Transcript Slide 1

Health Insurance
Shannon Harr
Camille Pane, MD
Chris Maher
Lauren O’Connor
Tom Miller
Overview
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Insurance
History of National Health Insurance
HR 676
Healthy Americans Act
Florida Quality Care Act
Insurance
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Insurance:
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A contract (policy) in which an individual or entity
receives financial protection, or reimbursement,
against losses from an insurance company, which
pools clients’ risks to make payments more
affordable, in exchange for a premium.
Cost-Sharing
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Pool money
together
“Share the
risk”
Delivery & Financing: Self-Pay
Payment
Patients
Providers
Services
Delivery & Financing:
rd
3
Party
3rd Party
Payers
Patients
Services
Payment
(Deductibles, coinsurance, copays)
Providers
What does all this Really Mean?
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Premium: Amount YOU pay every month
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Deductible: Amount YOU pay after receiving a
service, up to a specified yearly maximum
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Ex: Procedure costs $1000, you pay $500
Coinsurance: % YOU pay after receiving a
service
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Ex: You pay $250 every month for your insurance
plan
Ex: Procedure costs $1000, you pay 30% or $300
Copayment: Amount YOU pay every time you
are seen by a provider
Insurance: Who is Paying?
Government Health Insurance
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Government Health Insurance
 Medicare
 Medicaid
 Military health care
TRICARE/CHAMPUS
 CHAMPVA
 The Department of Veterans Affairs (VA)
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SCHIP
 State-specific plan
 Indian Health Service
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Private Health Insurance
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Private Health Insurance
Employment-based plans
 Direct-purchase plan
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Managed Care
HMO
 PPO
 POS
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47 M Uninsured
History: National Health Insurance
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(1974) President Nixon introduced a National
Health Insurance Program
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Employers would be required to provide private
insurance for their employees, a separate
government system would provide the same benefits
for the rest of the population.
Watergate scandal diverted focus
Ford withdrew the administration's plan saying it
would make inflation worse.
History: National Health Insurance
Continued…
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(1993) Clinton Plan
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Envisioned creating large regional purchasing
alliances that would enroll public and private
employees, the self-employed, the unemployed, and
Medicare and Medicaid patients.
1,364 page bill was very complicated and it was
bad timing with regards to the markets
Universal Coverage
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Personal mandates and subsidies
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Single-payer
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Every American have health insurance that meets some
minimum standard, the gvnt. provides subsidies or tax credits
to the poor to enable them to purchase insurance
Imagine Medicare extended to cover all age groups but
includes coverage for dental services, long-term care,
prescription drugs, and more comprehensive mental health
care.
Universal Vouchers
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Combines publicly funded social insurance for basic care with
competition. Individuals and families would have free choice
of plans and freedom to purchase additional services with
their own after-tax dollars.
HR 676
110th Congress
“A bill to provide for comprehensive health
insurance coverage for all United States
residents, and for other purposes.”
Sponsors
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Introduced by John Conyers, D-MI
Other sponsors:
Kucinich
 Rangel
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Eligibility
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All residents of the U.S. and its territories
No mention is made of legal/illegal immigrant status
 Individuals will be presumed eligible if they present for
services, but will then need to complete an application
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Benefits
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Primary care & prevention
Inpatient & outpatient care
Emergency care
Prescription drugs
DME
Long term care
Mental health & substance abuse services
Dental care (non-cosmetic)
Chiropractic care
Vision care & correction
Hearing services including hearing aids
Benefits/Portability
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Benefits available anywhere in the U.S. through
licensed clinicians
No deductibles, copayments, coinsurance
Private insurers may not sell coverage that
duplicates the basic benefit package
Insurers may, however, sell plans that provide
benefits not offered through the basic benefit
package
Budget
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Operating budget
Clinician payments (FFS)
 Global budgets for institutional providers
 Capitation payments
 Administrative costs
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Capital expenditures
Construction/renovation of health facilities
 Major equipment purchases
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Health professional education budget
Funding
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Existing sources of revenue for health care
Increasing personal tax on top 5% income
earners
Modest & progressive excise tax on payroll/selfemployment income
Small tax on stock/bond transactions
Funding continued
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System savings will provide huge amounts of $$
Significantly reduced overhead
 Monopsony purchasing power for medications
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The Healthy
Americans Act of 2007
…guarantees universal, private health
insurance for ALL Americans.
Sponsor:
Senator Ron Wyden (D, OR)
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Senator since 1996
Served 15 years in U.S. House of Representatives
What is HAA?
A new system in which every American will have
the power to choose a comprehensive, private
health insurance plan in the state of their
residency.
The insurance will be high-quality yet affordable
for every American.
Even if they change, lose, or become too sick to
work at their job, Americans will always have
care.
How does HAA work?
The Healthy Americans Act matches insurers with health care
consumers in a competitive environment.
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This competition should drive down prices
Each state will establish a Health Help Agency (HHA)
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These HHAs will lower admin costs
Also provide unbiased information about competing private health
insurance plans
Determine premium reductions
With these resources, individuals will be able to choose which works
best for them and their families.
