The Affordable Care Act: Opportunities for Care and for Single Payer

The Affordable Care Act:The Affordable Care Act:Opportunities for Care and for Opportunities for Care and for

Single Payer Single Payer

Ellen R. Shaffer PhD MPHEllen R. Shaffer PhD MPHEQUAL Health NetworkEQUAL Health Network

www.equalhealth.infowww.equalhealth.info415-922-6204 [email protected] [email protected]

February 7, 2010February 7, 2010

February 2011February 2011 EQUALEQUAL 22

The Affordable Care ActThe Affordable Care Act

The Affordable Care Act is a major victoryThe Affordable Care Act is a major victory

Single payer would go fartherSingle payer would go farther

Both are under attackBoth are under attack

Reproductive Rights is an Older Women’s Reproductive Rights is an Older Women’s issueissue


Crisis: Access, Cost, QualityCrisis: Access, Cost, Quality

50 million uninsured50 million uninsured

DeathsDeaths

Bankruptcy – even with insuranceBankruptcy – even with insurance

$2.5 Trillion a year = $8,000/person$2.5 Trillion a year = $8,000/person– Most expensive in the worldMost expensive in the world

3737thth in outcomes in outcomes– Shortage of primary careShortage of primary care– FragmentedFragmented


Health Reform: A StartHealth Reform: A Start

ACA delivered what Obama campaign promisedACA delivered what Obama campaign promised

Significant though limited reformsSignificant though limited reforms

Takes important steps to expand coverage and Takes important steps to expand coverage and improve quality, and begins to control costsimprove quality, and begins to control costs

Claim the victory of half a loaf and use policy Claim the victory of half a loaf and use policy space to proceed deliberately to win the rest.space to proceed deliberately to win the rest.

Will Administration advance, retreat, hold the Will Administration advance, retreat, hold the line?line?


Patient Protection and Affordable Care Patient Protection and Affordable Care Act (ACA): The GainsAct (ACA): The Gains

Expanded Coverage and AccessExpanded Coverage and Access

Improving QualityImproving Quality

Consumer ProtectionsConsumer Protections ALL = Lower CostsALL = Lower Costs

How Will We Benefit?How Will We Benefit?


ACA Benefits Phased In ACA Benefits Phased In 2010-20202010-2020

Public health grant programsPublic health grant programs2010-20132010-2013– 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” gon2020: Medicare drug price “doughnut hole” gon


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 contributionsPremium subsidies up to 400% of poverty level ($88,000 for 4)Premium subsidies up to 400% of poverty level ($88,000 for 4)Limits ib premiums, out of pocket spendingLimits ib premiums, out of pocket spending

Undocumented immigrants generally not coveredUndocumented immigrants generally not covered

February 2011 EQUAL 8

Estimated Health Insurance Coverage Estimated Health Insurance Coverage in 2019in 2019

SOURCE: Congressional Budget Office, March 20, 2010

Total Nonelderly Population = 282 Million

Figure 6

Return to KaiserEDU Tutorials


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


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


Immediate ImprovementsImmediate Improvementsin 2010in 2010

Coverage:Coverage:– New High Risk Pool (for uninsured with New High Risk Pool (for uninsured with

pre-existing conditions)pre-existing conditions)

– Covers Young Adults through Age 26 on Covers Young Adults through Age 26 on parentsparents’’ coverage coverage

QualityQuality– Increased funding for Community ClinicsIncreased funding for Community Clinics


Immediate Immediate ImprovementsImprovements

20102010

Stops Insurance Abuses:Stops Insurance Abuses:– Discrimination against children with pre-Discrimination against children with pre-

existing conditions prohibitedexisting conditions prohibited– Rescissions Illegal (withdrawal of care)Rescissions Illegal (withdrawal of care)– Bans lifetime limits on coverage Bans lifetime limits on coverage

Affordability:Affordability:– Small business tax credits of up to 35%Small business tax credits of up to 35%– Rebates begin to close the Medicare Part D Rebates begin to close the Medicare Part D

Doughnut HoleDoughnut Hole– Reduces cost of early retiree coverageReduces cost of early retiree coverage


Insurance Exchanges: WhoInsurance Exchanges: WhoState-based Exchanges begin in 2014

Uninsured individuals, self-employed and small businesses can buy standardized, affordable coverage

Safety net for insured who lose a job

Est. 2.4 million eligible in CA

NOT MOST UNION MEMBERS.NOT FOR MEDICARE!!

