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1 Health Care Coverage: Different Problems, Different Solutions, Everyone’s Issue Marcia L. Comstock, MD MPH Carol A. Staubach, MPH.

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Presentation on theme: "1 Health Care Coverage: Different Problems, Different Solutions, Everyone’s Issue Marcia L. Comstock, MD MPH Carol A. Staubach, MPH."— Presentation transcript:

1 1 Health Care Coverage: Different Problems, Different Solutions, Everyone’s Issue Marcia L. Comstock, MD MPH Carol A. Staubach, MPH

2 2 Today’s Agenda on the Uninsured What does it mean? What does it mean? Why should you care? Why should you care? How did we get here? How did we get here? What do you think? What do you think? What do others think? What do others think? What can be done? What can be done?

3 3 Cover the Uninsured Week Does insurance “coverage” equal “access”? Does insurance “coverage” equal “access”? Is each of us our “brothers’ keeper”? Is each of us our “brothers’ keeper”? Should it matter to us as an individual, as a member of a family, as a member of society that many Americans are not assured access to healthcare that promotes and sustains health and productivity? Should it matter to us as an individual, as a member of a family, as a member of society that many Americans are not assured access to healthcare that promotes and sustains health and productivity?

4 4 Key Facts About Health Insurance About 246 million people have health insurance that pays part of the costs of getting care. About 246 million people have health insurance that pays part of the costs of getting care. Almost 46 million individuals do not have health insurance. Almost 46 million individuals do not have health insurance. The likelihood of an individual or family being covered depends on many factors, including the kind of job they have, their income level, where they live, their age, and their health status. The likelihood of an individual or family being covered depends on many factors, including the kind of job they have, their income level, where they live, their age, and their health status.

5 5 Who Lacks Access to Health Insurance? More than 1 in 7 Americans – almost 46 million – do not have health insurance. They are not necessarily “poor.” They are not necessarily “poor.” Over 80% are members of working families, often they can’t afford to buy health insurance. Over 80% are members of working families, often they can’t afford to buy health insurance. Over 80% of uninsured children live in families with at least one working parent. Over 80% of uninsured children live in families with at least one working parent. Some uninsured could afford to buy health insurance, but choose not to. Some uninsured could afford to buy health insurance, but choose not to.

6 6 Who are the Uninsured? Source: Economic Research Initiative on the Uninsured; based on MEPS 2002 data.

7 7 Most Uninsured People Work Note: Numbers may not add up to 100% due to rounding. Source: Economic Research Initiative on the Uninsured, 2005.

8 8 Most Uninsured People Have Incomes Above the Poverty Line Note: Numbers may not add up to 100% due to rounding. Source: Economic Research Institute of the Uninsured, 2005.

9 9 In fact, the fastest growing segment of the population lacking insurance is for individuals and families with annual incomes over $75,000.

10 10 The Uninsured* are More Likely to Not Get Care Due to Cost Source: Centers for Disease Control and Prevention, National Center for Health Statistics, *People under age 65 in 2003.

11 11 Becoming Uninsured Could Happen To You!!! Unexpected changes can affect coverage: Serious illness or injury Serious illness or injury Worsening of a chronic condition Worsening of a chronic condition Losing or switching jobs (after federal COBRA protection runs out or is unaffordable) Losing or switching jobs (after federal COBRA protection runs out or is unaffordable) Changes to health insurance policies Changes to health insurance policies

12 12 What are the Consequences of Being Uninsured? People without insurance: Are less likely to get health care that they need, especially preventive care and treatments for chronic health problems Are less likely to get health care that they need, especially preventive care and treatments for chronic health problems Are at risk for the huge expenses of catastrophic health care Are at risk for the huge expenses of catastrophic health care May have worse health outcomes May have worse health outcomes ~18,000 died last year because they did not have health insurance, according to IOM ~18,000 died last year because they did not have health insurance, according to IOM

13 13 What are the Consequences of Having Uninsured People in Our Community? A burden on hospitals for uncompensated care A burden on hospitals for uncompensated care Cost-shifting to employers Cost-shifting to employers Negative impact on community health Negative impact on community health Drain on economic development Drain on economic development

14 14 How Did We Get Here? In the beginning……. Insurance: Coverage by contract in which one party agrees to indemnify (guard or secure against anticipated loss) or reimburse another for any loss that occurs under terms of the contract.