Government’s Responsibility:
Ensure every American has and can afford health
insurance:
Through the Health Help Agencies
 Lower premiums and tax deductions
 Individuals will need to verify their enrollment
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Done through interaction with state, local, and federal
government
Eligibility:
All Americans will be covered:
Individual mandate will be implemented
 Must purchase one of the options given by the state
of residency
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Menu of health insurance plans
 Coverage must be equal or greater than BC/BS Standard
Plan used by Congress
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Previous and existing conditions, occupation, genetic
information, gender and age will NOT
impact eligibility or price paid for insurance.
Benefits
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Primary care
Inpatient & outpatient care
Emergency care
Prescription drugs
DME
Mental health & substance abuse services
Dental care (non-cosmetic)
Chiropractic care
Vision care & correction
Hearing services including hearing aids
Wellness and prevention
Not covered:
 Long-term care
How is the insurance Affordable?
One way is to put more money in people’s
pockets:
During first two years, employers who currently
provide health benefits will convert it to higher
wages.
 Employees will use the increase to purchase their
own private health insurance
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How is the insurance Affordable?
For employers who currently do not provide
health benefits:
Required to pay “Employer Shared Responsibility
Payments” (ESRPs)
 After the initial two years, ALL employers will be
required to pay the ESRPs.
 These payments will reflect the ability to pay
according size and type of industry
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What’s wrong with this?
Other Types of Funding:
Subsidies will be offered:
Varying up to 400% above the poverty line
 Full coverage provided to those below 100%
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Employers will contribute through a set equation
related to business size and yearly profits.
Incentives and Rewards
Gives insurers financial incentives:
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Have them invest in prevention and disease management
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Will give individuals more reason to choose their plans, to keep healthy, and
stay with the same insurer
What if large numbers of individuals leave the state?
Rewards individuals and their families when they participate in
wellness programs
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Reduce the monthly premiums
Rewards providers for helping their patients stay healthy
Cost Containment:
Competition will drive down costs and promote quality.
Taxpayers will not be asked to foot the bill for expensive visits to the emergency
room, because:
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Every individual has adequate coverage
They will use prevention and wellness services
Ultimately, the average growth in health care spending will slow by 0.86%
between 2007-2016.
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Results in savings of $1.48 trillion.
Did I miss something?
Average increase in annual rate of health care spending = around 10%
Will slow by 0.86% b/w 2007-2016… so will be equal to 9.14% in 2016
Yet individuals still have wage raises (after the initial spike) of about 3% annually
Proposed Legislation
Florida Quality Care Act
-Group coverage for Floridians until
National Health Insurance or HR 676
implemented
Call to Action
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To stay relevant, Republicans must:
Recognize that universal health coverage is necessary
 Come up with a reasonable and rational plan
 Stay true to the values of:
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Personal responsibility and accountability
 Fiscal Responsibility and accountability
 The importance of the individual
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Out of Necessity…
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Due to existing laws (EMTALA, etc.) the burden
of the uninsured continually falls on hospitals
and physicians
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Not cost-effective or a reasonable allocation of
resources
…Comes Innovation
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Require that everyone in the State of Florida
have health insurance
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Subsidize the insurance for the working poor
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Use Florida’s most abundant natural resource
(tourists) to be the primary funding for this
program
But is it Republican?
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BENEFITS
Coverage for deserving and
eligible Floridians
Resurgence of the small to
mid-sized business sector
Rewards capitalism and
competition
Self-reliance & freedom of
choice
Emphasizes responsibility
and accountability
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COSTS
Citizenship requirement
(keeping with R. values)
Coverage is limited to allow
for universal provision but
can be augmented based on
individual contributions
(choices still remain)
Private health insurance &
drug companies could feel a
squeeze
(Or would they?)
Target Groups
Who to Draw In?
1. Small to mid-sized
business owners &
employees
2. Working Americans on
Cusp- no handouts but
sense of having earned
right to healthcare
Who not to isolate ($$$)
1. Big Pharma
2.
Private Health
Insurance Companies
Handling Big Pharma
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Emphasize that lower prices throughout
industry doesn’t mean less income
More insured= more medication/rx’s
Better coverage reduces need for generics
Kick-backs for research endeavors (i.e., focus
on science, not marketing)
Blame Canada
Private Insurance Co’s
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Private insurance is not eliminated:
Insurance is required for all Floridians.
Florida coverage is optional for those eligible but
those who choose/prefer private insurance can still
have it.
Private insurance can actually expand by focusing on
benefits not covered by statewide insurance system
(ie. cosmetic, preventative care etc…).
Become health investment sources for HSA, LTCSA
and investment options.
