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Exhibit ES-4. Cumulative Impact on National Health Expenditures (NHE) of Insurance Connector Approach
Plus Selected Individual Options
$31
$1,554
$1,258
$997
$770
$573
$407
$84
$163$272
$0
$400
$800
$1,200
$1,600
$2,000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Cumulative impact
Annual net impact
Dollars in billions
Note: Selected individual options include improved information, payment reform, and public health.Source: Based on projected expenditures absent policy change and Lewin estimates.
Savin
gs
to N
HE
Exhibit ES-5. Total National Health Expenditures, 2008–2017 Projected and Various Scenarios
Insurance Connector plus selectedindividual options*
Spending at current proportion (16.2%)of GDP
* Selected individual options include improved information, payment reform, and public health.Source: Based on projected expenditures absent policy change and Lewin estimates.
Dollars in trillions
Exhibit 1. Projected National Health Expenditures (NHE)by Payer Source, 2005–2016
* Consumer payments include out-of-pocket payments and private health insurance.Source: J. A. Poisal, C. Truffer, S. Smith et al., “Health Spending Projections Through 2016: Modest ChangesObscure Part D’s Impact,” Health Affairs Web Exclusive (Feb. 21, 2007):w242–w253.
Projected
Total 2005 2011 2016
NHE (in billions) $1,987.7 $2,966.4 $4,136.9
NHE as percent of GDP 16.0% 17.5% 19.6%
Payer Source
Private $1,085.0 $1,566.1 $2,123.3
Consumer Payments* 943.8 1,347.0 1,811.9
Other Private Funds 141.2 219.1 311.4
Public 902.7 1,400.3 2,013.6
Federal 643.7 1027.4 1,486.5
State and Local 259.0 372.9 527.1
Exhibit 2. International Comparison of Health Spending,1980–2005
0
1000
2000
3000
4000
5000
6000
7000 United StatesGermanyCanadaFranceAustraliaUnited Kingdom
0
2
4
6
8
10
12
14
16
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Source: OECD Health Data 2007.
Average spending on healthper capita ($US PPP)
Total health expendituresas percent of GDP
Exhibit 3. Financial Burden for Low- and Middle-Income Families Is Increasing
2624
16
7
33
24 23
10
0
25
50
<100% FPL 100% to <200% FPL 200% to <400% FPL 400%+ FPL
1996 2003
Percent of nonelderly adults spending 10% or more of disposable incomeon family out-of-pocket medical costs and premiums
Note: Financial burden includes out-of-pocket costs for premiums for private insurance and other health services.Source: J. S. Banthin and D. M. Bernard, “Changes in Financial Burdens for Health Care: National Estimates for thePopulation Younger than 65 Years,” Journal of the American Medical Association, Dec. 13, 2006 296(22):2712–19.
Exhibit 4. One-Third of Adults Ages 19–64 Are Uninsuredor Underinsured, as Are Two-Thirds of Low-Income Adults
6583
32
19
4
9
26
49
13
0%
20%
40%
60%
80%
100%
Total 200% of poverty or more Under 200% of poverty
Uninsured during year
Underinsured*
Insured, not underinsured
* 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 incomes if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 Commonwealth Fund Biennial Health Insurance Survey (Schoen et al. 2005b).Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.
Percent
Exhibit 5. Growth in National Health Expenditures (NHE)Under Various Scenarios
Source: The Commonwealth Fund; data from J. A. Poisal, C. Truffer, S. Smith et al., “Health Spending ProjectionsThrough 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs Web Exclusive (Feb. 21, 2007):w242–w253.
Cumulative savings projections to 2016:One-time savings of 5%: $1.56 trillionSlowing trend by 1% annually: $1.72 trillionCombination of one-time savings and slowing trend: $3.19 trillion
$4.14 T
$3.93 T
$3.77 T
$3.58 T
(19.6% GDP)
(18.6% GDP)
(17.8% GDP)
(16.9% GDP)
Exhibit 8. Distribution of 10-Year Impact on Spendingfrom Promoting Health Information Technology
-$87.8
$0.2
-$19.3 -$27.2
-$41.4
-$100
-$80
-$60
-$40
-$20
$0
$20
$40
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Dollars in billions
SA
VIN
GS C
OSTS
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Exhibit 9. Distribution of 10-Year Impact on Spendingfrom Center for Medical Effectiveness
and Health Care Decision-Making
-$367.5
-$97.7-$49.1
-$107.1-$113.6
-$400
-$300
-$200
-$100
$0
$100
$200
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Dollars in billions
SA
VIN
GS C
OSTS
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Exhibit 10. Distribution of 10-Year Impact on Spendingfrom Patient Shared Decision-Making
-$9.2
-$7.6
-$0.4-$0.2-$1.2
-$10
-$8
-$6
-$4
-$2
$0
$2
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Dollars in billions
SA
VIN
GS C
OSTS
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
-$190.5
-$68.2-$48.9-$38.5-$34.9
-$250
-$200
-$150
-$100
-$50
$0
$50
$100
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Exhibit 11. Distribution of 10-Year Impact on Spendingfrom Reducing Tobacco Use
Dollars in billions
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
SA
VIN
GS C
OSTS
-$282.6
-$72.5-$101.2
-$57.2-$51.8
-$400
-$300
-$200
-$100
$0
$100
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Exhibit 12. Distribution of 10-Year Impact on Spendingfrom Reducing Obesity
Dollars in billions
