Will the Midterm Elections Transform Our Health System? · 2018-10-04 · Will the Midterm Elections Transform Our Health System? Daniel Derksen, M.D. | October 3, 2018 | Duvall Auditorium,

Will the Midterm Elections Transform Our Health System?Daniel Derksen, M.D. | October 3, 2018 | Duvall Auditorium, Tucson, ArizonaAssociate VP for Health Equity, Outreach & Interprofessional Activities Walter H. Pearce Endowed Chair & Director, Center for Rural Health

• I do not represent the positions of the UA or the Arizona Board of Regents.• I will express my personal opinions based on

more than 30 years of experience as a family physician and in applied health policy to inform the public, providers, and policymakers. • I cite primary source data in this presentation &

the handout posted at: http://crh.arizona.edu

Daniel Derksen, M.D. Statement

Dan Derksen, MD

Dan Derksen, M.D.UAHS Associate Vice President

for Health Equity, Outreach & Interprofessional Activities

March 1, 2017 CNN Town Hall Question

“How will you make sure the country doesn’t return to having 48 million people without health insurance?”

Dan Derksen, MD

New YorkerWorld View

UAHS World View?

Dan Derksen, MD

YouAreHere!

You Are

Here!

Dan Derksen, MD

Arizona Hispanic Center of ExcellenceCenter for Elimination of Border Health Disparities

Office of Diversity and Inclusion

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UA Arthritis CenterState Office of Rural Health

Center for Rural HealthArizona Center on Aging

Opioid Assistance and Referral LineW. Region Public Health Training Center

Area Health Education CentersAZ Poison Control & Information Center

Arizona’s Smokers’ HelplineAZ Telemedicine Program

Banner University Medical Center

Center for Innovation in Brain ScienceCenter for Population Science & Discovery

UA Cancer CenterPrevention Research Center

Academic

Silos

Shawn Braley

Dan Derksen, MD

What’s past is prologueShakespeare: The Tempest

Eight Years Ago

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Affordable Care Act Signing March 2010https://www.washingtonpost.com/graphics/national/obama-legacy/obamacare.html

Five Years Ago Brewer wins Medicaid expansionBy Kyle Cheney & Jason Millman 06/13/2013

AZ Gov. Jan Brewer muscled to victory in her Medicaid expansion crusade, outmaneuvering conservative opposition to push through a key piece of President Obama’s agenda.

Dan Derksen, MD

https://www.politico.com/story/2013/06/arizona-medicaid-expansion-jan-brewer-092723

AZ Pre-ACA Health Coverage 2013Payer Source Arizonans % AZ Pop

Medicaid + CHIP (AHCCCS + KidsCare) 1,320,000 20%

Uninsured 1,225,000 19%Total AZ Population 6,458,000 100%

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AZ Health Coverage 2018Medicaid + CHIP 1,689,000 24%

Uninsured 725,000 10%Total AZ Population 7,016,000 100%

Medicaid/AHCCCS+CHIP: Medicaid/CHIP July 2018: https://www.medicaid.gov/state-overviews/stateprofile.html?state=arizona

Arizona ACA Impact

AZ #5 in Health Sector Job Growth

Since 2010

AZ #13 in Uninsured

Decline

https://www.azcentral.com/story/money/business/health/2017/01/27/ducey-cites-obamacare-harm-arizona-seeking-repeal-laws-positives-complicate-issue/96998808/

Dan Derksen, MD

AZ Hospital Financial Trends SinceMedicaid Restoration and Expansion

AzHHA@https://static1.squarespace.com/static/572a399a1bbee0add26af051/t/5aa86c57f9619a457058032e/1520987224999/January+2018+Hospital+Financial+Reports.pdf

For the 12 months ending Jan 2014 and Jan 2018:• Uncompensated care dropped from 7.9% to 2.4%• Avg. operating margin increased from 3.1% to 5.1%

Dan Derksen, MD

Federal Per Capita Medicaid Enrollee Spending by State 2017

0

2,000

4,000

6,000

8,000

10,000

12,000

DC NY WV RI CT OR VT MOMS DE KY MN AR TN MT OH ND PA MEMA ID LA MD IA IN US AK NC UT NM KS SC AL WI CA WYWA OK TX MI NJ GA FL VA AZ NE SD HI CO NV IL NH

Data: J. Holahan and M. Buettgens, Block Grants and Per Capita Caps: The Problem of Funding Disparities Among States, Urban Institute, Sept. 2016, available at http://www.urban.org/research/publication/block-grants-and-capita-caps.Rosenbaum S Commonwealth Fund Mar 2017: http://www.commonwealthfund.org/publications/issue-briefs/2017/jan/medicaids-future-aca-repeal

U.S. AVG.

