The

case for Health care reform and ACA

Andres Barkil-Oteo Department of Psychiatry Yale University

Outline
Why?: The current state of health and health care in USA What?: Intro to Health Insurance How?: IntroducFon to the Aordable Care Act (ACA)

Value in health care

International Comparison of Spending on Health, 1980 2009

Average spending on health per capita ($US PPP*)
United States Canada Germany France Australia United Kingdom

Total expenditures on health as percent of GDP

8,000 7,000 6,000 5,000

18 16 14 12 10

4,000

8
3,000 2,000 1,000 0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008

6 4 2 0
1980 1982 1984 1986 1988 1990 1992 1994 1996 1998

United States France Germany Canada United Kingdom Australia

2000

2002

2004

2006

* PPP=Purchasing Power Parity. Data: OECD Health Data 2011 (database), version 6/2011. 4 Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

2008

Infant Mortality Rate

Infant deaths per 1,000 live births
NaFonal average and state distribuFon
U.S. average Bottom 10% states Top 10% states

InternaFonal comparison, 2007

12
10.3

11.1 10.2 9.9 9.9 9.6 10.1

10.8 10.0 9.9

7.2

7.0

6.9

6.8

7.0

6.8

6.8

6.9

6.7

6.8

6.8 5.1

5.3

5.1

5.0

4.9

4.8

4.7

4.7

5.0

5.0

5.0

4.0 2.0 2.5 2.6 2.7 3.1

0
n d de lan we ce I S
20 20

Ja

02

19

19

20

20

20

04

20

20

^ Denotes years in 2006 and 2008 NaFonal Scorecards. Data: NaFonal and stateNaFonal Vital StaFsFcs System, Linked Birth and Infant Death Data (AHRQ 20032008; Mathews and MacDorman, 2011); internaFonal comparisonOECD Health Data 2011 (database), Version 06/2011. Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

20

pa

98

99

00

01

03

05

06

07

y a d tes ark ad an wa or an inl Sta nm F N C De ed nit U

Is US Health Really the Best in the World?

Of 13 countries, the United States ranks an average of 12th (second from the bohom) for 16 available health indicators 13th (last) for low-birth-weight percentages 13th for neonatal mortality and infant mortality overall 11th for post neonatal mortality 13th for years of potenFal life lost (excluding external causes) 11th for life expectancy at 1 year for females, 12th for males 10th for life expectancy at 15 years for females, 12th for males 10th for life expectancy at 40 years for females, 9th for males 7th for life expectancy at 65 years for females, 7th for males 3rd for life expectancy at 80 years for females, 3rd for males

Stareld 2000 JAMA

Kaiser: The Uninsured a primer

The Uninsured
Uninsured adults have a 25 percent greater mortality risk than adults with coverage Lack of health insurance is associated with as many as 44 789 deaths per year more than those caused by kidney disease

Wilper et al 2009

Percent of Adults Ages 1964 Uninsured by State

19992000
WA MT OR ID WY NV CA UT CO NE IA IL KS MO TN AR MS TX LA FL AK AK AL GA TX LA FL IN OH WV KY VA NC SC AZ NM OK AR MS AL GA SD ND MN WI MI PA NY MA RI NJ CT DE MD DC NV CA UT CO VT NH ME OR ID WY NE IA IL KS MO TN IN OH WV KY VA NC SC SD WA MT ND MN WI MI PA NY MA RI NJ CT DE MD DC VT NH ME

20092010

AZ

NM

OK

HI

HI

23% or more 19%22.9% 14%18.9% Less than 14%

Data: U.S. Census Bureau, 200001 (revised) and 201011 Current Population Survey ASEC Supplement. Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

Nonelderly Uninsured by Family Work Status, 2010

Part-Time Workers, 16% 1 or More FullTime Workers, 61%

No Workers, 24%

Total = 49.1 million uninsured

Data may not total 100% due to rounding. SOURCE: KCMU/Urban InsFtute analysis of 2011 ASEC Supplement to the CPS.

Uninsured and Underinsured Adults

Percent of adults ages 1964 who are uninsured or underinsured
100
Underinsured* Uninsured during year

Millions of adults ages 1964 who are uninsured or underinsured, 2010

Insured all year, not underinsured Underinsured* Uninsured during year

75

50

52
42 35
9 14

44

102
16

25 26 0
2003 2007 2010

29
28 28

Total: 184 million**

* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income; medical expenses equaled 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. ** Subgroups may not sum to total because of rounding. Data: 2003, 2007, and 2010 Commonwealth Fund Biennial Health Insurance Surveys. 11 Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

Underinsured
62.1% of all bankruptcies have a medical cause. Most medical debtors were well educated and middle class; three quarters had health insurance. The share of bankruptcies ahributable to medical problems rose by 50% between 2001 and 2007 You loose coverage when you loose job, you loose the health insurance when is most needed!