SA
VIN
GS C
OSTS
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Exhibit 13. Distribution of 10-Year Impact on Spendingfrom Positive Incentives for Health
-$19.0
-$11.5
-$4.5 -$5.2
$2.2
-$25
-$20
-$15
-$10
-$5
$0
$5
$10
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Dollars in billions
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
SA
VIN
GS C
OSTS
Exhibit 14. Distribution of 10-Year Impact on Spendingfrom Hospital Pay-for-Performance
-$34.0
-$4.1-$1.7-$0.8
-$27.4
-$40
-$30
-$20
-$10
$0
$10
$20
Systemwide Federal Gov't State and
Local Gov't
Private Payer Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 15. Distribution of 10-Year Impact on Spendingfrom Episode-of-Care Payment
-$229.2
-$377.4
$39.7$90.1
$18.3
-$500
-$400
-$300
-$200
-$100
$0
$100
$200
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 16. Distribution of 10-Year Impact on Spendingfrom Strengthening Primary Care and Care Coordination
-$9.1
-$193.5
-$156.9
-$4.1-$23.4
-$250
-$200
-$150
-$100
-$50
$0
$50
$100
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 17. Distribution of 10-Year Impact on Spending from Limit on Federal Tax Exemptions for Premium Contributions
-$131.1
-$55.2-$19.3
$129.7
-$186.2-$250
-$200
-$150
-$100
-$50
$0
$50
$100
$150
$200
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 18. Distribution of 10-Year Impact on Spendingfrom Reset Benchmark Rates for Medicare Advantage Plans
-$49.6
-$124.0
$0.0 $0.0
$74.4
-$150
-$100
-$50
$0
$50
$100
$150
$200
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 19. Distribution of 10-Year Impact on Spendingfrom Competitive Bidding
-$104.2
-$282.5
$0.0 $0.0
$178.3
-$400
-$300
-$200
-$100
$0
$100
$200
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 20. Distribution of 10-Year Impact on Spendingfrom Negotiated Prescription Drug Prices
-$43.4
$7.5$17.1
$3.5
-$71.5
-$100
-$80
-$60
-$40
-$20
$0
$20
$40
Systemwide Federal
Gov't
State and
Local Gov't
Private
Employer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 21. Distribution of 10-Year Impact on Spendingfrom All-Payer Provider Payment Methods and Rates
-$122.4
$0.0 $0.0
-$17.7
-$104.7
-$140
-$120
-$100
-$80
-$60
-$40
-$20
$0
$20
$40
$60
Systemwide Federal
Gov't
State and
Local Gov't
Private
Payer
Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 22. Distribution of 10-Year Impact on Spendingfrom Limit on Payment Updates in High-Cost Areas
-$157.8
-$259.7
$62.1$27.3$12.6
-$300
-$250
-$200
-$150
-$100
-$50
$0
$50
$100
$150
Systemwide Federal Gov't State and
Local Gov't
Private Payer Households
Source: Based on estimates by The Lewin Group for The Commonwealth Fund, 2007.
Dollars in billions
SA
VIN
GS C
OSTS
Exhibit 23. Cumulative Changes in AnnualNational Health Expenditures, 2000–2007
0
25
50
75
100
125
2000 2001 2002 2003 2004 2005 2006* 2007*
Net cost of private health insurance administration
Family private health insurance premiums
Personal health care
Workers earnings
Notes: Data on premium increases reflect the cost of health insurance premiums for a family of four/the average premium increase is weighted by covered workers. * 2006 and 2007 private insurance administration and personal health care spending growth rates are projections.Sources: A. Catlin, C. Cowan, S. Heffler et al., “National Health Spending in 2005: The Slowdown Continues,” Health Affairs, Jan./Feb. 2007 26(1):143–53; J. A. Poisal, C. Truffer, S. Smith et al., “Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs Web Exclusive (Feb. 21, 2007):w242–w253; Henry J. Kaiser Family Foundation/Health Research and Educational Trust, Employer Health Benefits Annual Surveys, 2000–2007 (Washington, D.C.: KFF/HRET).
109%
65%
91%
24%
Percent change
Exhibit 24. Cumulative Impact on National HealthExpenditures (NHE) of Insurance Connector Approach
Plus Selected Individual Options
$31
$1,554
$1,258
$997
$770
$573
$407
$84
$163$272
$0
$400
$800
$1,200
$1,600
$2,000
2008 2009 2010 2011 2012 2013 2014 2015 2016 2017
Cumulative impact
Annual net impact
Dollars in billions
Note: Selected individual options include improved information, payment reform, and public health.Source: Based on projected expenditures absent policy change and Lewin estimates.
Savin
gs
to N
HE
Exhibit 25. Net Federal Spending withInsurance Connector Alone Compared with Net Federal
with Insurance Plus Savings Options
$50$109
$195
$10$13$31 $0
$50
$100
$150
$200
$250
2008 2012 2017
Federal spending offset
Net federal with insurance plus savings options*Dollars in billions
* Selected options include improved information, payment reform, and public health.Source: Lewin Group modeling estimates of insurance option alone or insurance in combination with savings optionscompared with projected federal spending under current policies.
$82Insurance Alone
$122Insurance Alone
$205Insurance Alone
Exhibit 26. Total National Health Expenditures, 2008–2017 Projected and Various Scenarios
Insurance Connector plus selectedindividual options*
Spending at current proportion (16.2%)of GDP
* Selected individual options include improved information, payment reform, and public health.Source: Based on projected expenditures absent policy change and Lewin estimates.