15 15 Before Health Insurance… US railroads and wanted to insure productivity of employees US railroads and wanted to insure productivity of employees Hired contract physicians (surgeons) to care for employees Hired contract physicians (surgeons) to care for employees No insurance—healthcare services provided for employees…but in the interest of their employer! No insurance—healthcare services provided for employees…but in the interest of their employer!

16 16 The Beginning of Health Insurance-”The Blues” Blue Cross 1 st created by President of Baylor University to pay for hospital care Blue Cross 1 st created by President of Baylor University to pay for hospital care If everyone paid a small amount ($15/wk), those that needed hospitalization could be cared for (benefit of $25,000) If everyone paid a small amount ($15/wk), those that needed hospitalization could be cared for (benefit of $25,000) 1932-Texas Legislature passed the enabling statute to create the first blues plan 1932-Texas Legislature passed the enabling statute to create the first blues plan Law became a national model Law became a national model It was expanded after a decade to include payment for physician services, “blue shield” It was expanded after a decade to include payment for physician services, “blue shield” The plans were NFP companies The plans were NFP companies BODs represented community-citizens, providers, businessmen BODs represented community-citizens, providers, businessmen Concept of “shared social responsibility” Concept of “shared social responsibility”

17 17 Employer Role in Healthcare Originally employer-based insurance was not for healthcare. It started as insurance for lost wages when ill Originally employer-based insurance was not for healthcare. It started as insurance for lost wages when ill Early 1940s: amendments to Tax Codes allow business to offer health insurance to help recruit workers despite wartime wage freezes Early 1940s: amendments to Tax Codes allow business to offer health insurance to help recruit workers despite wartime wage freezes : growth in cost & utilization of medical services by employees, supported by labor unions : growth in cost & utilization of medical services by employees, supported by labor unions Health insurance typically 80/20; co-pays, deductibles Health insurance typically 80/20; co-pays, deductibles 1980s: growth of managed care as response to rising costs- temporarily effective—1 st dollar coverage, NOT insurance 1980s: growth of managed care as response to rising costs- temporarily effective—1 st dollar coverage, NOT insurance Late 1990s-resurgence of costs Late 1990s-resurgence of costs move to consumer-directed health plans…..??solution move to consumer-directed health plans…..??solution Some employers offer on-site clinics/pharmacies….?Back to the future? Some employers offer on-site clinics/pharmacies….?Back to the future?

18 18 The 5 A’s of Access Health insurance does not equal access to the right healthcare! Affordability Affordability Accessibility Accessibility Acceptability Acceptability Assurance Assurance Appropriateness Appropriateness

19 19 Coverage & Access: What Does it Mean? Coverage refers to the ‘menu’ of what is available through an insurance policy (limited vs comprehensive.) Relates to technical adequacy and assurance of services Coverage refers to the ‘menu’ of what is available through an insurance policy (limited vs comprehensive.) Relates to technical adequacy and assurance of services Access refers to what is 'practically' available and encompasses barriers such as affordability and logistical accessibility Access refers to what is 'practically' available and encompasses barriers such as affordability and logistical accessibility Coverage opens the door but does not ensure access! Coverage opens the door but does not ensure access!

20 20 Issues with Coverage & Access What are we trying to achieve with coverage and access?? What are we trying to achieve with coverage and access?? Language is important! People don’t use these terms to mean the same thing. Language is important! People don’t use these terms to mean the same thing. If coverage equals insurance, we need to answer the question, insurance for what? If coverage equals insurance, we need to answer the question, insurance for what? We have not been able to reconcile our split approach to “sponsorship” of health insurance, or pick one over the other. We have not been able to reconcile our split approach to “sponsorship” of health insurance, or pick one over the other. Coverage means more than insurance. It is 'protection', 'security' that is defined at the individual level Coverage means more than insurance. It is 'protection', 'security' that is defined at the individual level

21 21 Do you have health insurance? Do you have health insurance? Did you purchase it yourself? Did you purchase it yourself?