Himmelstein et al 2009

Fuchs NEJM 2012

Iatrogenic events
US esFmates 12 000 deaths/year from unnecessary surgery 7000 deaths/year from medicaFon errors in hospitals 20 000 deaths/year from other errors in hospitals 80 000 deaths/year from nosocomial infecFons in hospitals 106 000 deaths/year from non-error, adverse eects of medicaFons The average number esFmated is 225 000 deaths per year Admission to a hospital is the third leading cause of death in the United States, ater deaths from heart disease and cancer.

Stareld 2000 JAMA

Number of deaths for leading causes of death

1- Heart disease: 599,413 2- Cancer: 567,628 3- Chronic lower respiratory diseases: 137,353 4- Stroke (cerebrovascular diseases): 128,842 5- Accidents (unintenFonal injuries): 118,021

CDC esFmates for 2010

Number of deaths for leading causes of death Modied

1- Heart disease: 599,413 2- Cancer: 567,628 3- Iatrogenic causes during hospital admissions 225,000 4- Chronic lower respiratory diseases: 137,353 5- Stroke (cerebrovascular diseases): 128,842 6-- Accidents (unintenFonal injuries): 118,021

CDC esFmates for 2010

Any room for improvement?

EXECUTIVE SUMMARY

Exhibit 1

Overall Health System Performance

Overall Performance Top Quartile Second Quartile Third Quartile Bottom Quartile Not Populated

Source: Commonwealth Fund Scorecard on Local Health System Performance, 2012.

Fisher et al NEJM 2009

Sutherland et al 2009 NEJM

DierenFal of medicare spending

PaFents in the highest spending regions spend more Fme in the hospital have more frequent physician visits and undergo more MRI procedures CT scans. DiscreFonary decisions by physicians seem to account for most of the regional variaFon in spending (Sutherland et al 2009 NEJM) Medicare will be $660 billion in the hole by 2023. Reducing annual growth in per capita spending from 3.5% (the naFonal average) to 2.4% (the rate in San Francisco) would leave Medicare with a healthy esFmated balance of $758 billion, a cumulaFve savings of $1.42 trillion (Fisher et al 2009 NEJM)

Sutherland et al 2009 NEJM

What about outcomes?

Skinner et al 2006 HA

Sutherland et al 2009 NEJM

Chronic Disease Under Control: Diabetes and Hypertension

U.S. Average
Percent of adults age 18+

By Insurance, 20052008
Percent of nonelderly adults ages 1864

100

19992000 88 79 86

20032004

20072008
85

Private

Public

Uninsured

76

75

72

50
31

50 41

55 49

29

25

0
Diabetes under control* High blood pressure under control**

Diabetes under control*

High blood pressure under control**

*Refers to diabetic adults whose hemoglobin A1c is <9.0% **Refers to hypertensive adults whose blood pressure is <140/90 mmHg. Data: J. M. McWilliams, Harvard Medical School analysis of National Health and Nutrition Examination Survey. Source: Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

Use of Electronic Medical Records

Percent of primary care physicians using electronic medical records
100 99 97 97 96 95 94 94

75

72

68

50 28 25 17

46 37

2000

2006

2009

NETH

NZ

NOR

UK

AUS

ITA

SWE

GER

FRA

CAN

United States

International Comparison, 2009

AUS=Australia; CAN=Canada; FRA=France; GER=Germany; ITA=Italy; NETH=Netherlands; NZ=New Zealand; NOR=Norway; SWE=Sweden; UK=United Kingdom. Data: Commonwealth Fund International Health Policy Survey of Physicians. Source: Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

What is going on here?

The pathways to beher health do not generally depend on beher health care In those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care. Beher health (lower mortality and a higher level of funcFoning) cannot be achieved without paying greater ahenFon to poor Americans

Schroeder 2007 NEJM

What?: Intro to Health Insurance

Truth or cFon on internaFonal health care systems

Wasteful systems run by bureaucrats RaFon care with limited choice and waiFng lists Its all socialized medicine Those systems are too foreign to work in the US

TR Reid The healing of America 2009

Wasteful systems run by bureaucrats?

