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Ramping Up Mobilization for Health Ramping Up Mobilization for Health
Care Reform:Care Reform: The EQUAL Health NetworkThe EQUAL Health Network
Ellen R. Shaffer PhD MPHEllen R. Shaffer PhD MPHJoe Brenner MAJoe Brenner MA
EQUAL Health NetworkEQUAL Health Networkwww.equalhealth.infowww.equalhealth.info
415-922-6204 415-922-6204 ershaffer@gmail.com
APHA Session 281APHA Session 281
Sunday, November 7, 2010 4:00 PM-5:30 M
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 22
Health Care Reform 2010Health Care Reform 2010
Public health organizations and advocates Public health organizations and advocates played active roles in promoting and supporting played active roles in promoting and supporting proposals to expand coverage for health care in proposals to expand coverage for health care in 2009 and 2010, a central matter of social justice.2009 and 2010, a central matter of social justice.The national debate polarized the public and The national debate polarized the public and served as a lightning rod for competing policy served as a lightning rod for competing policy agendas at a time of economic instability. agendas at a time of economic instability. The contentious nature of the debate and the The contentious nature of the debate and the outcome illuminate the importance of outcome illuminate the importance of ramping ramping up mobilizationup mobilization for further progressive reforms. for further progressive reforms.
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 33
Why is This Controversial?Why is This Controversial?
CritiquesCritiques– ““Statist” government takeoverStatist” government takeover– Corporate takeoverCorporate takeover
Significant though limited reformsSignificant though limited reforms– Important to claim and build on victoriesImportant to claim and build on victories– Use policy space to address limitsUse policy space to address limits
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 44
OutlineOutline
What the Affordable Care Act doesWhat the Affordable Care Act does
Conflicting critiquesConflicting critiques
Political and economic contextPolitical and economic context
Wins, losses for ongoing mobilizationWins, losses for ongoing mobilization
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 55July, 2010July, 2010 EQUAL/Center for Policy AnalysisEQUAL/Center for Policy Analysis 55
What HappenedWhat Happened
Patient Protection and Affordable Care Act Patient Protection and Affordable Care Act (PPACA)(PPACA)
The new law takes important steps to expand The new law takes important steps to expand coverage and improve quality, and begins to coverage and improve quality, and begins to control costscontrol costs
Significant though limited reformsSignificant though limited reformsImportant to claim and build on victoriesImportant to claim and build on victoriesUse policy space to address limitsUse policy space to address limits
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 66
A man in his early 20s with a worsening dental infection was unable to afford a dentist. He finally saw a physician who prescribed an antibiotic, but the patient was unable to pay for the prescription. He came to our clinic when the infection had spread to his chest. He died soon after admission. The egregious is commonplace in our non-system. JAMAVol. 286 No. 20, November 28, 2001"Within the System of No-System," Robert L. Ferrer, MD, MPH
Uninsured: Dying from a Toothache Uninsured: Dying from a Toothache in the U.S. in the U.S.
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 77
The Problems:The Problems:People Are SufferingPeople Are Suffering
50 million in U.S. uninsured 50 million in U.S. uninsured
6.7 million uninsured in California6.7 million uninsured in California
44,000 deaths each year due to lack of health 44,000 deaths each year due to lack of health
insuranceinsurance– 1 person died every 12 minutes1 person died every 12 minutes
60% of U.S. bankruptcies due to health costs60% of U.S. bankruptcies due to health costs– 75% of medical bankruptcies happen to people 75% of medical bankruptcies happen to people with with
health insurancehealth insurance
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 88
52%
56%
60%
64%
68%
72%
1979 1985 1991 1997 2003Per
cen
t co
vere
d b
y o
wn
em
plo
yer
insu
ran
ce
Private employer-provided health
insurance
The Great Risk Shift in Health CareThe Great Risk Shift in Health Care69.0%
54.9%
Over 15 percentage point decline
Source: Economic Policy Institute, State of Working America, 2006/2007
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 99
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 1010
Adjusted odds of mortality by Adjusted odds of mortality by race and insurance statusrace and insurance status
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 11111111
ACA: The GainsACA: The Gains Expanded Coverage and AccessExpanded Coverage and Access
Improving QualityImproving Quality
Consumer ProtectionsConsumer Protections
ALL = Lower CostsALL = Lower CostsHow Will We Benefit?How Will We Benefit?