Long Live the Entrepreneurial Spirit
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Employers
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Relieves burden from those
who can’t afford to offer
private insurance for all
employees
Employee contributions and
freedom of choice eliminates
the employer “bad guy”
perception
Healthier workers are more
productive workers
More quality employees to
smaller sector as benefit gap
diminishes
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Employees
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Continued coverage for self
and family reduces
unemployment fears
Choose occupations based on
motivation/education, not
benefit packages
Customization and personal
contributions allow for
independent need and longterm care contribution
Your $ doesn’t die with you
Plan Summary
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Provide statewide health insurance coverage for the
working poor.
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$200 individual deductible, max $400/family to offset costs
and prevent abuse
Graduate student tax deductions in amount of deductible to
encourage higher education
Freedom to choose facility and provider with specialist
exception (recommendation required)
Features
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No Cards= Government invasion of privacy (FL
license, ID or birth certificate is enough)
General benefits include 1 annual dental cleaning &
medically necessary dental work, 2 year vision screening
and 1 pair prescription glasses, mental health treatment
and counseling, all physical health needs done through
private physicians (ER visits only as necessary).
Vaccination coverage
80% prescription coverage (rest covered by HSA etc…)
Features Cont…
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Freedom to contribute to HSA account
Freedom to contribute to LTCSA
Freedom to invest in stock market with capital
gains exemptions up to bracket allowances
(brackets based on age, dependents, income)
More Ideas to Incorporate –
Individual Funding & Contributions
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HSA Accounts
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annual rollover
portable
LTCSA
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tax exempt
Portable
Trust
10 year max (C.O.L
increases)
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Encourage Market
Involvement
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allow tax exempt
investments
More Ideas – Financial Benefits for
Organizations Involved
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Limits on liability for health industry
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Limits on malpractice premiums for health
workers
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Financial rewards and tax breaks for biomedical
research
Show Me the Money
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How is it going to get paid for?
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This plan must be distinctly Floridian…
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Therefore, we use Florida’s most abundant
natural resource; which is what?
Tourists
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They come to FL with bags full of money just
itching to spend it.
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In fact, they spent about $62 Billion in 2005.
More Ideas – Consumption-Based
Funding
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In keeping with the spirit of Florida’s tax
system, all funding for this program will come
from consumption taxes
2 cent gas tax
 Toll increases
 Increased luxury tax
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Terms:
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Moral hazard refers to the possibility that the redistribution of risk (such as insurance which
transfers risk from the insured to the insurer) changes people's behavior. For example, a person
whose has health insurance will be less likely to prevent health problems (e.g.: drink and party too
much) because they know the insurance will cover any medical expenses.
Adverse selection refers to a market process in which bad results occur due to information
asymmetries between buyers and sellers: the "bad" products or customers are more likely to be
selected. For example, if health insurance rates increase, healthy people drop coverage and sick
people will keep the insurance causing the pool of insured to only be sick people.
With “community rating," everyone pays the same premium. An insurer using community
rating to set insurance premiums ignores any differences in expected costs among insured groups
or people. If an insurer uses community rating, but people know and use their expected costs to
decide whether or not to buy insurance, then only the sickest people may wind up signing up for
insurance.
Under "modified" community rating, price differences could be based on age and sex. The
remainder of the definition will be the same as regular community rating.
References
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Fuchs, Emanuel. "Health Care Reform: Why?
What? When? How?." Health Affairs 24
(6)(2005): 1399-1414.
"Health Insurance." Health Insurance Wikipedia.
2006. Wikipedia. 28 Mar 2007
<http://en.wikipedia.org/wiki/Health_insur
ance>.
Mahar, Maggie. Money Driven Medicine. New
York, NY: HarperCollins, 2006.
Tourism's Impact on Florida May be Greater than we
Know. Florida TaxWatch. March 8, 2007. Florida
TaxWatch. 28 Mar 2007
References
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“HAA How It Works.” U.S. Senate Website 2006. U.S. Senate. 26
Mar 2007
<http://wyden.senate.gov/Healthy_Americans_Act/HAA_Ho
w_It_Works.pdf>
Klein, Ezra. “The Healthy Americans Act.” The American
Prospect 2006. Prospect Online. 25 Mar 2007
<http://www.prospect.org/weblog/2006/12/post_2260.html>
“MA Health Care Reform Law of 2006!.” Affordable Care
Today 2006. ACT Website. 27 Mar 2007
<http://www.hcfama.org/act/mahealthreformlaw.asp>
References
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Physicians for a National Health Program. Single Payer FAQ.
Retrieved via
http://www.pnhp.org/facts/singlepayer_faq.php?page=all on
March 5, 2007
Woolhandler, S., Himmelstein, D.U. National Health Insurance:
Liberal Benefits, conservative Spending. Retrieved from
Connecticut Coalition for Universal Health Care via
http://cthealth.server101.com/national_health_insurance.htm on
March 5, 2007
Enthoven, A.C., Fuchs, V.R. Employment-Based Health Insurance:
Past, Present and Future. Health Affairs. 2006: 25(6); 1538-1547.
Blumenthal, D. Employer-Sponsored Health Insurance in the
United States--Origins and Implications. NEJM. 2006: 355(1); 8288.