Applies to Members of Congress


Family of FourFamily of FourJoe’s family Joe’s family

incomeincome::

Eligible for MediCalEligible for MediCal

$302/month; $3,624/yr*$302/month; $3,624/yr*

$663/month; $7,956/yr*$663/month; $7,956/yr*

$25,000/yr$25,000/yr

$50,000/yr$50,000/yr

$80,000/yr$80,000/yr

Joe pays max. premium ofJoe pays max. premium of::

* Actual cost may be less depending on age of the worker

February 2011February 2011 EQUALEQUAL 1515, , EQUAL Health NetworkEQUAL Health Network 1515

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


Other Key FeaturesOther Key FeaturesInvestments in public healthInvestments in public health

Quality ImprovementsQuality Improvements– Free preventive careFree preventive care– More $ to primary care docs & nursesMore $ to primary care docs & nurses

Consumer ProtectionsConsumer Protections

MedicareMedicare– Trust Fund Preserved to 2029Trust Fund Preserved to 2029– Prescription Drug “Donut Hole” closed - 2020Prescription Drug “Donut Hole” closed - 2020


Immediate Benefits for CaliforniaImmediate Benefits for California

BenefitBenefit

Small business tax creditSmall business tax credit

$250 relief from donut hole$250 relief from donut hole

Early Retiree Reinsurance Early Retiree Reinsurance Program benefitsProgram benefits

Ending lifetime coverage Ending lifetime coverage limitslimits

Youth up to age 26 coveredYouth up to age 26 covered

Increased Coverage forIncreased Coverage for: :

503,000 small businesses503,000 small businesses

382,000 Medicare 382,000 Medicare beneficiariesbeneficiaries

430,000 early retirees430,000 early retirees

19 million residents19 million residents

196,000 individuals196,000 individuals$761 million federal dollars are available to California to provide $761 million federal dollars are available to California to provide coverage for uninsured residents with pre-existing medical conditionscoverage for uninsured residents with pre-existing medical conditions


Affordability: NowAffordability: Now

Rebates begin to close the Rebates begin to close the Medicare Part D Donut Hole:Medicare Part D Donut Hole:

$250 in 2010; 50% brand name drugs 2011$250 in 2010; 50% brand name drugs 2011

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


Affordability:Affordability:“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?


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


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

No Public Option

February 2011February 2011 EQUALEQUAL 2323, , EQUAL Health NetworkEQUAL Health Network 2323

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


Costs of coverage for subsidy eligible individuals in Costs of coverage for subsidy eligible individuals in exchange compared to existing non-group market exchange compared to existing non-group market

(premium and out-of-pocket)(premium and out-of-pocket)


Financing Health Reform, Financing Health Reform, 2010-20192010-2019

Total Cost = $938 BillionSavings to Federal Deficit = $124 Billion

Source: Congressional Budget Office, 2010

Federal savings

New revenues

Figure 15

Return to KaiserEDU Tutorials


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/month200% FPL ($21,660/yr): $113200% FPL ($21,660/yr): $113250% FPL ($27,075/yr): $191250% FPL ($27,075/yr): $191300% FPL ($32,490/yr): $ 257300% FPL ($32,490/yr): $ 257

Hardship exemption: Available if lowest cost plan exceeds Hardship exemption: Available if lowest cost plan exceeds 8% of an individual’s income8% of an individual’s income

Comparison: Single payer bills: c. 10% payroll tax Comparison: Single payer bills: c. 10% payroll tax


Elements of Single PayerElements of Single Payer

Single payment source: governmentSingle payment source: government• Vast reduction in administrative costsVast reduction in administrative costs• Effective levers for cost controlEffective levers for cost control

• Universal coverageUniversal coverage

• Can improve administration, information, Can improve administration, information, quality of carequality of care


Universal Coverage: Universal Coverage: Undocumented ImmigrantsUndocumented Immigrants

Important human rightImportant human right

Preventive care improves health, reduces Preventive care improves health, reduces ER useER use

Undocumented in CA pay $80,000 more in Undocumented in CA pay $80,000 more in fees than receive in lifetime govt. benefitsfees than receive in lifetime govt. benefits


Cost ControlCost Control

• Budgets control costs on the supply side Budgets control costs on the supply side Growth in health spending linked to Growth in health spending linked to – State GDP, population growthState GDP, population growth– Technological changeTechnological change– Demographics (employment, etc.)Demographics (employment, etc.)

