The Rationale for Healthcare Reform and the Affordable Care Act (ACA)

8/2/2019 The Rationale for Healthcare Reform and the Affordable Care Act (ACA)

1/55

ThecaseforHealthcarereformandACA

AndresBarkil-Oteo

DepartmentofPsychiatryYaleUniversity


2/55

Outline

Why?:ThecurrentstateofhealthandhealthcareinUSA What?:IntrotoHealthInsurance How?:IntroducFontotheAffordableCareAct(ACA)


3/55

Valueinhealthcare


4/55

International Comparison of Spending on Health, 19802009

*PPP=PurchasingPowerParity.

Data:OECDHealthData2011(database),version6/2011.

Averagespendingonhealthpercapita($USPPP*)

TotalexpendituresonhealthaspercentofGDP

4

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

United States

Canada

Germany

France

Australia

United Kingdom

0

2

4

6

8

10

12

14

16

18

1980

1982

1984

1986

1988

1990

1992

1994

1996

1998

2000

2002

2004

2006

2008

United States

France

Germany

CanadaUnited Kingdom

Australia

CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.


5/55

7.2 7.0 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8

10.3

11.1

10.29.9 9.9 9.6

10.110.8

10.0 9.9

5.3 5.1 5.0 4.9 4.8 4.7 4.7 5.0 5.0 5.0

0

4

8

12

1998

1999

2000

2001

2002

^

2003

2004

^

2005

2006

2007

U.S. average Bottom 10% states Top 10% states

NaFonalaverageandstatedistribuFon InternaFonalcomparison,2007

2.02.5 2.6 2.7

3.1

4.0

5.1

6.8

Icelan

d

Swed

enJapa

n

Finlan

d

Norw

ay

Denm

ark

Cana

da

Unite

dStat

es


Infant Mortality RateInfantdeathsper1,000livebirths

^Denotesyearsin2006and2008NaFonalScorecards.

Data:NaFonalandstateNaFonalVitalStaFsFcsSystem,LinkedBirthandInfantDeathData(AHRQ20032008;Mathewsand

MacDorman,2011);internaFonalcomparisonOECDHealthData2011(database),Version06/2011.


6/55

IsUSHealthReallytheBestintheWorld?

Of13countries,theUnitedStatesranksanaverageof12th(secondfromtheboom)for16availablehealthindicators

13th(last)forlow-birth-weightpercentages 13thforneonatalmortalityandinfantmortalityoverall 11thforpostneonatalmortality 13thforyearsofpotenFallifelost(excludingexternalcauses) 11thforlifeexpectancyat1yearforfemales,12thformales 10thforlifeexpectancyat15yearsforfemales,12thformales 10thforlifeexpectancyat40yearsforfemales,9thformales 7thforlifeexpectancyat65yearsforfemales,7thformales 3rdforlifeexpectancyat80yearsforfemales,3rdformales

Starfield2000JAMA


7/55

Kaiser:TheUninsuredaprimer


8/55

TheUninsured

Uninsuredadultshavea25percentgreatermortalityriskthanadultswithcoverage

Lackofhealthinsuranceisassociatedwithasmanyas44789deathsperyearmorethanthosecausedbykidneydisease

Wilperetal2009


9/55

Data: U.S. Census Bureau, 200001 (revised) and 201011 Current Population Survey ASEC Supplement.

Percent of Adults Ages 1964 Uninsured by State


19992000 20092010

19%22.9%

Lessthan14%

14%18.9%

23% or more

WA

OR

ID

MT ND

WY

NV

CAUT

AZNM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TN NC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD

WA

OR

ID

MT ND

WY

NV

CAUT

AZNM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TNNC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD


10/55

1 or More Full-

Time Workers,

61%

No Workers,

24%

Part-Time

Workers,

16%

NonelderlyUninsuredbyamilyWorkStatus,2010

Datamaynottotal100%duetorounding.

SOURCE:KCMU/UrbanInsFtuteanalysisof2011ASECSupplementtotheCPS.

Total = 49.1 million uninsured


11/55

Uninsured and Underinsured Adults

11

Percent of adults ages 1964 who are

uninsured or underinsured

26 28 28

91614

0

25

50

75

100

2003 2007 2010

Underinsured*

Uninsured during year


Insured all year, not underinsured

Underinsured*

Uninsured during year

Millions of adults ages 1964 who are

uninsured or underinsured, 2010

102

29

52

Total: 184 million**

35

42 44

* 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 (


12/55

Underinsured

62.1%ofallbankruptcieshaveamedicalcause. Mostmedicaldebtorswerewelleducatedandmiddleclass;threequartershadhealthinsurance.

Theshareofbankruptciesaributabletomedicalproblemsroseby50%between2001and2007

Youloosecoveragewhenyouloosejob,youloosethehealthinsurancewhenismostneeded!