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 12121212
ACA Benefits Phased In ACA Benefits Phased In 2010-20202010-2020
2010-20132010-2013– Consumer protectionsConsumer protections– Affordability and quality improvementsAffordability and quality improvements
2014: Major coverage expansions2014: Major coverage expansions– Health Insurance ExchangesHealth Insurance Exchanges
For individuals, small business employeesFor individuals, small business employeesIndividual Mandate, Employer contributionsIndividual Mandate, Employer contributions
– Medicaid ExpandedMedicaid ExpandedEveryone up to 133% of poverty levelEveryone up to 133% of poverty level
2020: Medicare drug price “doughnut hole” gone 2020: Medicare drug price “doughnut hole” gone
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 1313
Public Health Grant ProgramsPublic Health Grant Programs
Public Education CampaignsPublic Education Campaigns
Centers on Excellence on DepressionCenters on Excellence on Depression
Education and Training Grants & Loan Education and Training Grants & Loan RepaymentRepayment
Community Health CentersCommunity Health Centers
School-based Health ClinicsSchool-based Health Clinics
Community Transformation GrantCommunity Transformation Grant
Early Childhood Home VisitationEarly Childhood Home Visitation
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 14141414
Coverage: NowCoverage: Now
New High Risk Pool: New High Risk Pool: Pre-Existing Pre-Existing Condition Insurance PlansCondition Insurance Plans (for uninsured (for uninsured with pre-existing conditions)with pre-existing conditions)
Covers Young Adults through Age 26 Covers Young Adults through Age 26 on parentson parents’’ coverage coverage
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 1515
Affordability: NowAffordability: Now
Rebates begin to close the Rebates begin to close the Medicare Part D Donut Hole:Medicare Part D Donut Hole:
$250 this year$250 this year
Small business tax credits of up to 35%Small business tax credits of up to 35%
States and feds can reject “unreasonable” States and feds can reject “unreasonable” premiumspremiums
Reduces cost of early retiree coverageReduces cost of early retiree coverage
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 1616
Quality: NowQuality: Now
Free preventive careFree preventive care– Decision point: Will HRSA Decision point: Will HRSA
cover contraception thru cover contraception thru prevention?prevention?
* Exception for * Exception for “Grandfathered plans“Grandfathered plans””
Increased funding Increased funding for Community for Community ClinicsClinics
More money for More money for primary care and primary care and public healthpublic health
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 17171717
Consumer Protections: NowConsumer Protections: Now
Discrimination against children with Discrimination against children with pre-existing conditions prohibitedpre-existing conditions prohibited
Rescissions Illegal (withdrawal of Rescissions Illegal (withdrawal of care)care)
Bans lifetime limits on $ amount of Bans lifetime limits on $ amount of coverage coverage
Annual limits phased outAnnual limits phased out
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 1818
Consumer Protections:Consumer Protections:“Medical Loss Ratio”“Medical Loss Ratio”
80-85% of premium must 80-85% of premium must be spent on health care be spent on health care (vs. admin., profit)(vs. admin., profit)RebatesRebatesCurrent policy debate: Current policy debate:
“ “Wellness programs” run Wellness programs” run by insurance co.s = by insurance co.s = Medical care?Medical care?
oror Marketing? Marketing?
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 19191919
2014: Major coverage 2014: Major coverage expansionsexpansions
Medicaid ExpandedMedicaid ExpandedEveryone up to 133% of poverty levelEveryone up to 133% of poverty level$14,404 for individuals $14,404 for individuals $29,326 for a family of four$29,326 for a family of four
Health Insurance ExchangesHealth Insurance ExchangesFor individuals, small business employeesFor individuals, small business employeesIndividual Mandate, Employer contributionsIndividual Mandate, Employer contributions
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 20202020
Coverage: Medicaid: 2014Coverage: Medicaid: 2014
Will cover everyone up to 133% of poverty Will cover everyone up to 133% of poverty
16 million would be newly covered 16 million would be newly covered (2 million in California will be eligible) (2 million in California will be eligible)
CA: $15,000 individual; $30,400 family of CA: $15,000 individual; $30,400 family of fourfour
Maintains Healthy FamiliesMaintains Healthy Families
Maintenance of Effort til thenMaintenance of Effort til then
Undocumented immigrants generally not Undocumented immigrants generally not coveredcovered
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 21212121
State Insurance Exchanges, 2014: WhoState Insurance Exchanges, 2014: Who
Uninsured individuals, self-employed and small businesses can buy coverage
NOT FOR MEDICARE!!