22 22 The Plight of Employers

23 23 Our Health Care Crisis Total health care spending represents 16 percent of the gross domestic product Total health care spending represents 16 percent of the gross domestic product Estimated to reach 20 percent by Estimated to reach 20 percent by The US has the highest per worker health care costs in the world The US has the highest per worker health care costs in the world Impact Impact Erodes corporate profits Erodes corporate profits Reduces growth of business Reduces growth of business For small enterprises or those with low profit margins For small enterprises or those with low profit margins Reduces number of jobs Reduces number of jobs Reduces compensation packages Reduces compensation packages Increases unemployment and uninsurance Increases unemployment and uninsurance

24 24 What Do We Get for What We Spend? We spend 33% more than Canada, our nearest competitor on costs We spend 33% more than Canada, our nearest competitor on costs We do not have more doctors or nurses or hospital days We do not have more doctors or nurses or hospital days We do have more MRIs and get more tests-many unnecessary We do have more MRIs and get more tests-many unnecessary We rank lowest of English speaking countries on patient satisfaction and access and on the doctor-patient relationship We rank lowest of English speaking countries on patient satisfaction and access and on the doctor-patient relationship We rank well only on access to specialists and non- urgent care! Is this most important? We rank well only on access to specialists and non- urgent care! Is this most important?

25 25 Health Care Costs and Profit Margins Source: Cowan CA, McDonnell PA, Levit KR, Zezza MA. Burden of health care costs: businesses, households and governments. Health Care Financing Review. 2004

26 26 Projections by 2015 Can Employers Really Afford It? Comparing Healthcare trend figures at compounded rates: 15%,12%,10% and 8% over a 10 year period. Starting point $7,200 or approximately $600 PEPM rates: 15%-$29,128 12%-$22,362; 10%-$18,675; 8%-$15,544 Cost per employee per year

27 Trends 9.2 % increase in premiums 9.2 % increase in premiums Previous years 2000 – 2004 – 14% Previous years 2000 – 2004 – 14% Smallest employers (under 200) hit with highest increases across all sectors – 15% Smallest employers (under 200) hit with highest increases across all sectors – 15% Manufacturing sector hit with highest increases – 11.2 %; healthcare and transportation the least at less than 8% Manufacturing sector hit with highest increases – 11.2 %; healthcare and transportation the least at less than 8%

28 28 Reaction to Premium Increases For Employers For Employers Cost shifting to employees Cost shifting to employees Cost sharing in premiums Cost sharing in premiums Increase co-pays and deductibles Increase co-pays and deductibles Reduce coverage Reduce coverage Drop Insurance Drop Insurance Employee Response Employee Response Pay the Increase Pay the Increase Drop Coverage Drop Coverage

29 Status of Employer Coverage 60% of employers offer insurance, down from 69% in % of employers offer insurance, down from 69% in % for firms greater than % for firms greater than % for firms between 50 – % for firms between 50 – % for firms between 25 – 49 87% for firms between 25 – 49 72% for firms between 10 – 24 72% for firms between 10 – 24 47% for firms between % for firms between 3 - 9

30 30 The Small Employer Firms with less than 20 employees make up 89% of American business and 19% of the working population. Firms with less than 20 employees make up 89% of American business and 19% of the working population. Firms with 20 – 499 employees make up 10% of businesses and represent 33% of the working population Firms with 20 – 499 employees make up 10% of businesses and represent 33% of the working population

31 31 Who Provides Coverage & Who Doesn’t Firms with higher wages where 65% or more of workers earn $20,000 or greater have higher coverage rates than where the majority earn $20,000 or less annually. Firms with higher wages where 65% or more of workers earn $20,000 or greater have higher coverage rates than where the majority earn $20,000 or less annually. Nearly 50% of employers not offering health benefits, pay annual wages of less than $15,000 per year to 40 percent or more of their employees, compared to 13 percent of companies that do offer health benefits. Nearly 50% of employers not offering health benefits, pay annual wages of less than $15,000 per year to 40 percent or more of their employees, compared to 13 percent of companies that do offer health benefits. There are a greater proportion of part-time workers in smaller firms who do not offer benefits. There are a greater proportion of part-time workers in smaller firms who do not offer benefits. The demographics reflect a larger proportion of females, workers under age 30, and minority employees. The demographics reflect a larger proportion of females, workers under age 30, and minority employees. 65 percent of those small employers’ not offering benefits have annual gross revenues that are less than $500,000, 65 percent. For employers with $1,000,000 in gross revenues or more, only 18 percent do not offer benefits. 65 percent of those small employers’ not offering benefits have annual gross revenues that are less than $500,000, 65 percent. For employers with $1,000,000 in gross revenues or more, only 18 percent do not offer benefits. Firms in business less than five years are less likely to offer benefits. Firms in business less than five years are less likely to offer benefits.