Himmelsteinetal2009


13/55

uchsNEJM2012


14/55

Iatrogenicevents

USesFmates 12000deaths/yearfromunnecessarysurgery 7000deaths/yearfrommedicaFonerrorsinhospitals 20000deaths/yearfromothererrorsinhospitals 80000deaths/yearfromnosocomialinfecFonsinhospitals 106000deaths/yearfromnon-error,adverseeffectsofmedicaFons TheaveragenumberesFmatedis225000deathsperyear AdmissiontoahospitalisthethirdleadingcauseofdeathintheUnitedStates,aerdeathsfromheartdiseaseandcancer.

Starfield2000JAMA


15/55

Numberofdeathsforleadingcausesofdeath

1-Heartdisease:599,413

2-Cancer:567,628

3-Chroniclowerrespiratorydiseases:137,353

4-Stroke(cerebrovasculardiseases):128,842

5-Accidents(unintenFonalinjuries):118,021

CDCesFmatesfor2010


16/55

Numberofdeathsforleadingcausesofdeath

Modified

1-Heartdisease:599,413

2-Cancer:567,628

3-Iatrogeniccausesduringhospitaladmissions225,000

4-Chroniclowerrespiratorydiseases:137,353

5-Stroke(cerebrovasculardiseases):128,842

6--Accidents(unintenFonalinjuries):118,021

CDCesFmatesfor2010


17/55

Anyroomforimprovement?


18/55

Overall Health System Performance

Exhibit 1EXECUTIVE SUMMARY

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

Top Quartile

Second Quartile

Third Quartile

Bottom Quartile

Not Populated

Overall Performance


19/55

isheretalNEJM2009


20/55

Sutherlandetal2009NEJM


21/55

DifferenFalofmedicarespending

PaFentsinthehighestspendingregionsspendmoreFmeinthehospitalhavemorefrequentphysicianvisitsandundergomoreMRIproceduresCT

scans.DiscreFonarydecisionsbyphysiciansseemtoaccountformostof

theregionalvariaFoninspending(Sutherlandetal2009NEJM)

Medicarewillbe$660billionintheholeby2023.Reducingannualgrowthinpercapitaspendingfrom3.5%(thenaFonalaverage)to2.4%(therate

inSanrancisco)wouldleaveMedicarewithahealthyesFmatedbalance

of$758billion,acumulaFvesavingsof$1.42trillion(isheretal2009

NEJM)



22/55

Whataboutoutcomes?

Skinneretal2006HA


23/55



24/55

Chronic Disease Under Control: Diabetes and Hypertension

85

49

76

55

72

29

Diabetes under control* High blood pressure under

control**

Private Public Uninsured

*Refers to diabetic adults whose hemoglobin A1c is


25/55

Use of Electronic Medical Records

17

28

46

97 97 96 95 94 94

7268

37

99

0

25

50

75

100

2000 2006 2009 NETH NZ NOR UK AUS ITA SWE GER FRA CAN

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.

Percent of primary care physicians using electronic medical records

Source:CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.

United States


26/55

Whatisgoingonhere?

Thepathwaystobeerhealthdonotgenerallydependonbeerhealthcare

Inthoseinstancesinwhichhealthcareisimportant,toomanyAmericansdonotreceiveit,receiveittoolate,orreceivepoor-qualitycare.

Beerhealth(lowermortalityandahigherleveloffuncFoning)cannotbeachievedwithoutpayinggreateraenFontopoorAmericans

Schroeder2007NEJM


27/55


28/55

TruthorficFononinternaFonalhealthcaresystems

Wastefulsystemsrunbybureaucrats RaFoncarewithlimitedchoiceandwaiFnglists Itsallsocializedmedicine ThosesystemsaretooforeigntoworkintheUS

TRReidThehealingofAmerica2009


29/55

Wastefulsystemsrunbybureaucrats?

1920s:nonforprofit,hospitalsrun,samepremiumforallmembers,allapplicantswereenrolledandpaidthesamepremium

1945:orprofitenteredthemarket:chargingmorepremium,denyingcoverage

TheUnitedStatesistheonlyadvanceddemocracywithforprofithealthinsuranceindustry



30/55


31/55

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


32/55

orbes2011h)p://,nyurl.com/7duz7ta


33/55

RaFoncarewithlimitedchoiceandwaiFnglists?


34/55

Waiting Time to See Doctor When Sick or Need Medical

Attention,

Among Sicker Adults, 2008

80

71

62 61 59

53

43

36

0

25

50

75

100

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 hospitalizedor 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.

Percent of adults who could get an appointment on the same or next day

when sick or needed medical attention



35/55

Access Problems Because of Costs, 2010

5 6

10 10 1113 14

15

22

25

33

0

25

50

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.

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



36/55

Itsallsocializedmedicine!