Safety net for insured who lose a job Applies to Members of Congress
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 2222, , EQUAL Health NetworkEQUAL Health Network 2222
Insurance Reform: Insurance Reform: Limits on Limits on Insurance PremiumsInsurance Premiums
Cannot charge more if: You are sickYou are female (Gender-rating)You are female (Gender-rating)
Age-rating limited, 3:1Age-rating limited, 3:1
No more annual or lifetime limits
Administrative costs limitedAdministrative costs limitedNo underwritingNo underwriting
Easier to compare plansEasier to compare plans
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 2323
Premiums on the ExchangePremiums on the Exchange
Premium contributions limited based on income as Premium contributions limited based on income as a percent of Federal Poverty Level (FPL):a percent of Federal Poverty Level (FPL):
150% FPL ($16,245/yr): $ 68/month150% FPL ($16,245/yr): $ 68/month
200% FPL ($21,660/yr): $113200% FPL ($21,660/yr): $113
250% FPL ($27,075/yr): $191250% FPL ($27,075/yr): $191
300% FPL ($32,490/yr): $ 257300% FPL ($32,490/yr): $ 257
Hardship exemption: Available if lowest cost plan Hardship exemption: Available if lowest cost plan exceeds 8% of an individual’s incomeexceeds 8% of an individual’s income
November 2010 EQUAL Health Network 24
Costs of coverage for subsidy eligible individuals in exchange compared to existing non-group market
(premium and out-of-pocket)
November 2010 EQUAL Health Network 25
Estimated Health Insurance Coverage in 2019
SOURCE: Congressional Budget Office, March 20, 2010
Total Nonelderly Population = 282 Million
Figure 6
Return to KaiserEDU Tutorials
November 2010 EQUAL Health Network 26
Financing Health Reform, 2010-2019
Total Cost = $938 BillionSavings to Federal Deficit = $124 Billion
Source: Congressional Budget Office, 2010
Federal savings
New revenues
Figure 15
Return to KaiserEDU Tutorials
November 2010 EQUAL Health Network 27
National Deficit With and Without Health Reform
$1,100,000,000,000
$1,150,000,000,000
$1,200,000,000,000
$1,250,000,000,000
$1,300,000,000,000
$1,350,000,000,000
$1,400,000,000,000
$1,450,000,000,000
2008 2010 2012 2014 2016 2018 2020
Year
Fede
ral D
efic
it
With Health Reform
Without Health Reform
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 28282828
Significant LimitsSignificant Limits
Reproductive Health – Retreat from Reproductive Health – Retreat from current lawcurrent law– Contraception (High-risk pools)Contraception (High-risk pools)– Abortion care (Exchanges)Abortion care (Exchanges)
ImmigrantsImmigrants’’ inclusion: Undocumented inclusion: Undocumented cannot purchase thru Exchangecannot purchase thru ExchangeAffordabilityAffordabilityState options for innovative approaches State options for innovative approaches – Single payerSingle payer
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 2929
ACA: Political ViewsACA: Political Views
Expands government role in assuring and Expands government role in assuring and providing coverage and regulating providing coverage and regulating insuranceinsurance
Concessions from drug, insurance, Concessions from drug, insurance, hospital industrieshospital industries
Civil society lost on important issuesCivil society lost on important issues
But finance capital still vehemently But finance capital still vehemently opposedopposed
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3030July, 2010July, 2010 EQUAL/Center for Policy AnalysisEQUAL/Center for Policy Analysis 3030
Always a Tough RoadAlways a Tough Road
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3131
Health Care Considered #1 Drag Health Care Considered #1 Drag on Economy- Until Fall, 2008on Economy- Until Fall, 2008
Speculative bubbles burstSpeculative bubbles burst– Houses/real estateHouses/real estate– FinanceFinance
WarsWars
Tax breaks for wealthyTax breaks for wealthy– Redistribution of incomeRedistribution of income– Reverse Robin HoodReverse Robin Hood
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3232
Unemployment by Race, Unemployment by Race, Dec. 2007- Aug. 2010Dec. 2007- Aug. 2010
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3333
Home Prices Jan. 96 – June 2010Home Prices Jan. 96 – June 2010
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3434
Income Inequality 1979-2005: EPIIncome Inequality 1979-2005: EPI