Administration: 5% limitAdministration: 5% limitNegotiate prescription drug pricesNegotiate prescription drug pricesIncrease primary care: No co-pays or Increase primary care: No co-pays or deductiblesdeductibles


Delivery SystemDelivery System

• Current mix: public and private providers Current mix: public and private providers • Choice of primary care MDChoice of primary care MD

• Referral needed to specialistReferral needed to specialist

• Payment methods, risk adjusted:Payment methods, risk adjusted:• Fee for serviceFee for service• Facility budgetFacility budget• CapitationCapitation

• Financial incentives to practice in underserved Financial incentives to practice in underserved areas & for primary careareas & for primary care


Comprehensive BenefitsComprehensive Benefits

Medical and surgicalMedical and surgical

Mental health, substance abuseMental health, substance abuse

DentalDental

Prescription drugsPrescription drugs

Hospice, SNF after hospitalHospice, SNF after hospital

Health educationHealth education

Translation, transportationTranslation, transportation


Accountable GovernanceAccountable Governance

• Elected Health CommissionerElected Health Commissioner• Health Policy BoardHealth Policy Board• Office of Medical Practice StandardsOffice of Medical Practice Standards• Office of Consumer AdvocacyOffice of Consumer Advocacy• Health Care FundHealth Care Fund• Inspector GeneralInspector General


QualityQuality

Access to primary careAccess to primary care

Monitor health outcomesMonitor health outcomes

Program: decrease medical errorsProgram: decrease medical errors

Planning for health providers, facilitiesPlanning for health providers, facilities


Single Payer BillsSingle Payer Bills

CongressCongress– HR 676 ConyersHR 676 Conyers– S 703 SandersS 703 Sanders– HR 3000 B LeeHR 3000 B Lee

StateState– CA SB 810CA SB 810– Vermont – Hsiao ReportVermont – Hsiao Report


How Is Single Payer FinancedHow Is Single Payer Financed

HR 676 Federal bill – Rep. Conyers MIHR 676 Federal bill – Rep. Conyers MI

Existing federal revenues for health careExisting federal revenues for health care

Increase income tax on top 5% income Increase income tax on top 5% income earnersearners

Excise tax on payroll and self-employment Excise tax on payroll and self-employment income (SSI)income (SSI)

Tax on stock and bond transactionsTax on stock and bond transactions


HR 676: System SavingsHR 676: System Savings

Reduced paperworkReduced paperwork

Bulk procurement of medicinesBulk procurement of medicines

Improved access to preventive careImproved access to preventive care


Vermont ProposalVermont Proposal

Payroll tax (SSI)

Exempts workers who are paid and employers who pay wages below 180% of the FPL

exemption is phased out at 220% of FPL.

payroll contribution capped at $120,000.


VermontVermontFirms employing between 1 and 10 employees will spend in total $173 million more than they would have under PPACA reforms in 2019, or $1,702 per employee. However, larger firms will experience lower spending than they would have under PPACA. Spending for firms with between 101 and 500 employees will be $20 million less, or $332 less per household, while firms with more than 500 employees will spend $111 million less, or $1,039 less per household. Firms who currently provide health insurance to their employees would see lower costs than they would have under PPACA reforms. In total, offering firms will spend $211 million less in 2019, or $947 per household. However, firms not currently offering insurance will pay more. Non-offering firms will see increase in costs of $285 million in 2019 under option 1a reforms, or $1,722 per employee. 97


Vermont: HouseholdsVermont: Households

Total costs including contributions will be lower under option 1A by $339 million in 2019 as compared to ACA, or $1,201 per household.

Total additional benefits will also be lower.

However, the net financial benefit will be $198 million, or $704 per household.