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


37/55


Beginningin1952theTrumanAdministraFon,throughederalSecurityAdministratorOscarEwing,hadbegunadvocaFngmedicalcareforthe

agedwhatwouldbecomeMedicare.ThiswasaretreatfromTrumans

earliercallsforuniversalhealthcareforallAmericans.Theimplacable

opposiFonoftheAMAandotherpressuregroupsmadeuniversalhealth

careanimpossibletask

Opera,onCoffeecup:LedbytheWomansAuxiliarytotheAmericanMedicalAssocia,on,wasanall-outefforttosFmulateasmanyleersto

Congressopposingsocializedmedicineanditsmenaceasproposedinthe

bill

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


38/55


"Theterm['socializedmedicine']waspopularizedbyapublicrelaFonsfirmworkingfortheAmericanMedicalAssociaFonin1947todisparage

PresidentTruman'sproposalforanaFonalhealthcaresystem.Itwasa

label,atthedawnofthecoldwar,meanttosuggestthatanybody

advocaFnguniversalaccesstohealthcaremustbeacommunist.Andthe

phrasehasretaineditspoliFcalpowerforsixdecades



39/55


40/55

ThosesystemsaretooforeigntoworkintheUS

orthemajorityofAmericanswhogettheirinsurancethroughtheiremployer,weareGermany.

orveterans,weareEngland orSeniors,weareCanada ortheuninsured,weareCambodia



41/55

How?


42/55


43/55

Insurance:Threeleggedstool

McDonoughInsidehealthreform2011

Individualmandate

InsurancesubsidiesGuaranteedissue

ACA


44/55

Individualmandate

RAND2012h)p://,nyurl.com/77mmxgw


45/55

Insurancesubsidies

ExpandMedicaidupto133%ofthepovertylevel

CreatenewHealthInsuranceExchangeswhereindividualsandsmallemployerscanpurchasecoverage

Providepremiumsubsidiesupto400%ofthepovertylevel



46/55


47/55

Estimated Health Insurance Coverage in 2019

Congressional Budget Office, 2010

TotalNonelderlyPopulaFon=282Million


48/55

SomeUninsuredWillRemain

CongressionalBudgetOffice(CBO)esFmates23millionuninsuredin2019 Whoarethey?

Immigrantswhoarenotlegalresidents EligibleforMedicaidbutun-enrolled Exemptfromthemandate(mostbecausecantfindaffordablecoverage) Choosetopaypenaltyinlieuofge|ngcoverage

Manyremaininguninsuredwillbelow-income


49/55

Guaranteedissue/Insurancereform

ProhibiFononannualandlifeFmebenefitscap ProhibiFonofrescissions:rescindingcoverageaerapolicyholdergetssick.

AllinsurancepoliciesmustcoverclinicalprevenFvehealthserivceswithAorBraFngs

ParentscankeeptheiradultchildrenontheirhealthinsuranceFlltheyreaches26

CapmedicallossraFoto80% NodiscriminaFonorpreexisFngcondiFonexclusionsbasedonhealthstatus



50/55

inancingHealthReform,2010-2019

TotalCost=$938Billion

SavingstoFederalDeficit=$124BillionCongressionalBudgetOffice,2010

ederalsavings

Newrevenues


51/55

ACAImplementaFonTimeline

2010

Someinsurancemarketchangesnocost-sharing

forprevenFveservices,

dependentcoveragetoage

26,nolifeFmecaps

Pre-exisFngcondiFoninsuranceplan

SmallbusinesstaxcreditsPremiumreview

2011-2013

Nocost-sharingforprevenFveservicesin

MedicareandMedicaid

IncreasedpaymentsforprimarycareReducedpaymentsforMedicareprovidersand

healthplans

NewdeliverysystemmodelsinMedicareandMedicaid

Taxchangesandnewhealthindustryfees

2014

MedicaidexpansionHealthInsuranceExchanges

Premiumsubsidies InsurancemarketrulesprohibiFonondenying

coverageorchargingmore

tothosewhoaresick,

standardizedbenefits

IndividualmandateEmployerrequirements


52/55

ACAinacFon

2.5millionyoungadultsarenowenrolledintheirparents'healthinsurance

105millionAmericansnolongerfacelifeFmebenefitcapsontheirinsuranceplans

86millionAmericans,includingthoseinMedicareandprivatecoverage,havereceivedfreeprevenFveservicessuchascheck-upsandcancer

screenings

17millionchildrencannolongerbedeniedcoveragebecauseofpre-exisFngcondiFons

3.6millionMedicareseniorshavereceivedsavingsonprescripFondrugsbecauseoftheclosingoftheso-called"donuthole;"in2011

360,000smallemployersusedthesmallemployertaxcredittomakeinsurancemoreaffordablefortheirtwomillionemployees.

JohnMcDonough2011h)p://,nyurl.com/856wj8s

Nearly Half Say They eel Confused About ACA; Three In Ten Angry;


53/55

31%

25%

47%

30 30 3128

31 32

28

3230

34 34 34

30 30

30

3533

31

27 28

55

4442 43

45

53

47

52

43

50

53

46

0%

20%

40%

60%

80%

Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar

NearlyHalfSayTheyeelConfusedAboutACA;ThreeInTenAngry;

QuarterEnthusiasFc

Percentwhosaythateachofthefollowingdescribestheirfeelingsaboutthehealthreformlaw:

AngryConfused Enthusiastic

Source: Kaiser Family Foundation Health Tracking Polls

2010

2011

2012

ACA signed intolaw on March 23,

2010


54/55

NowyoucouldbeangryorenthusiasFcbutdefinitelynot

confused!


55/55

END

Documents

The Rationale for Healthcare Reform and the Affordable Care Act (ACA)