Bottom fifth of households: average, inflation-Bottom fifth of households: average, inflation-adjusted income growth of just $200 over the adjusted income growth of just $200 over the entire 26-year period.entire 26-year period.By contrast, a small number of households at By contrast, a small number of households at the top 0.1% of the income scale saw average the top 0.1% of the income scale saw average income growth of almost $6 million over the income growth of almost $6 million over the same time.same time.1947 and 1973: income growth was distributed 1947 and 1973: income growth was distributed roughly equally, with the poorest 20% of families roughly equally, with the poorest 20% of families seeing income growth at least as fast as the seeing income growth at least as fast as the richest 20% richest 20%
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3535
Contending ForcesContending Forces
Wall Street/Finance capitalWall Street/Finance capital– Now own/direct many corporationsNow own/direct many corporations
Agenda: Agenda: – Reduce regulation, standard of livingReduce regulation, standard of living– Cut taxes, cut public sectorCut taxes, cut public sector
The Public/Civil societyThe Public/Civil society– Want jobs, accountable businesses and Want jobs, accountable businesses and
governmentgovernment
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3636
Competing Policy Agendas:Competing Policy Agendas:Economic growth/recoveryEconomic growth/recovery
Create wealth through financial maneuversCreate wealth through financial maneuvers– Government funnels contracts, minimizes taxes, regulation, Government funnels contracts, minimizes taxes, regulation,
social spendingsocial spending– ““Companies that maximize shareholder wealth… have higher Companies that maximize shareholder wealth… have higher
productivity, greater increases in shareholder wealth, and productivity, greater increases in shareholder wealth, and greater employment gains..” greater employment gains..” McKinsey Nov. 1994McKinsey Nov. 1994
Create wealth through productivityCreate wealth through productivity– Government supports baseline survival, can advance social Government supports baseline survival, can advance social
justice and wellbeingjustice and wellbeing– Guarantees rule of law – financial regulation Empower Guarantees rule of law – financial regulation Empower
organizations of civil society - unionsorganizations of civil society - unions– Invest in productivity: Health care reform, Education, Energy, Invest in productivity: Health care reform, Education, Energy,
EnvironmentEnvironment
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3737
Progressive Political AgendasProgressive Political Agendas
Restore rule of law, political stabilityRestore rule of law, political stability
Empower organizations of civil societyEmpower organizations of civil society
Health care reformHealth care reform
EnergyEnergy
Union rightsUnion rights
Financial regulationFinancial regulation
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3838
Conflicting PrioritiesConflicting Priorities
Non-health care businessNon-health care business– Maintain control of workforceMaintain control of workforce– Minimize health care expensesMinimize health care expenses
Health care businessesHealth care businesses– Preserve revenue generation: Drugs, Preserve revenue generation: Drugs,
hospitals, professional groups, technologyhospitals, professional groups, technology– Resist regulationResist regulation
Public: Affordable, quality health care, with Public: Affordable, quality health care, with choice of providerschoice of providers
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 3939
Economy Slow 2010Economy Slow 2010Personal consumption lowPersonal consumption lowTrade imbalance: Trade imbalance: – U.S. importing more than exportingU.S. importing more than exporting– Low interest ratesLow interest rates
Government spending not enough Government spending not enough – Slump in state and local spendingSlump in state and local spending– Defense spending doesn’t compensateDefense spending doesn’t compensate
The U.S. economy remains starved for The U.S. economy remains starved for aggregate demand aggregate demand
– Economic Policy InstituteEconomic Policy Institute
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4040July, 2010July, 2010 EQUAL/Center for Policy AnalysisEQUAL/Center for Policy Analysis 4040
Corporate mediaCorporate media
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4141
Who Owns Your TV?Who Owns Your TV?