1920s: non for prot, hospitals run, same premium for all members, all applicants were enrolled and paid the same premium 1945: For prot entered the market: charging more premium, denying coverage The United States is the only advanced democracy with for prot health insurance industry

TR Reid The healing of America 2009

International Comparison of Spending on Insurance Administration, 2009

Percent of NHE* Japana Finland Australiaa Austria Canada Netherlands Switzerland Germany France United Statesb 1.9% 2.1% 3.6% 3.6% 3.7% 4.0% 4.9% 5.4% 7.0% 7.0% Per capita ($US PPP**) $53.6 $63.2 $118.3 $146.8 $153.3 $185.1 $253.2 $221.8 $270.8 $531.5

* NHE = naFonal health expenditures; ** PPP = purchasing power parity. a 2008. b Includes claims administraFon, underwriFng, markeFng, prots, and other administraFve costs; based on premiums minus claims expenses for private insurance. Data: OECD Health Data 2011 (database), Version 06/2011. Source: Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

h)p://,nyurl.com/3ohmvjd

Forbes 2011 h)p://,nyurl.com/7duz7ta

RaFon care with limited choice and waiFng lists?

Percent of adults who could get an appointment on the same or next day when sick or needed medical attention
100 80 75 71 62 50 61 59 53

Waiting Time to See Doctor When Sick or Need Medical Attention, Among Sicker Adults, 2008

43 36

25

NETH

NZ

FRA

UK

GER

AUS

US

CAN

Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalized or had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; UK=United Kingdom; US=United States. Data: 2008 Commonwealth Fund International Health Policy Survey. Source: Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

Access Problems Because of Costs, 2010

Percent of adults who had any of three access problems* in past year because of costs
50

33 25 22 13 14 15

25

10 5 0 6

10

11

UK

NETH

SWE

SWIZ

NOR

FRA

NZ

CAN

AUS

GER

US

* Did not get medical care because of cost of doctors visit; skipped medical test, treatment, or follow-up because of cost; or did not fill Rx or skipped doses because of cost. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; NOR=Norway; SWE=Sweden; SWIZ=Switzerland; UK=United Kingdom; US=United States. Data: 2010 Commonwealth Fund International Health Policy Survey. Source: Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

Its all socialized medicine!

h)p://,nyurl.com/7832fc3

Its all socialized medicine!

Beginning in 1952 the Truman AdministraFon, through Federal Security Administrator Oscar Ewing, had begun advocaFng medical care for the agedwhat would become Medicare. This was a retreat from Trumans earlier calls for universal health care for all Americans. The implacable opposiFon of the AMA and other pressure groups made universal health care an impossible task Opera,on Coee cup: Led by the Womans Auxiliary to the American Medical Associa,on, was an all-out eort to sFmulate as many lehers to Congress opposing socialized medicine and its menace as proposed in the bill

h)p://,nyurl.com/7832fc3

Its all socialized medicine!

"The term ['socialized medicine'] was popularized by a public relaFons rm working for the American Medical AssociaFon in 1947 to disparage President Truman's proposal for a naFonal health care system. It was a label, at the dawn of the cold war, meant to suggest that anybody advocaFng universal access to health care must be a communist. And the phrase has retained its poliFcal power for six decades

TR Reid The healing of America 2009

Health care models

Bismarck model: Germany, Japan, France. Health care providers and payers are private. Insurance paid for through deducFon on payroll. Insurance is non prot, they cover everybody and government regulate premiums and services Beveridge model: NHS in UK. Insurance and providers are paid by the government, healthcare is a Public service like the re department Na,onal health insurance (Single Payer): Canada. Payer is government with government plans, providers are private. Out of Pocket: Many developing countries.

TR Reid The healing of America 2009

Those systems are too foreign to work in the US

For the majority of Americans who get their insurance through their employer, we are Germany. For veterans, we are England For Seniors, we are Canada For the uninsured, we are Cambodia

TR Reid The healing of America 2009

How?

