiser Family Foundation 2012
http://www.cbs.state.or.us/ins/sehi/mandated_health_provisions.pdf
15
 Health and Human Services
• Medicare (Entitlement >65)
• Medicaid (Eligibility - poor)
• CHIP (Eligibility – near poor kids)
• Indian Health Service


Veterans Affairs/TriCare
Federal Employee Health Benefits Program
(FEHBP)
16
$880 billion budget
Medicare $524 B
Medicaid $243 B fed$
Total CMS $ 767 B
www.hhs.gov
Kaiser Family Foundation 3/17/11
17
 Serves 47 million
• >1 million in AZ
 Four
•
•
•
•
people over age 65
Parts
Part A:
Part B:
Part C:
Part D:
Hospital costs
Physician Services
Medicare Advantage
Rx
www.hhs.cms.gov
Kaiser State Health Facts/Medicare/Oregon. Accessed 10/13
18
 Also
pays $9B for Graduate Medical
Education (GME)
• – med school enrollment increasing but cap on
federally-funded residency slots
19
20
"You’ve got . . . 10,000 new seniors, baby
boomers, becoming eligible for the
entitlement programs" . . . everyday for
the next 18 years.
Rep. Cantor, R-VA
House Majority Leader
Representative Eric Cantor, April 27, 2011, PoliticFact, Richmond Times Dispatch 4/27/11
21
The Silver Tsunami
. . . Enrollment will increase from 47 million to approx 74 million –
number of beneficiaries over age 80 will triple.
Congressional Budget Office 2/1/12
22
 Health
care for 60 million eligible poor
> 133% FPL
• Pregnant women, children, moms
• Medically needy (aged, blind, disabled) and
nursing home care
• 1.5 million in AZ (2010)
 $343 billion per year –
• 2/3 is federal match (FMAP)
• 1/3 paid by states
Kaiser State Health Facts/2009 data
3 out of 5 kids are born on
Medicaid
23
 Takes
up >25% of most state
budgets
 Increases
in unemployment = increases in
eligibility (but decreased state revenue)
 Fairly
generous benefits (mental health, dental
and vision) but access problems due to low
reimbursement
24
25
26
27
 Separation
of powers
 Senate and House: Checks and balances
• Reactive rather than proactive
• Compromise the key to passing policy
• Congress is currently highly partisan
• Change is slow and incremental
28
Even Congress Hates Congress
Approval rating: 9%
“It’s so bad sometimes I
tell people I’m a lawyer,”
Senator Lindsey Graham
(R-S.C.). “I don’t want to be
associated with a body that
in the eyes of your fellow
citizens seems to be
dysfunctional.”
“We’re below sharks and
contract killers,” added
Rep. Trey Gowdy (R-S.C.).
Politico, October 26, 2011/January 2012
US Government Income and Outlay, based on historical tables from the
White House Office of Management and Budget (Table 1.1). *2012 is
estimated by OMB.
http://www.whitehouse.gov/omb/budget/Historicals
30
“I love change except for the part about
doing things differently”
anonymous
“There is nothing more difficult to carry out, nor more doubtful of
success, nor more dangerous to handle, than to initiate a new order
of things. For the reformer has enemies in all those who profit by the
old order, and only lukewarm defenders in all those who would profit
by the new order.”
Machiavelli Rule of Reform
31
32
33%
1.
2.
3.
33%
33%
Yes
No
Don’t know
1
2
3
33
33%
1.
2.
3.
33%
33%
Yes
No
Don’t know
1
2
3
34
33%
1.
2.
3.
33%
33%
Yes
No
Don’t know
1
2
3
35
1.
2.
3.
Yes
No
Don’t know
33%
1
33%
2
33%
3
36
37
38
33%
1.
2.
3.
33%
33%
Yes
No
Don’t know
1
2
3
39
1.
2.
3.
Yes
No
Don’t know
33%
1
33%
2
33%
3
40
1.
2.
3.
Yes
No
Don’t know
33%
1
33%
2
33%
3
41
33%
1.
2.
3.
33%
33%
Yes
No
Don’t know
1
2
3
42
33%
1.
2.
3.
33%
33%
Yes
No
Don’t know
1
2
3
43
1.
2.
3.
Yes
No
Don’t know
33%
1
33%
2
33%
3
44
Health Care System: Before the ACA
Dual
Eligibles
Medicare
Underinsured
Uninsured
Age
Medicaid
65
Retiree
Benefits
Health Care
“On Demand”
EmployerProvided
Managed Care
18
CHIP
Very
Poor
Near Work.
Poor Poor
Middle
Class
Upper- Very
Mid Class Rich
Income
Adam Sheingate, Professor, John Hopkins University Political Science Department, August 2012
Health Care System: After ACA
Dual
Eligibles
Medicare
Health Exchanges
Uninsured
Underinsured
Medicaid Expansion
Age
Medicaid
65
Retiree
Benefits
Health Care
“On Demand”
EmployerProvided
Managed Care
Circa 2012:
Medicaid Exp.,
Health Exch.
18
CHIP
Very
Poor
Near Work.
Poor Poor
Middle
Class
Upper- Very
Mid Class Rich
Income
Adam Sheingate, Professor, John Hopkins University Political Science Department, August 2012

Cover up to 35 million more people
• Individual Mandate (SCOTUS considers the fine a “tax”)
• Employer Mandate
• Insurance Regulation
 Kids covered on parents policy to age 26
 No exclusion for pre-existing conditions
• Health Insurance Exchanges and subsidies
• Changes to Medicaid
 State can choose to include
adults > 137% of FPL
47
 Fill
in donut hole in Medicare Rx
 Reduce Hospital readmissions
 Reduce Medicare premiums
 Increase Medicare preventive services
 Increase access to
Medicaid services
 Increase access and
quality for dual eligibles
48




Accountable Care Organizations
responsible for quality and costs;
can earn “shared savings”
Incentive payments for Patient
Centered Medical Home
$44,000 bonus payment for
adoption and “meaningful use” of
HIT
10% bonus to primary care
physicians and surgeons working
in Health Profession Shortage
Areas (HPSAs)







Cut reimbursement to Medicare
providers
No payment for preventable
readmissions
Reduce payment updates for
hospitals, home health and SNFs
Value-based purchasing
performance and quality
Bundled payment for an episode
of care
Cut reimbursement to Medicare
Advantage (MA) plans
Independent Payment Advisory
Board to reduce rate of spending
49

Invite speakers on key issues
• AOA Dept Gov. Relations
• AACOM Dept Gov. Relations
• Former HPF and TIPS Fellows





Educate yourself
• Monitor, analyze and advocate for issues
Educate elected officials about key issues
Attend DO Day on the Hill – or Visit State Capitol
AACOM Health Policy Internship
Training in Policies Studies Program OGME II and III
50
Generate Discussion
51
52
53