Dr. Robert Moss Wofford College THE NEW AMERICAN HEALTH CARE SYSTEM

Health care reform is not new! FDR proposed a bill in 1935 for national health insurance. –Opposition, including AMA, countered that it was “socialized medicine”, would “limit physicians’ freedom”, and interfere with doctor-patient relationship. –Defeated –Defeated again under President Truman, for same reasons

Medicaid and Medicare acts of 1960’s Only covered elderly and poor; left employer-based private insurance to most of the population. U.S. spent approx 6% of GDP on health care. 1971: President Richard Nixon and Senator Ted Kennedy both proposed plans for mandatory coverage; both defeated.

1976, WHO called for universal coverage for all by 2000, as a matter of social justice, as well as economic development 50 million people [world wide] experience “financial catastrophe” each year as a result of health care costs. People who are ill, or worried about their health or that of loved ones aren’t very productive. Health is a right for all; not to be distributed to only those who can afford care.

1990’s: Spiraling costs make mandatory coverage and “managed competition” major priorities of Clinton administration; no plan even comes to a vote. % of uninsured continues to rise, with costs.

COST: Unsustainable growth, in the world’s most expensive health care system

Does that higher cost give us the best health care system? “Life expectancy in the United States is 78 years, ranking 45 th in the world, well behind Switzerland, Norway, Germany, and even Greece, Bosnia, and Jordan. The US infant mortality rate is 6.37 per 1000 live births, higher than almost all other developed countries, as well as Cuba.” Emmanuelle, E. JAMA, May 16, 2007—Vol 297, No. 19

Does that give us the “best” system? Ranked #1 in innovation, and bringing new technology to patients. But… MEASURE #1 NATION U.S. RANKOUT OF Number of hospital beds per capita [#1 has the most beds] % of TB cases successfully treated (#1 has the highest success rate) Maternal Mortality per 10,000 Greece [1] WHO, 2007 data

Preventable adverse events during childbirth [OECD 2011]

Does it at least give us better ACCESS to healthcare? 50 MILLION with no insurance, and little or no access to healthcare!

Well then, all of that money must at least give us more trained physicians… U.S. 2.7 physicians/1,000 Azerbaijan3.8 Cuba 6.4! South Korea: 3.3 Greece: 6! Italy: 4.2 Russia: 4.3 Switzerland: 4.1

WHO 2008 report: Renewed the call for universal access to primary care.

How did nations respond? 19% uninsured!? [3/4 of these for more than a year]; 80% are working families! OECD: The Organization for Economic Cooperation and Development is a well funded (approximately $500 million in 2010) agency representing the economic interests of 31 high-income nations.

NYT Rwanda Article

HOW COULD THAT BE?? 1.Treatment of illness, rather than primary care and prevention. 2.Incentives that reward quantity of care delivered, not quality. 3. Few cost controls 4.Inefficiency, including 20-31% administrative costs. 5. Lack of access

Take-home message 1. Health care reform desperately needed! 2. Although woefully inadequate, ‘Obamacare’ is the biggest step in health care reform in nearly 50 years. 3. It WILL improve access, improve quality, and cut costs. But is it the best way, and is it enough?

“Obamacare”: aka, “The Affordable Care Act of 2009” Hold onto your hats… There’s A LOT of stuff in here!! We’ll discuss 11 points Healthcare.gov

What is it? 1. Exchanges, to make affordable insurance available to all Competetive marketplace or “exchange” for health insurance Administered by states, meeting national standards/rules. 4 levels of coverage mandated. All must include basic coverage. –60%, 70%, 80% and 90% of costs covered. –Federal subsidies: Total for up to 2X poverty [$44,000 for a family of 4] Partial for up to 4X poverty [$88,000 for a family of 4] In exchanges, at least 1 policy covering abortion, and at least 1 not must be covered. –Abortion cost coverage must be separate; no federal subsidies may be used to fund. Riegelman, Richard: “Health Reform 101” in: Public Health 101. Online supplement. Jones and Bartlett publishing, 2010