AZ#8

LowestCost

While Arizona’s Federal Medical Assistance Percentage (FMAP) is high

(69%), its federal spending is 8th lowest

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U.S. Coverage: >40% Public# covered in millions (%)

Private Health Insurance1

Employer Sponsored ESI

Individual Purchase (Non-Group)

179 (54%)157(43%)22 (11%)

Medicaid + CHIP2 73 (22%)Medicare3 59 (18%)Uninsured 28 (8.8%)

Total Population4 328 (100%)Note: 9 million Americans have both Medicaid and Medicare (dual eligible)1.2016 KFF Data at: https://www.kff.org/other/state-indicator/total-population2. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html3. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html4. US Census 2018 U.S. Population: https://www.census.gov/popclock/

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Medicaid + CHIP Cover 73M 22% of Americans

Over half are children

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Accessed 10/01/2018 for enrollment and pop. estimates as of July 2018: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.htmlhttps://www.census.gov/popclock/

Medicaid Also Covers the Blind, Disabled, Frail Elderly, Long Term Care

MEDICAID Blind, Elderly, Disabled

Of 68 Million on Medicaid in 2016 24% Enrollees

Park, H. NYT 03/07/17: https://www.nytimes.com/interactive/2017/03/07/us/politics/medicaid-reform-impact-on-states.html?_r=0

Of Medicaid’s $566 Billion Costs 63% of Costs

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States Not Expanding Medicaid - Higher Rural Hospital ClosuresMAYBE: 3 States ID, UT, NEYES: 33 States

NO: 14 States

-14 ruralhospitals

ACA Medicaid Expansion by State

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Uninsured, CMS Medicaid & Medicare payment policies drive

rural provider fiscal viability

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Hispanic+4 Million

Insured

Black +3MWhite +8.9M

Accessed 10/02/18 at: https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf

Uneven Decline in Uninsured by Race & Ethnicity Post-ACA

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30%Uninsured

In 2016

2016Uninsured

7%

Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.

Dan Derksen, MD

Interaction Institute for Social Change, Artist: Angus Maguire

Shift from Passive Observers to Active Participants

2019 Prelude? Tax Cuts & Jobs Act 12/2017

• Repeals ACA tax penalty for being uninsured in 2019• Increases uninsured by 4M by 2019, 13M by 2027• Destabilizes individual health insurance market• Increases fed deficit $1.5 trillion over 10 years

Dan Derksen, MD

46% projected 2019 deficit relates to bills signed in last 12 mo.

https://www.congress.gov/bill/115th-congress/house-bill/1/text?format=txthttps://www.cbo.gov/publication/53300http://www.crfb.org/blogs/fiscal-year-defined-24-trillion-new-debthttps://www.wsj.com/livecoverage/tax-bill-2017/card/1512431352

Tax Cuts & Jobs Act 12/2017

Temporarily lowers individual tax rate Individuals gain +1.6% income overall

Drops to +0.3% in 2027https://www.congress.gov/bill/115th-congress/house-bill/1/text?format=txthttps://www.cbo.gov/publication/53300https://www.wsj.com/livecoverage/tax-bill-2017/card/1512431352

Permanently lowers corporate tax rate from 35% to 21%

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Repeal the Social Security ActReplace ‘entitlements’ with: •Medicaid Block Grants•Medicare Market Vouchers• Privatize Social Security

Accessed 09/26/18 at:http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf

House Speaker Paul Ryan

One View of Paying for the Corporate Tax Cut

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?

How Would Arizona Do with a Medicaid /AHCCCS Block Grant?

States faring worse with Medicaid block grants: X Expanded MedicaidX Cost efficient X Rapid growth in low-income elderly

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Park, H. NYT 03/07/17: https://www.nytimes.com/interactive/2017/03/07/us/politics/medicaid-reform-impact-on-states.html?_r=0

U.S.Avg.

2017 American Health Care Act Effects

# Insured Decreasing Over 10 Years -24 M

# Insured Decreasing in 2018 Alone -14 M

Medicaid $$$ Cut to States Over 10 Years -880 B

2019 Preamble? One Vote Short in 2017 of: Almost $1 Trillion in Medicaid Cuts

CBO-JCT Cost and Coverage Estimates of the American Health Care Act, 03/23/2017: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628.pdf

Dan Derksen, MD

Dan Derksen, MD

CNN Town Hall March 1, 2017Town Hall March 1, 2017

Town Hall March 1, 2017“We’re not gonna throw anybody off of

health care - as long as that fundamental principle is there, we will be fine.” Sen. McCain

From 3/1/17 At 22min:45sec: https://www.youtube.com/watch?v=19G_xRx9G-c

Dan Derksen, MD

McCain Votes NO

July 27, 2017 at: https://www.washingtonpost.com/video/national/mccain-votes-against-skinny-repeal-health-care-bill/2017/07/28/206422e2-7356-11e7-8c17-533c52b2f014_video.html?utm_term=.fb5b87c3c8cc

