1. The Affordable Care Act (Obamacare) and the Single Payer Alternative Leonard Rodberg Professor and Chair, Urban Studies Department, Queens College and Research Director, NY Metro Chapter, Physicians for a National Health Program November 2015

2. The Affordable Care Act 2010 “A f***** big deal” – Joe Biden

3. Yes, more people have insurance

4. …and Millions Are Still Uninsured Millions Note: The uninsured include about 5 million undocumented immigrants. Source: Congressional Budget Office. (Projected)

5. * Estimate is statistically different from estimate for the previous year shown (p<.05). SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2014. Why Health Care Was On the Agenda: Escalating Cost

6. …and costs are still out of control While… Millions still have no coverage. High deductibles and co-pays keep those with coverage from actually using it. Billing-related administrative waste still consumes 20-30% of our health care dollar.

7. What the Affordable Care Act (Obamacare) Did: It established the principle that the federal government has the responsibility to see that everyone has access to health care. What It Didn’t Do: It failed to achieve either cost control or universal access.

8. Total health expenditures as percent of GDP Source: OECD Health Data 2010 (Oct. 2010). It doesn’t have to be this way. Every other country covers all their citizens, and spends half of what we do.

9. What Makes the Difference? Unlike in the US -- in these countries government has a central role in Funding the system Overseeing and regulating it. Our own Medicare program for seniors shows the benefits of a government-funded, regulated system Reliable financing Slower cost growth Transparent coverage decisions.

10. Most Americans Get Their Coverage from the Private Sector… Source: Health Insurance Coverage in the United States: 2013, Census Bureau, 2014 (169.0 million) (49.0 million) (54.1 million) (42.0 million) (34.5 million) (14.1 million)

11. But Most of the Money Comes from the Public Sector Out of pocket 12% Other private funds (charity, etc.) 7% State and Local Government (existing Medicaid, other) 13% Federal Government (existing Medicare, Medicaid, other) 34% Source: Health Affairs, Feb. 2010; data for 2009 Private Insurance 34% (Federal tax subsidy)

12. In Deciding on a Plan, the President Made a Fateful Choice He could have chosen to (1) build on the public sector, which now provides more than half the money, or (2) expand the private sector. He chose to build his program by (1) enlarging Medicaid for the poor, and (2) expanding private insurance for the rest of us

13. The New Reform Plan: Affordable Care Act (ACA) Continued reliance on private insurance Employment-based insurance unchanged Market competition determines premiums, co-pays, and deductibles Experimental pilot programs try to reduce costs Result: About 10% of the population will get covered, the rest will see little change.

14. Starting in 2014, online insurance “marketplaces” offer private insurance to individuals and employers Citizens and legal immigrants required to purchase private insurance or sign up for Medicaid. Premium subsidies up to 400% poverty level Medicaid for all below 138% poverty level “Hardship waiver” if premium too expensive  can remain uninsured! Affordable Care Act or ACA: The Health Reform Law of the Land

15. Underinsurance is Now the Norm

16. What’s Covered

17. … and Costs Keep On Rising National Health Expenditures (trillions) Notes: * Modified current projection estimates national health spending when corrected to reflect underutilization of services by previously uninsured. Source: D. M. Cutler, K. Davis, and K. Stremikis, Why Health Reform Will Bend the Cost Curve, Center for American Progress and The Commonwealth Fund, December 2009. Estimated Financial Effects of PPACA as Amended, Richard Foster, CMS Actuary, April 2010 $4.67 $4.5 6.4% annual growth 6.6% annual growth 6.0% annual growth $4.7 National Health Expenditures as Percent of GDP 17.8 17.9 18.0 18.2 18.8 19.3 19.8 20.2 20.5 21.0

18. Principal Consequences Little change for most people Those using the marketplaces face costly premiums, deductibles and copays and limited choice of doctors and hospitals Millions remain uninsured and underinsured Costs continue to rise

19. How Canadians Get Health Care Provinces pay for all health care, with federal government contributing  a “single payer” system No co-pays or deductibles Doctors bill the province once a month Hospitals receive an annual budget Funded through federal and provincial taxes Result: 100% of the population covered, spend 10% of GDP on health care

20. The Public Route to Health Care Reform: Conyers’ Expanded and Improved Medicare for All Single Payer HR 676 Extend Medicare to cover everyone Comprehensive benefits, free choice of provider No cost-sharing (no deductibles, no co-pays) Public agency pays the bills Funded through progressive taxes Costs no more than we are now spending

21. Single PayerReform in New York State: Gottfried-Perkins New York Health Bill Universal coverage: everybody in, nobody out! Comprehensive benefits No co-pays or deductibles Free choice of doctor and hospital All payments from a single state fund Covering everyone while spending less

22. Who Would Be Eligible? Every resident of New York StateEvery resident of New York State No barriers due to age, sex, income,No barriers due to age, sex, income, employment, or health status employment, or health status No premiumsNo premiums No co-paysNo co-pays No deductiblesNo deductibles New York Health #1

23. Comprehensive Benefits Primary and preventive carePrimary and preventive care Inpatient and outpatient hospital careInpatient and outpatient hospital care Care coordinatorCare coordinator assists in navigating the system, receiving necessary care Prescription drugsPrescription drugs Dental, vision, & hearing careDental, vision, & hearing care Free choice of doctor, including primary care physician & specialists, and hospitalFree choice of doctor, including primary care physician & specialists, and hospital New York Health #2

24. New York Health #3 Who Will Run It? Administered by NYS Dept of HealthAdministered by NYS Dept of Health Overseen by broadly-representativeOverseen by broadly-representative Board of Trustees including Board of Trustees including consumers and providers consumers and providers

25. How Will It Be Paid For? How Will It Be Paid For? Insurance premiums eliminatedInsurance premiums eliminated Graduated payroll assessment, 80%/20% paidGraduated payroll assessment, 80%/20% paid by employer/employee by employer/employee Graduated assessment on upper-bracket non- wage income (dividends, rents, capital gains) Federal funds from Medicare, Medicaid, ACAFederal funds from Medicare, Medicaid, ACA (needs Federal waiver in 2017) (needs Federal waiver in 2017) All funds placed in NY Health Trust FundAll funds placed in NY Health Trust Fund New York Health #4

26. Big Savings from Unified System: Billing and insurance overhead now consume nearly 30 cents of every dollar 28% Spending through private insurers

27. Covering Everyone while Saving Money! Additional costs Covering the uninsured and poorly-insured +1.4% Elimination of cost-sharing and co-pays +3.9% Enhanced Medicare & Medicaid fees +3.8% Savings Reduced insurance administrative costs -9.9% Reduced physician & hospital admin costs -7.2% Bulk purchasing of drugs & devices -5.7% Reduced fraud -1.9% Source: Economic Analysis of the NY Health Act, Gerald Friedman, April 2015 4.0 11.2 10.8 26.0 -28.6 -20.7 -16.3 - 5.4 -71.0 2019 $B Total Costs +9.1% Total Savings -24.7% Net Savings -15.6% - 45

28. How to Pay for It

29. Nearly Everyone Would Save Money

30. Mexican Universal Health Care https://www.youtube.co m/v/N938k6lIugY