2. Mandate higher efficiency Standardization of administrative procedures and forms At least 85% of fees must go to medical costs for large insurance market; 80% for individual. –Currently 70-74% Subsidize the development costs of non-profit and not- for-profit health plans health insurers must justify any rate increase of 10% or more before the increase takes effect. Reduce fraud Very low copay policies will be taxed as of 2018 Riegelman, Richard: “Health Reform 101” in: Public Health 101. Online supplement. Jones and Bartlett publishing, 2010

3. Preventive care – at no additional cost to you. All policies must cover, without copay. Already in effect. –mammograms, –Other cancer screenings, –prenatal care, maternity care –flu shots and –Regular check-ups Does this increase policy costs? Is this cost effective?

4. Increase primary care workforce 96 million persons, 28 percent of whom are uninsured, reside in communities identified as medically underserved for primary health care [GWU School of Public Health] Fourth year medical students entering primary care receive loan relief in exchange for their service in communities with limited access to care. 10% of loans per year service.

5. 5. Children's & Young Adult coverage Young adults can remain on parents’ policies until 26. Insurance companies cannot deny or limit coverage for people under the age of 19 due to preexisting conditions. 2.5 MILLION more children have health insurance than in Does this increase policy costs? Is this cost effective?

6. Preexisting conditions Cannot be denied, or charged higher premiums based upon preexisting conditions, employment status, health status, or gender. Cannot place a cap on benefits. Some difference permitted due to age.

7. Expansion of Medicaid To TWICE poverty level. First year, 100% of increased costs paid for by federal government Slowly shifted to equal share state-federal. Was to be mandatory; but now many states have pledged to opt out.

NEJM study, 9/2012: “Medicaid expansions were associated with a significant reduction in adjusted all-cause mortality (by 19.6 deaths per 100,000 adults, for a relative reduction of 6.1%; P=0.001). Mortality reductions were greatest among older adults, nonwhites, and residents of poorer counties. Expansions decreased rates of uninsurance (relative reduction of 14.7%; P<0.001), (for a relative reduction of 21.3%; P=0.002), and increased rates of self- reported health status of “excellent” or “very good” (for a relative increase of 3.4%; P=0.04).

8. Tax credits to small businesses 4 million small businesses are eligible for tax credits to help them provide insurance benefits to their workers. Credit worth up to 35% of the employer’s contribution to the employees’ health insurance.

9. Accountable Care Organizations; Advanced Payment Models Portion of reimbursement, and “Bonuses” based upon objective measures of quality of care Quality ratings will be publicly available. Process: –Vaccination –% of women receiving mammograms and pap smears Outcome: –% of diabetics with blood sugar under control. –Low viral load for HIV patients –BP for hypertension Efficiency: –Proper documentation of medical need for few “over-used” tests and procedures –Use of generic drugs where appropriate

10. Incentives for quality improvements 1% of Medicaid-Medicare reimbursements in 2014; 2% in 2016 Major incentive to practices and hospitals. “Teaching to the test”? Adverse patient penalty?

Now the big one: Businesses w 50+ employees: assessment for a large employer that does not offer coverage will be $2,000 per full- time employee beyond the company's first 30 workers.

Individuals: If no mandate, “adverse selection” Who will sign up? What will that do to premiums? Penalty: $695 or 2% of income Increases to as much as $2,000 per family by million currently uninsured; CBO estimates with mandate,

Companies with >50 employees Penalty up to $2,000

Compare w Wofford EMPLOYEE PREMIUM TOTAL PLAN COST Single premium: $180/year $7,200 Family premium: $7020/year $18,400 This doesn’t include deductibles and copays.

Is this “socialized medicine”? The V.A. is, but this ISN’T.

Is this “national health INSURANCE”? Medicare and Medicaid are, but this ISN’T.

Is it a “tax” or a “fee”? And why are so many people determined to repeal it?

How much will this cost us? Obamacare vs our current system: revenues from the excise tax on high- premium insurance plans CBO says Obamacare reduces our deficit by $109 billion by [July 2012 report]