Senate Bill 921 (Kuehl)Senate Bill 921 (Kuehl)The Health Care for All Californians ActThe Health Care for All Californians Act

Similar to HR 1200 (McDermott/Wellstone)Similar to HR 1200 (McDermott/Wellstone)

Financing: State Health FundFinancing: State Health Fund

Earmarked state health care taxes replace Earmarked state health care taxes replace insurance premiumsinsurance premiums

Combine existing federal, state, county Combine existing federal, state, county health funds (=50% current health care health funds (=50% current health care payments)payments)


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


Toward Single PayerToward Single Payer

legislative commitment to universal legislative commitment to universal coveragecoveragenational benefits standardnational benefits standardincome-based definition of affordabilityincome-based definition of affordabilityan employer mandate, an employer mandate, global budget for Medicareglobal budget for Medicarethe recognition that insurance must be the recognition that insurance must be much more strongly regulated, with new much more strongly regulated, with new institutions for doing thatinstitutions for doing that


ACAACAEffective 1/1/2011 to 12/31/2016, there will be a 10% bonus in Medicare payments to PCPs that have at least 60% of Medicare billing in the areas of office, nursing home and home care visits. From 1/1/13 to 12/31/14: will raise Medicare rates for primary care physicians for evaluation and management services, and services related to immunization. National Health Service Corps funding is planned to rise from $320M/year in 2010 to 1.15B/year in 2015. These funds are those used to help PCPs in high need areas pay back their debt. Title VII funds to family medicine residency programs and academic departments of family medicine have also been reauthorized. January 1, 2011, funding for community health centers will increase by $11 billion.


Why is This Controversial?Why is This Controversial?

Opponents can not muster votes to repealOpponents can not muster votes to repeal

But will focus on undermining itBut will focus on undermining it

Public dividedPublic divided– ““Statist” government takeoverStatist” government takeover– Corporate takeoverCorporate takeover– Some support, experiencing benefitsSome support, experiencing benefits

Unfinished issues continue to be controversial:Unfinished issues continue to be controversial:– Social divisions – abortion, immigrantsSocial divisions – abortion, immigrants– Role of government – public optionRole of government – public option


SB 840SB 840The California Health Insurance System will be funded by a combination of monies already collected and used by government health agencies such as Medicare and Medi-Cal, and new revenues. Government monies already pay for about half of all health expenditures. The use of Medicare and Medicaid funds will require waivers negotiated with the federal government. (140240)The specific new revenues for CUHA have not yet been included in the bill. A Premium Commission will recommend additional new revenues to pay for the remaining cost of the program. These will likely include health premiums based on a percentage of wages, paid partly by employers and partly by employees. The Lewin Group (2004) studied a proposal for approximately 12% of wages along with some other taxes, and found it adequate


National Deficit With and Without National Deficit With and Without Health ReformHealth 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


Why Do We Do Worse Than Other Why Do We Do Worse Than Other Countries?Countries?

ProblemProblem ACA RemedyACA Remedy

For-profit insurance co.s For-profit insurance co.s RegulatesRegulates

Too many specialistsToo many specialists Supports primary care Supports primary care and preventionand prevention

Fragmented careFragmented care Medicare InnovationsMedicare Innovations

InequalitiesInequalities Expands coverage Expands coverage through the public sectorthrough the public sector


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


Contest for the FutureContest for the Future

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


Trust Women/Silver Ribbon MonthTrust Women/Silver Ribbon Month

Anniversary of Roe v. Wade: Jan. 22Anniversary of Roe v. Wade: Jan. 22

Broad coalition of health, repro rights, Broad coalition of health, repro rights, social justice groupssocial justice groups

The majority needs a visible, vocal The majority needs a visible, vocal campaigncampaign

Speak out, take action, wear silver ribbon:Speak out, take action, wear silver ribbon:

“ “Trust Women”Trust Women”


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 important role of effective, Reclaim the important 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 Security Defend Medicare and Social Security


Building for the FutureBuilding for the Future

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

[email protected]@list.equalhealth.info

www.equalhealth.infowww.equalhealth.info

Thanks for contributions to this presentation to: Keely Monroe, Lisa Thanks for contributions to this presentation to: Keely Monroe, Lisa Kernan Social Justice Fellow; EQUAL partners including Deborah Kernan Social Justice Fellow; EQUAL partners including Deborah LeVeen, Elinor Blake, Karl Keener, Joel Adelson, Lee Lawrence, LeVeen, Elinor Blake, Karl Keener, Joel Adelson, Lee Lawrence, Robert Mason; and many organizationsRobert Mason; and many organizations


