Ramping Up Mobilization for Health Care Reform: The EQUAL Health Network Ellen R. Shaffer PhD MPH Joe Brenner MA EQUAL Health Network .

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 [email protected]

APHA Session 281APHA Session 281

Sunday, November 7, 2010 4:00 PM-5:30 M

mailto:[email protected]

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.


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


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


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.


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


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



Adjusted odds of mortality by Adjusted odds of mortality by race and insurance statusrace and insurance status


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?


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


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


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


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


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


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


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?


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


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


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


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)


Estimated Health Insurance Coverage in 2019

SOURCE: Congressional Budget Office, March 20, 2010

Total Nonelderly Population = 282 Million

Figure 6

Return to KaiserEDU Tutorials

http://www.kaiseredu.org/tutorials_index.asp


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

http://www.kaiseredu.org/tutorials_index.asp


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


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


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


Always a Tough RoadAlways a Tough Road


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


Unemployment by Race, Unemployment by Race, Dec. 2007- Aug. 2010Dec. 2007- Aug. 2010


Home Prices Jan. 96 – June 2010Home Prices Jan. 96 – June 2010


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%


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


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


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


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


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


Corporate mediaCorporate media


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


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


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


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


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


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


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.


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


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


Work with EQUALWork with EQUAL

Join the EQUAL ListservJoin the EQUAL Listserv– Send a blank message toSend a blank message to

[email protected]@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


Thank YouThank YouFor Making History!For Making History!

Ramping Up Mobilization for Health Care Reform: The EQUAL Health Network Ellen R. Shaffer PhD MPH Joe Brenner MA EQUAL Health Network .

Documents