General Electric: NBC, A&E, History ChannelGeneral Electric: NBC, A&E, History Channel
Walt Disney: ABC, ESPNWalt Disney: ABC, ESPN
News Corp: FoxNews Corp: Fox
CBS: CBSCBS: CBS– Sold Salt Lake City network to 4 Points Media, Sold Salt Lake City network to 4 Points Media,
subsidiary of Cerberus, which owned Chryslersubsidiary of Cerberus, which owned Chrysler
Viacom: Comedy CentralViacom: Comedy Central
Time Warner: CNN, HBO, TCMTime Warner: CNN, HBO, TCM
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4242
Election 2010Election 2010Republican agenda:Republican agenda:– Fight about health care as lead up to 2012 Fight about health care as lead up to 2012
electionelection– Focus on abortionFocus on abortion
Moderate Democrats and Republicans:Moderate Democrats and Republicans:– Deficit Commission: Slash Medicare, Social Deficit Commission: Slash Medicare, Social
SecuritySecurity– Free trade/expand exportsFree trade/expand exports
Dems beat big money in CADems beat big money in CAVT governor stumping for single payerVT governor stumping for single payer
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4343
Boehner Proposal Sept. 2010Boehner Proposal Sept. 2010
Cut non-security related spending back to fiscal year 2008 levels and enact a two-year freeze on all current tax rates
EPI: Lose another 1 million jobs
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4444
Stay Mobilized!!!Stay Mobilized!!!
Corporate domination of campaign Corporate domination of campaign spending was successful in many races – spending was successful in many races – but not allbut not all
Analyze what’s working and do more of itAnalyze what’s working and do more of it
Traditional advocacy groups limited – Traditional advocacy groups limited – unions, women, seniors, etc.unions, women, seniors, etc.
Take the initiative to create vehicles for Take the initiative to create vehicles for advocacyadvocacy
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4545
The ACA: The ACA: Educate, Defend, ImplementEducate, Defend, Implement
Regulations.GovRegulations.Gov– Comment on Medical Loss Ratio, repro rightsComment on Medical Loss Ratio, repro rights
State activitiesState activities– Implement exchangesImplement exchanges– Incorporate larger businesses soonerIncorporate larger businesses sooner– Create public insuranceCreate public insurance
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4646
Reproductive RightsReproductive Rights
Contraception is a preventive health care Contraception is a preventive health care serviceservice
Abortion has been stigmatized and Abortion has been stigmatized and marginalizedmarginalized– 30% of women have had an abortion30% of women have had an abortion– ““Safe rare and legal” not sufficient’Safe rare and legal” not sufficient’
Overturn Hyde amendment limiting federal Overturn Hyde amendment limiting federal fundingfunding
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4747
ImmigrantsImmigrants
Of the 12.3 million immigrants without Of the 12.3 million immigrants without health insurance, more than half (6.3 health insurance, more than half (6.3 million) are working, and about 900,000 million) are working, and about 900,000 are children.are children.
Other countries treat US nationals abroad: Other countries treat US nationals abroad: Demand reciprocity.Demand reciprocity.
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 4848
State and National Single Payer State and National Single Payer CampaignsCampaigns
Reclaim the importance role of effective, Reclaim the importance role of effective, accountable government in creating accountable government in creating affordable health care, economic affordable health care, economic prosperity and a socially just societyprosperity and a socially just society
Defend Medicare and Social SecurityDefend Medicare and Social Security
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 49494949
ACA: Steps Towards ACA: Steps Towards Single PayerSingle Payer
Expands coverageExpands coverage
Required financing by government, Required financing by government, individuals and employers will create individuals and employers will create incentives for greater cost controlsincentives for greater cost controls
New quality measures and delivery system New quality measures and delivery system reforms will guide cost control while reforms will guide cost control while protecting benefitsprotecting benefits
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 50505050
Work with EQUALWork with EQUAL
Join the EQUAL ListservJoin the EQUAL Listserv– Send a blank message toSend a blank message to
join-equal@list.equalhealth.infojoin-equal@list.equalhealth.info
See our website:See our website:– www.centerforpolicyanalysis.orgwww.centerforpolicyanalysis.org
Thanks for contributions to this presentation to: Keely Thanks for contributions to this presentation to: Keely Monroe, Lisa Kernan Social Justice Fellow; EQUAL partners Monroe, Lisa Kernan Social Justice Fellow; EQUAL partners including Deborah LeVeen, Elinor Blake, Karl Keener, Joel including Deborah LeVeen, Elinor Blake, Karl Keener, Joel Adelson, Lee Lawrence, Robert Mason; and Jacob HackerAdelson, Lee Lawrence, Robert Mason; and Jacob Hacker
November 2010November 2010 EQUAL Health NetworkEQUAL Health Network 5151
Thank YouThank YouFor Making History!For Making History!
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