32 32 Hidden Costs of Insurance Employee Retirement Income Security Act of Federal governs self-funded plans; states oversee fully insured plans. Employee Retirement Income Security Act of Federal governs self-funded plans; states oversee fully insured plans. Rules, regulations and offerings differ from state to state Rules, regulations and offerings differ from state to state Variables Variables Risk Rating & Underwriting – Some less fair than others Risk Rating & Underwriting – Some less fair than others Administrative Costs – can be as high as 40% of premium Administrative Costs – can be as high as 40% of premium

33 33 WHAT DO YOU THINK?

34 34 What is good public policy to promote adequate coverage & access for all? Is there a level of health services that everyone should be guaranteed? Is there a level of health services that everyone should be guaranteed? Should it be heavily subsidized by government and employers? Should it be heavily subsidized by government and employers? Should individuals who can afford to be allowed to "buy up?" Should individuals who can afford to be allowed to "buy up?"

35 35 Should we work toward financial equity (justice/fairness)? Should we work toward financial equity (justice/fairness)? What does pluralism mean in healthcare? Pluralism that meets the needs of individuals for the kind of care and setting that is appropriate to them? Pluralism in funding streams? What does pluralism mean in healthcare? Pluralism that meets the needs of individuals for the kind of care and setting that is appropriate to them? Pluralism in funding streams? Do we need to ration healthcare? How should it be done? Do we need to ration healthcare? How should it be done?

36 36 WHAT DO OTHERS THINK?

37 37 Voices from Communities… “The measure of a health care system is how it cares for the have-nots.” CEO, Community Health Center, California “The measure of a health care system is how it cares for the have-nots.” CEO, Community Health Center, California “Will the majority of the voting public support giving something up to get everyone covered?” Psychologist, Mississippi “Will the majority of the voting public support giving something up to get everyone covered?” Psychologist, Mississippi “Are we willing to ration for ourselves? When we get sick, we want everything available.” Physician representative of the White House “Are we willing to ration for ourselves? When we get sick, we want everything available.” Physician representative of the White House “More people realize now [than in the early 90s] that the uninsured represent a threat to all of us.” Physician Leader, NH “More people realize now [than in the early 90s] that the uninsured represent a threat to all of us.” Physician Leader, NH

38 38 Harris-Commonwealth Fund Opinion Leaders Survey Covering the uninsured should be Congress’ top priority over the next 5 years Covering the uninsured should be Congress’ top priority over the next 5 years The proportion of Americans without health insurance (currently 18% under 65) should be reduced by half to about 8% in 10 years. The proportion of Americans without health insurance (currently 18% under 65) should be reduced by half to about 8% in 10 years.

39 39 The Citizens’ Health Care Working Group Charged by Congress with engaging the public in a dialogue on healthcare Charged by Congress with engaging the public in a dialogue on healthcare What healthcare benefits and services should be provided? What healthcare benefits and services should be provided? How does the American public want healthcare delivered? How does the American public want healthcare delivered? How should healthcare coverage be financed? How should healthcare coverage be financed? What trade-offs is the public willing to make? What trade-offs is the public willing to make? Recommendations and an action plan will be presented to Congress Recommendations and an action plan will be presented to Congress

40 40 What Does the Public Think? 95% thinks the US healthcare system is in a state of crisis or has major problems 95% thinks the US healthcare system is in a state of crisis or has major problems >90% believe it should be public policy that all Americans have affordable health care coverage >90% believe it should be public policy that all Americans have affordable health care coverage ~90% think it would be better to provide a defined level of services for everyone, rather than providing coverage for particular groups of people as it is now (elderly, poor, employees) ~90% think it would be better to provide a defined level of services for everyone, rather than providing coverage for particular groups of people as it is now (elderly, poor, employees)

41 41 What Does the Public Think? >60% believe the most important reason to have health insurance is to pay for high medical costs >60% believe the most important reason to have health insurance is to pay for high medical costs ~30% believe the most important reason to have health insurance is to pay for everyday medical expenses ~30% believe the most important reason to have health insurance is to pay for everyday medical expenses ~74% believe everyone should be required to enroll in basic health coverage, either public or private ~74% believe everyone should be required to enroll in basic health coverage, either public or private

42 42 What Does the Public Think? ~ 69% think some people should be responsible for paying more than others Criteria varied: Income most popular response; health behaviors also quite high Should public policy continue to use tax laws to encourage employer-based health insurance? Yes47.9% ( ) No52.1% ( )