Optimal use of professionalsOptimal use of professionalsThe Patient-Centered Medical Home modelThe Patient-Centered Medical Home modelNon-physician primary care providersNon-physician primary care providersExtenders of care emanating elsewhereExtenders of care emanating elsewhere

56


Include public health in our thinking Include public health in our thinking and planningand planning

Integrated with clinical care, part of PCMHIntegrated with clinical care, part of PCMHIndependent community-based providersIndependent community-based providersSupported in title IV and V of the ACASupported in title IV and V of the ACA

57


Improving the SystemImproving the SystemQuality measure developmentQuality measure development

Outcomes and function statusOutcomes and function status Management and coordination across episodes Management and coordination across episodes

and care transitionsand care transitions Patient-centerednessPatient-centeredness

58


System ChangeDrivers are toward integrated systems of care, including

quality measures applied to patient transfers

Broadening to include more emphasis on care in the home – Section 3024 establishes an Independence at Home Medical Practice category, serving at least 200 applicable beneficiaries and using electronic health information systems, remote monitoring, and mobile diagnostic technology

59


System Change continued..System Change continued..Community health teams, patient centered-

medical homes, health teams (Section 3502)

Regionalized systems for emergency care

60


System Change: Big PictureSystem Change: Big PictureSecretary develops a national strategy to

improve the delivery of health care services, patient health outcomes and population health

Secretary develops quality measures assessing health outcomes and functional status, management and coordination across episodes and care transition, and experience, quality, and use of information to and used by patients

61


Big Picture continued…Big Picture continued…Center for Medicare and Medicaid Innovation

in CMS

National Health Care Workforce Commission

Patient-centered Outcomes Research Institute and trust fund: rural-relevant comparative effectiveness research?

62


Using Elements of the Using Elements of the Legislation as a PackageLegislation as a Package

Integrating systems for payment and quality improvement

Patient focus and primary care

Opportunity for public health overlay

63


ACA Opportunities:ACA Opportunities:Title IV, Subtitle ATitle IV, Subtitle A

The new National Prevention, Health Promotion and Public Health Council

The new Advisory Group on Prevention, Health Promotion, and Integrative Public Health

Use of a new Prevention and Public Health Fund

CDC to convene an independent Community Preventive Services Task force

64


ACA Opportunities:ACA Opportunities:Title IV, Subtitle A, continued…Title IV, Subtitle A, continued…

Planning and implementation of a national public-private partnership for a prevention and health promotion outreach and education campaign to raise public awareness of health improvement across the life span

Establish and implement a national science-based media campaign on health promotion and disease prevention

65


ACA Opportunities:ACA Opportunities:Title IV, Subtitle BTitle IV, Subtitle B

School-based health centers

Medicare coverage of personalized prevention plan services

66


ACA Opportunities:ACA Opportunities:Title IV, Subtitle CTitle IV, Subtitle C

CDC grants for implementation, evaluation, and dissemination of evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities, and develop a stronger evidence base of effective prevention programming

Grants to provide public health community interventions, screenings, and clinical referrals for persons between ages 55 and 64

67


ACA Opportunities:ACA Opportunities:Title IV, Subtitle DTitle IV, Subtitle D

Funding for research in the area of public health services and systems

Employer based wellness assisted

Epidemiology and Laboratory Capacity Grant Program

Funds to carry out childhood obesity demonstration projects

68


Significant LimitsSignificant Limits

Reproductive Health – Retreat from Reproductive Health – Retreat from current lawcurrent law– Contraception (Preventive?)Contraception (Preventive?)– Abortion care (Hi-risk pools, Exchanges)Abortion care (Hi-risk pools, Exchanges)

Immigrants’ inclusion: Undocumented Immigrants’ inclusion: Undocumented cannot purchase thru Exchangecannot purchase thru ExchangeAffordabilityAffordabilityState options for innovative approaches State options for innovative approaches – Single payerSingle payer

February 2011February 2011 EQUALEQUAL 7070July, 2010July, 2010 EQUAL/Center for Policy AnalysisEQUAL/Center for Policy Analysis 7070