Aordable Care Act (ACA)

Expand health insurance coverage Improve coverage for those with health insurance Improve access to and quality of care Control rising health care costs

Insurance: Three legged stool

Individual mandate

ACA
Guaranteed issue Insurance subsidies

McDonough Inside health reform 2011

Individual mandate

RAND 2012 h)p://,nyurl.com/77mmxgw

Insurance subsidies
Expand Medicaid up to 133% of the poverty level

Create new Health Insurance Exchanges where individuals and small employers can purchase coverage

Provide premium subsidies up to 400% of the poverty level

McDonough Inside health reform 2011

Post-Reform: Projected Percent of Adults Ages 1964 Uninsured by State

20092010
WA MT OR ID WY NV CA UT CO NE IA IL KS MO TN AR MS TX LA FL AK AK AL GA TX LA FL IN OH WV KY VA NC SC AZ NM OK AR MS AL GA SD ND MN WI MI PA NY MA RI NJ CT DE MD DC NV CA UT CO VT NH ME OR ID WY NE IA IL KS MO TN IN OH WV KY VA NC SC SD WA MT ND MN WI MI PA NY MA RI NJ CT DE MD DC VT NH ME

2019 (estimated)

AZ

NM

OK

HI

HI

23% or more 19%22.9% 14%18.9% 8%13.9% Less than 8%

Data: U.S. Census Bureau, 201011 Current Population Survey ASEC Supplement; estimates for 2019 by Jonathan Gruber and Ian Perry of MIT using the Gruber Microsimulation Model for The Commonwealth Fund. Commonwealth Fund NaFonal Scorecard on U.S. Health System Performance, 2011.

Estimated Health Insurance Coverage in 2019

Total Nonelderly PopulaFon = 282 Million

Congressional Budget Office, 2010

Some Uninsured Will Remain

Congressional Budget Oce (CBO) esFmates 23 million uninsured in 2019 Who are they? Immigrants who are not legal residents Eligible for Medicaid but un-enrolled Exempt from the mandate (most because cant nd aordable coverage) Choose to pay penalty in lieu of ge|ng coverage Many remaining uninsured will be low-income

Guaranteed issue/ Insurance reform

ProhibiFon on annual and lifeFme benets cap ProhibiFon of rescissions: rescinding coverage ater a policyholder gets sick. All insurance policies must cover clinical prevenFve health serivces with A or B raFngs Parents can keep their adult children on their health insurance Fll they reaches 26 Cap medical loss raFo to 80% No discriminaFon or preexisFng condiFon exclusions based on health status

McDonough Inside health reform 2011

Financing Health Reform, 2010-2019

Federal savings New revenues

Total Cost = $938 Billion

Savings to Federal Decit = $124 Billion
Congressional Budget Oce, 2010

ACA ImplementaFon Timeline

2010

2011-2013

2014
Medicaid expansion Health Insurance Exchanges Premium subsidies Insurance market rules prohibiFon on denying coverage or charging more to those who are sick, standardized benets Individual mandate Employer requirements

Some insurance market No cost-sharing for changesno cost-sharing prevenFve services in for prevenFve services, Medicare and Medicaid dependent coverage to age Increased payments for 26, no lifeFme caps primary care Pre-exisFng condiFon Reduced payments for insurance plan Medicare providers and Small business tax credits Premium review health plans New delivery system models in Medicare and Medicaid Tax changes and new health industry fees

ACA in acFon
2.5 million young adults are now enrolled in their parents' health insurance 105 million Americans no longer face lifeFme benet caps on their insurance plans 86 million Americans, including those in Medicare and private coverage, have received free prevenFve services such as check-ups and cancer screenings 17 million children can no longer be denied coverage because of pre- exisFng condiFons 3.6 million Medicare seniors have received savings on prescripFon drugs because of the closing of the so-called "donut hole;" in 2011 360,000 small employers used the small employer tax credit to make insurance more aordable for their two million employees.
John McDonough 2011 h)p://,nyurl.com/ 856wj8s

Nearly Half Say They Feel Confused About ACA; Three In Ten Angry; Quarter EnthusiasFc
Percent who say that each of the following describes their feelings about the health reform law:
80%

ACA signed into law on March 23, 2010

Confused

Enthusiastic

Angry

60%

55 44 45

53 47 42 31 43

52 43

50

53 46 47%

40%

30

30

28

31 30

32 30

35 30 32 28

33 30

34 31

34

34

31%

20%

27

28

25%

0%

2010

2011

Source: Kaiser Family Foundation Health Tracking Polls

2012

Apr

May

Jun

Jul

Aug Sep

Oct

Nov Dec

Jan

Feb Mar

Apr

May

Jun

Jul

Aug Sep

Oct

Nov

Dec

Jan

Feb Mar

Now you could be angry or enthusiasFc but denitely not confused!

END