43 43 What Does the Public Think? Guaranteeing all Americans have health insurance was cited as the number 1 spending priority in nearly all communities Guaranteeing all Americans get healthcare when they need it through public “safety net” programs, (if they cannot afford it) also ranked quite high in most places

44 44 What Does the Public Think? REACTION TO PROPOSALS TO ADDRESS UNINSURED: Not Popular: Offer uninsured Americans income tax deductions, tax credits or other financial assistance to help them purchase private insurance: Rely on free market competition among doctors, hospitals, other healthcare providers and insurance companies rather than having government define benefits and set prices

45 45 What Does the Public Think? REACTION TO PROPOSALS: Mixed reactions: Expand state government programs for low income (Medicaid, SCHIP) Require businesses to offer health insurance to all employees Require all Americans to enroll in basic healthcare coverage, public or private

46 46 What Does the Public Think? REACTION TO PROPOSALS: Most popular: Create a national health insurance program, financed by tax payers, in which all Americans would get their health insurance: (1 st in almost all cities) Expand neighborhood health clinics Open up enrollment in federal programs, e.g., Medicare or FEHBP

47 47 WHAT CAN BE DONE?

48 48 If you segment the uninsured, it is apparent that different answers are needed for different groups: The working poor The working poor Those temporarily uninsured between jobs Those temporarily uninsured between jobs Those who can afford but do not choose to buy insurance Those who can afford but do not choose to buy insurance The young and healthy who feel it is not worth the investment for them The young and healthy who feel it is not worth the investment for them

49 49 Solutions for Employers

50 50 Potential Solution Join a Purchasing Pool Small employers join forces to create purchasing power and reduce individual inequities by virtue of their size Small employers join forces to create purchasing power and reduce individual inequities by virtue of their size Share risks Share risks Negotiate competitive prices Negotiate competitive prices Gain access to a variety of plans Gain access to a variety of plans Provide affordable co-pays Provide affordable co-pays Streamline and reduce administrative costs Streamline and reduce administrative costs

51 51 Examples COSE – Council of Smaller Enterprises, part of Cleveland Chamber of Commerce COSE – Council of Smaller Enterprises, part of Cleveland Chamber of Commerce Assume role of purchaser Assume role of purchaser At least three health plan alternatives At least three health plan alternatives Health Pass – New York Business Group on Health – for employers with less than 50 workers Health Pass – New York Business Group on Health – for employers with less than 50 workers 28 benefit plan designs 28 benefit plan designs Provides consulting services Provides consulting services Handles all administrative duties Handles all administrative duties PacAdvantage – California – Pacific Business Group on Health – 2 – 50 employees PacAdvantage – California – Pacific Business Group on Health – 2 – 50 employees

52 52 Community and Private Sector Partnerships Muskegon County, Michigan – for those businesses with median hourly wage of $11.50 or less and have not offered any coverage in previous 12 months Muskegon County, Michigan – for those businesses with median hourly wage of $11.50 or less and have not offered any coverage in previous 12 months County pays 1/3; employer pays 1/3; employee pays 1/3 County pays 1/3; employer pays 1/3; employee pays 1/3 Plans offered are ½ of cost if employer sought plan as an individual employer Plans offered are ½ of cost if employer sought plan as an individual employer New Mexico Health Insurance Alliance New Mexico Health Insurance Alliance

53 53 Another (But Risky) Solution – Self Insurance Financial strategy used primarily by large employers – employer assumes all or part of risks Financial strategy used primarily by large employers – employer assumes all or part of risks Sets funds aside to pay claims as they come in (Vs paying an insurance company a premium) - actors out administrative costs Sets funds aside to pay claims as they come in (Vs paying an insurance company a premium) - actors out administrative costs Exempts the company from state mandates that can be costly and cumbersome for employers who operate in multiple states Exempts the company from state mandates that can be costly and cumbersome for employers who operate in multiple states Increase risk for small firm – one catastrophic medical case could be devastating Increase risk for small firm – one catastrophic medical case could be devastating Purchase Stop Loss Insurance to cover any individual’s medical expenses higher than $25,000 Purchase Stop Loss Insurance to cover any individual’s medical expenses higher than $25,000

54 54 Latest Health Plan Solution Consumer Directed Health Plans High Deductibles High Deductibles HSAs HSAs Requirements Requirements Learn to manage an HSA Learn to manage an HSA Learn to be a savvy medical consumer Learn to be a savvy medical consumer Learn to lead a healthier life Learn to lead a healthier life