Dan Derksen, MD

Dan Derksen, MD

“I believe we could do better working together, Republicans and Democrats,

and have not yet really tried” Sen. McCain

Arizona Nonpartisan Health Policy Collaboration in 2018

Legislature Unanimously Passes AZ Opioid Epidemic Act Gov. Ducey Signs 1/26/18

HB 2235 Dental

Therapists

HB 2324 CHW VoluntaryCertification

Dan Derksen, MD

Sen. Barto

Rep. Carter

Education Is a Social Determinant of Health

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Undermining Medicaid Coverage withSec. 1115 Soc. Sec. Act Waivers

Seeking CMS ok for work requirements: AR, AZ, IN, KS, KY, ME, NH, UT, WI

CMS approved them for AR, KY, IN, NH

https://www.healthaffairs.org/do/10.1377/hblog20181001.233969/full/https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issues/

Dan Derksen, MD

CMS Denies KS Lifetime Medicaid Limits

Arizona pulls back from imposing time limits on AHCCCS enrollmentStephanie Innes | May 13, 2018

https://www.nytimes.com/2018/06/29/health/kentucky-medicaid-work-rules.htmlhttp://tucson.com/news/local/arizona-pulls-back-from-imposing-time-limits-on-ahcccs-enrollment/article_7812f83c-3160-5fef-bd1d-aa3ff70a711c.html

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Judge Strikes Down Kentucky’s Medicaid Work RulesAbby Goodnough | June 29, 2018

What’s past is prologue

November 6, 2018

What to come, in yours and mine to discharge

William Shakespeare: The Tempest Act II

Dan Derksen, MD

37 states begin voting 5 to 45 days before Nov 6

Arizona Voting Starts Oct 10

2018 US Senate 2*51 R49 D

35 Seats Up26 held by D’s

Dan Derksen, MD

In 2016 in the U.S.245.5M Eligible to Vote

157.6M Registered to Vote136.8M Voted

http://www.pewresearch.org/fact-tank/2018/05/21/u-s-voter-turnout-trails-most-developed-countries/

*Seats needed to change majority

2018 US House 25*236 R193 D

6 Vac

All 435 Up

87% of Registered Americans Voted 56% of Eligible Americans Voted

2018 CurrentAZ Senate 3*

17 R13 D

2018 CurrentAZ House 6*

35 R25 D

In August 2018 in Arizona1,264,295 (34.8%) Registered Republicans1,256,170 (34.6%) Other1,111,580 (30.6%) Registered Democrats3,632,045 Registered Arizona Voters1

1. 09/23/2018 at: https://azsos.gov/elections/voter-registration-historical-election-data 2. AZ Capitol Times: https://azcapitoltimes.com/news/2018/07/26/nearly-half-of-eligible-voters-in-arizona-dont-cast-ballots/

Dan Derksen, MD

*Seats needed to change majority

74% of Registered Arizonans Voted in 201657% of Eligible Arizonans2 Voted in 2016

• Justice Gorsuch Age 51, 2017: Justice Scalia Age 80 (dec.)• Justice Kennedy: Retired Age 82 in July, 30 yrs SCOTUS• Justice Breyer: Age 80, in 25th year on SCOTUS• Ruth Bader Ginsburg: Age 85, in 26th year on SCOTUS

Midterm and the Supreme Court of the United States (SCOTUS)

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•Spiraling drug costs•Losing coverage•Cutting Medicaid, Medicare•Covering ‘pre-existing’ conditions•Shifting costs to elderly Americans with chronic disease - diabetes, hypertension, arthritis, heart disease

Healthcare Is the #1 Voter Concern This Midterm Election

Dan Derksen, MD

http://media1.s-nbcnews.com/i/today/z_creative/18416NBCWSJJunePoll6718Release.pdf

•From 2008-15 brand name drug prices rose by 164%, 12X rise in CPI (13.5%)•Prices fall 75% after patents endPolicy Interventions:•Fast track generic applications to FDA• Import off-patent drugs•FTC strict oversight of drug co. mergers

U.S. Drug Prices – Health Policy

Dan Derksen, MD

https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.0628https://data.bls.gov/pdq/SurveyOutputServlet?request_action=wh&graph_name=CU_cpibrief

•Allow Medicaid ‘buy-in’ for states (NV)•Manage costs: home, community (ALTCS)•Pay value-based care v fee-for-service•Eliminate steps not adding value: billing, collecting, EHR documenting•Shift from PhRMA & insurance company ‘hold harmless’ policy approaches to:

hold accountable

Innovative Policy Interventions

Dan Derksen, MD

Dan Derksen, MD

To carry a positive action we must develop a positive vision

Dalai Lama

Lake Mary

COCOnino National Forest

Día de los MuertosOct 31 to Nov 2

Though I have to say goodbyeRemember me

Dan Derksen, MD

Día de los Votos: Nov 6AZ: Register to Vote by Oct 9

Though I have to say goodbyeRemember to vote!

Dan Derksen, MD