Always a Tough RoadAlways a Tough Road


Structural Adjustment for the U.S.Structural Adjustment for the U.S.1980 - present1980 - present

DeregulationDeregulation

PrivatizationPrivatization

Constraints on public interest Constraints on public interest organizations (civil society)organizations (civil society)


Effect: Income Inequality ExplodesEffect: Income Inequality Explodes1979-20051979-2005

1947 and 1973: income growth was distributed 1947 and 1973: income growth was distributed roughly equally: income growth at least as fast roughly equally: income growth at least as fast for the poorest 20% of families as the richest for the poorest 20% of families as the richest 20% 20% 1979-2005: Bottom fifth of households: average, 1979-2005: Bottom fifth of households: average, inflation-adjusted income growth of just $200 inflation-adjusted income growth of just $200 over the entire 26-year period.over the 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.

Economic Policy InstituteEconomic Policy Institute


Health Care Policy: CorporationsHealth Care Policy: Corporations

Maintain control of health care Maintain control of health care benefits=workplace disciplinebenefits=workplace discipline

Oppose government role, favor private Oppose government role, favor private insurance industryinsurance industry

Public relationsPublic relations– LibertyLiberty– Freedom of choiceFreedom of choice


Health Care Industry: $2.5 THealth Care Industry: $2.5 T

Insurance co.s Insurance co.s – Lack clout to negotiate rates with Lack clout to negotiate rates with

concentrated providers (hospital chainsconcentrated providers (hospital chains– Individual market: adverse selectionIndividual market: adverse selection– Price gougingPrice gouging

Providers: Hospitals, docs, drugs, medical Providers: Hospitals, docs, drugs, medical supplysupply– [some] Government payments, yes[some] Government payments, yes– Negotiated prices, noNegotiated prices, no

February 2011February 2011 EQUALEQUAL 7575July, 2010July, 2010 EQUAL/Center for Policy AnalysisEQUAL/Center for Policy Analysis 7575

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


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

Trade imbalanceTrade imbalance

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


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


Contest for the FutureContest for the Future

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


Trust Women/Silver Ribbon MonthTrust Women/Silver Ribbon Month

Anniversary of Roe v. Wade: Jan. 22Anniversary of Roe v. Wade: Jan. 22

Broad coalition of health, repro rights, Broad coalition of health, repro rights, social justice groupssocial justice groups

The majority needs a visible, vocal The majority needs a visible, vocal campaigncampaign

Speak out, take action, wear silver ribbon:Speak out, take action, wear silver ribbon:

“ “Trust Women”Trust Women”


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 important role of effective, Reclaim the important 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 Security Defend Medicare and Social Security


Health Care Policy Is Linked With Health Care Policy Is Linked With Broader AgendasBroader Agendas

Demand policies that create a healthy economyDemand policies that create a healthy economyPublic investment to re-stimulate productivity Public investment to re-stimulate productivity and demand:and demand:– Jobs to lower-income people create demandJobs to lower-income people create demand– Health care, education, energy, environmentHealth care, education, energy, environment

Fair financing for public servicesFair financing for public servicesGovernment role to support baseline survival, Government role to support baseline survival, advance social justice and wellbeingadvance social justice and wellbeing– Guarantee rule of law – financial regulation Guarantee rule of law – financial regulation – Activate organizations of civil society Activate organizations of civil society


Building for the FutureBuilding for the Future

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

[email protected]@list.equalhealth.info

www.equalhealth.infowww.equalhealth.info

Thanks for contributions to this presentation to: Keely Monroe, Lisa Thanks for contributions to this presentation to: Keely Monroe, Lisa Kernan Social Justice Fellow; EQUAL partners including Deborah Kernan Social Justice Fellow; EQUAL partners including Deborah LeVeen, Elinor Blake, Karl Keener, Joel Adelson, Lee Lawrence, LeVeen, Elinor Blake, Karl Keener, Joel Adelson, Lee Lawrence, Robert Mason; and many organizationsRobert Mason; and many organizations

The Affordable Care Act: Opportunities for Care and for Single Payer

Documents

affordable care act

quality improvements2014

poverty level2020

aca benefits

major victorysingle

private nongroupother11

nownew high risk pool

immediate improvementsin