55 55 Employer Costs for Poor Health R. Goetzel, JOEM, Jan Total = $9,992

56 56 Trends in Health Status - CDC In 10 years In 10 years Obesity increased 61% Obesity increased 61% Diabetes increased 49% Diabetes increased 49% Serious smoking related illness affects 8.6 million Americans Serious smoking related illness affects 8.6 million Americans $92 billion in lost productivity annually $92 billion in lost productivity annually $75.5 billion in medical expenditures $75.5 billion in medical expenditures

57 57 Less Healthy People – Huge Costs

58 58 Determinants of Healthcare Costs Source: Center for Disease Control and Prevention

59 59 Statistically….For Every 100 Employees 64 are overweight 64 are overweight 25 have high blood pressure 25 have high blood pressure 18 or more have high cholesterol 18 or more have high cholesterol 6 have diagnosed diabetes 6 have diagnosed diabetes 4 have undiagnosed diabetes 4 have undiagnosed diabetes 16 smoke 16 smoke 8 are heavy drinkers 8 are heavy drinkers 29 don’t wear safety belts regularly 29 don’t wear safety belts regularly 50 sit all day to do their work 50 sit all day to do their work 21 have cardiovascular disease 21 have cardiovascular disease Source: Wellness Council of America 2005

60 60 Strategies to Integrate Benefits and Work Site Health Management WEYCO Inc. - service company for benefit plans and management Employees WEYCO Inc. - service company for benefit plans and management Employees Healthcare – eating the bottom line Healthcare – eating the bottom line Employers give employees an unrestricted medical card Employers give employees an unrestricted medical card Employees are making unilateral lifestyle decisions that affect the bottom line and other employees’ paycheck Employees are making unilateral lifestyle decisions that affect the bottom line and other employees’ paycheck

61 61 WEYCO, Inc. Health plans do not emphasize prevention, personal health improvement and compliance Health plans do not emphasize prevention, personal health improvement and compliance Little or no employee involvement in cost Little or no employee involvement in cost Plan Strategy Plan Strategy Align plan with Weyco health strategy Align plan with Weyco health strategy Involve employees and families in prevention Involve employees and families in prevention Move to qualified high deductible plans with health savings accounts (HSA) by 2007 Move to qualified high deductible plans with health savings accounts (HSA) by 2007

62 62 WEYCO, Inc. Health Strategy – As important as customer service, quality, & safety Health Strategy – As important as customer service, quality, & safety Personal health improvement Personal health improvement Reduce demand to reduce costs Reduce demand to reduce costs Eliminate lifestyles that create risk Eliminate lifestyles that create risk Illegal drugs and tobacco Illegal drugs and tobacco Excess use of alcohol Excess use of alcohol Unhealthy eating Unhealthy eating Physical inactivity Physical inactivity

63 63 WEYCO Inc. Worksite Programs Worksite Programs HRA & Biometrics HRA & Biometrics Health Education: Cardio, Strength & Flexibility, Weight Management, Stress Management Health Education: Cardio, Strength & Flexibility, Weight Management, Stress Management Web-based info & Telephonic Health Coach Web-based info & Telephonic Health Coach Physical Evaluations Physical Evaluations Screenings Screenings

64 64 WEYCO Inc. Incentives Incentives Employer contributions/credits for participation in preventive exams, personal evaluation, physical evaluation Employer contributions/credits for participation in preventive exams, personal evaluation, physical evaluation Credits used to reduce employee contributions to plan. Employee pays if chooses not to participate. Credits used to reduce employee contributions to plan. Employee pays if chooses not to participate. Preventive Exams at 100% - Health Credits if exams are completed & verified by 12/31 of each year Preventive Exams at 100% - Health Credits if exams are completed & verified by 12/31 of each year If employee waives coverage, WEYCO provides $ in an HRA if employee provide proof of other medical coverage If employee waives coverage, WEYCO provides $ in an HRA if employee provide proof of other medical coverage

65 65 WEYCO Policy Tobacco-Free Program Tobacco-Free Program Stop hiring or retaining tobacco users Stop hiring or retaining tobacco users Ban the use of tobacco on property Ban the use of tobacco on property Tobacco assessments and voluntary testing Tobacco assessments and voluntary testing Company sponsored smoking cessation programs Company sponsored smoking cessation programs Mandatory testing Mandatory testing Random testing for all employees Random testing for all employees Extend program to spouses Extend program to spouses

66 66 Recent State & Federal Efforts

67 67 S. 1955: Health Insurance Marketplace Modernization and Affordability Act of 2005 A bill to amend title I of the Employee Retirement Security Act of 1974 and the Public Health Service Act to expand health care access and reduce costs through the creation of small business health plans and through modernization of the health insurance marketplace A bill to amend title I of the Employee Retirement Security Act of 1974 and the Public Health Service Act to expand health care access and reduce costs through the creation of small business health plans and through modernization of the health insurance marketplace Introduced by Senator Michael Enzi (R-WY) Introduced by Senator Michael Enzi (R-WY) approved by the Senate Health, Education, Labor and Pensions (HELP) Committee approved by the Senate Health, Education, Labor and Pensions (HELP) Committee

68 68 Critics Fears Legislation, eliminates state jurisdiction and with it almost all state-enacted consumer protections for people buying insurance individually or through their employers Legislation, eliminates state jurisdiction and with it almost all state-enacted consumer protections for people buying insurance individually or through their employers States will no longer be able to mandate coverage of benefits, services, or categories of providers for individuals, small groups, or large group States will no longer be able to mandate coverage of benefits, services, or categories of providers for individuals, small groups, or large group Premium rating protections, enacted by states to make small group insurance more affordable to older and sicker workers, will be set aside Premium rating protections, enacted by states to make small group insurance more affordable to older and sicker workers, will be set aside Insurers will be allowed to sue states that do not comply. The bill sets a ceiling on, but no floor under, what states can do to protect insurance consumers Insurers will be allowed to sue states that do not comply. The bill sets a ceiling on, but no floor under, what states can do to protect insurance consumers

69 69 Massachusetts Universal Health Care Coverage Those without coverage must purchase an “affordable” plan (to be defined) or pay financial penalties Those without coverage must purchase an “affordable” plan (to be defined) or pay financial penalties Businesses with at least 11 workers will provide insurance or pay $295 per employee per year to the state Businesses with at least 11 workers will provide insurance or pay $295 per employee per year to the state Residents with coverage must certify their insurance status on state income tax forms, or face tax penalties Residents with coverage must certify their insurance status on state income tax forms, or face tax penalties State will provide sliding-scale subsidies for people who can't afford to buy a health plan on their own State will provide sliding-scale subsidies for people who can't afford to buy a health plan on their own

70 70 Observations Ability to gain consensus Ability to gain consensus Compromise may be a way to break the gridlock and logjam that exists in Washington and in states across the country Compromise may be a way to break the gridlock and logjam that exists in Washington and in states across the country Details important to the overall acceptability of the new program Details important to the overall acceptability of the new program How much people will have to pay to get insurance How much people will have to pay to get insurance What will the affordable plans cover What will the affordable plans cover Massachusetts precedent of agreeing to expanding coverage with Medicaid waiver program provided the building blocks of working together at state level to allow this next step Massachusetts precedent of agreeing to expanding coverage with Medicaid waiver program provided the building blocks of working together at state level to allow this next step

71 71 What About the Future??

72 72 Perspective of Leaders Comprehensive proposal in the short- term unlikely…until the REAL crisis strikes…?? By 2008 or 2012 elections Comprehensive proposal in the short- term unlikely…until the REAL crisis strikes…?? By 2008 or 2012 elections To develop a long range plan, create a sense of urgency! To develop a long range plan, create a sense of urgency! Healthcare industry leadership must agree that solving the problem will require compromise Healthcare industry leadership must agree that solving the problem will require compromise

73 73 How Can We Make Real Progress? We need to clarify what we want to achieve long-term! We need to clarify what we want to achieve long-term! Don’t assume the federal government will solve the problems Don’t assume the federal government will solve the problems Look to communities for solutions Look to communities for solutions Focus on health—not just healthcare Focus on health—not just healthcare Everyone needs to be involved! Our health is too important to leave to others Everyone needs to be involved! Our health is too important to leave to others

74 74 A Vision for Patient-Centered Care "The care we need and no less, the care we want and no more." Albert Mulley, MD Chief of Internal Medicine, Massachusetts General Hospital

75 75 Marcia L Comstock, MD MPH COOWRGH/FAHCL 117 Lafayette Road Wayne, PA Phone: Fax:

76 76 Carol A Staubach, MPH CA Staubach & Associates 305 E. St. Andrews Drive Media, PA Phone: Fax:


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