Visions of the Future: Healthcare in the Obama era Timothy R. Huerta, MSPA, Ph.D. Director, Center for Healthcare Innovation, Education and Research (CHIER)

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Visions of the Future: Healthcare in the Obama era Timothy R. Huerta, MSPA, Ph.D. Director, Center for Healthcare Innovation, Education and Research (CHIER) & Assistant Professor, Rawls College of Business Clinical Assistant Professor, School of Population and Public Health, U. of British Columbia

What does “Universal HealthCare” mean?

What does “High Quality” healthcare mean?

Do children have a right to Health Care?

Should your choices define your insurance costs?

What does healthcare in the United States look like today? Current Law (millions) Employer (53%) Private Non-employer 14.3 (5%) Medicaid/ SCHIP 37.3 (12%) Medicare 30.9 (10%) TRICARE 6.0 (2%) Uninsured 48.9 (16%) Dual Eligible 8.0 (3%)

Why isn’t there a plan yet?

A trick of the hands aka… how not to get burned

Where are we now?

10 plans Building Blocks Health Americans Act (Wyden) Ten Steps (Enzi) Every American Insured (Burr) Baldwin/Bingaman/Feingol d – Graham (15 states) AmeriCare (Stark) End Medicare 2-yr Waiting Period (Bingaman) Universal Coverage for Children (Kerry/Waxman) Small Business Health Fairness (Johnson) SHOP (Durbin/Kind) HSA Expansions (Cantor)

The Kinds of Programs Insurance Coverage Proposals Mixed Private-Public Programs Marginal changes to the system

Employer (49%) Private Non-employer 1.4 (<1%) Medicaid/ SCHIP 45.3 (15%) Medicare 32.1 (10%) TRICARE 5.9 (2%) Uninsured 4.0 (1%) Dual Eligible 8.4 (3%) Connector 59.4 (19%) Medicaid/ SCHIP 32.7 (11%) Private Non-Employer 61.1 (20%) Employer (48%) TRICARE 6.0 (2%) Uninsured 22.0 (7%) Medicare 30.9 (10%) Dual Eligible 8.0 (3%) What would Healthcare in the U.S. Look Like Population by Primary Source of Insurance, Under Current Law and Insurance Proposals, 2010 Current Law (millions)Building Blocks (millions) Source: The Lewin Group for The Commonwealth Fund. Total Population = million Wyden (millions) Uninsured 2.9 (1%) Medicare 30.9 (10%) TRICARE 6.0 (2%) Dual Eligible 8.0 (3%) HAA (82%) Employer 6.3 (2%) Employer (53%) Private Non-employer 14.3 (5%) Medicaid/ SCHIP 37.3 (12%) Medicare 30.9 (10%) TRICARE 6.0 (2%) Uninsured 48.9 (16%) Dual Eligible 8.0 (3%) Enzi (millions)Burr (millions) Stark (millions) Employer Coverage (51%) Private Non-Employer 40.4 (13%) TRICARE 6.0 (2%) Uninsured 26.6 (9%) Medicare 30.9 (10%) Medicaid/ SCHIP 38.0 (12%) Dual Eligible 8.0 (3%) Employer 2.1 (1%) AmeriCare (85%) Medicare 30.9 (10%) TRICARE 6.0 (2%) Dual Eligible 8.0 (3%)

Cantor (HSA Expansions) Enzi (Ten Steps) Stark (AmeriCare) Number of Uninsured People Newly Covered, in 2010 (millions) Bingaman (End Medicare Waiting Period) Johnson (Small Business Health Fairness) Kerry / Waxman (Universal Coverage for Children) Durbin / Kind (SHOP) Wyden (Healthy Americans) Burr (Every American Insured) Baldwin/Bingaman/Feingold – Graham (Federal / State Partnership-15 States) Note: Out of an estimated total uninsured in 2010 of 48.9 million. Source: The Lewin Group for The Commonwealth Fund. Building Blocks

Kerry / Waxman (Universal Coverage for Children) Bingaman (End Medicare Waiting Period) Change in Federal Spending, in 2010 (billions) Stark (AmeriCare) Johnson (Small Business Health Fairness) Cantor (HSA Expansion) Durbin / Kind (SHOP ) Wyden (Healthy Americans) Burr (Every American Insured) Baldwin/Bingaman/Feingold – Graham (Federal / State Partnership-15 States) Enzi (Ten Steps) Source: The Lewin Group for The Commonwealth Fund. Building Blocks

Change in National Health Expenditures, in 2010 (billions) Stark (AmeriCare) Bingaman (End Medicare Waiting Period) Johnson (Small Business Health Fairness) Kerry / Waxman (Universal Coverage for Children) Cantor (HSA Expansions) Durbin / Kind (SHOP) Wyden (Healthy Americans) Burr (Every American Insured) Baldwin/Bingaman/Feingold – Graham (Federal / State Partnership-15 States) Enzi (Ten Steps) Source: The Lewin Group for The Commonwealth Fund. Building Blocks

Figure 1. Features of Mixed Private–Public Reform Proposals President-elect Obama Senator Baucus (D-Mont.) Building Blocks Coverage Expansion Aims to cover everyoneXXX Individual requirement to have insuranceChildren onlyXX Employer shared responsibilityXXX Small business tax creditXX New insurance exchange or connectorXXX Medicare/public plan option for < 65XXX Subsidies/tax credits for low- to moderate- income families XXX Regulation of insurance marketsXXX Improves Medicare benefits for > 65X Medicare buy-in for older adults and phase out waiting period for disabled X (buy-in available until Exchange is created) X Medicaid/SCHIP expansionXXX System Improvements Expanded use of health ITXXX Medical effectiveness researchXXX Pay providers for performanceXXX Reduced Medicare Advantage paymentsXXX Federally negotiated Medicare Rx prices XX Primary care and care coordination XXX Source: Commonwealth Fund analysis of health reform proposals.

Major Features of Health Insurance Expansion Bills and Impact on Uninsured, National Expenditures Building Blocks WydenEnziBurr Baldwin / Bingaman / Feingold – Graham Stark Aims to cover all peopleXXX Individual requirement/ auto-enrollment XX Partial mandate XX Employer shared responsibility XXXX Insurance exchange or connector XXX Certification program For low-income families, small businesses Public program expansion X (Medicaid HSAs expanded) XX Subsidies for lower- income Families XXXXXX Risk poolingXXXX Standard benefit package XX For low- income families X Quality and efficiency measures XXXX Uninsured covered in (in millions) Net health system cost in 2010 (in billions) $17.8$13.7$64.1$31.1$37.7(58.1) Net federal budget cost in 2010 (in billions) $103.9($39.6)$176.4$161.3$ Out of an estimated total uninsured in 2010 of 48.9 million. 2 Out of an estimated total uninsured in 2010 of 26.7 million in the 15 states. Note: Wyden’s proposal is the Healthy Americans Act (S.334); Enzi’s proposal is Ten Steps (S.1783); Burr’s proposal is the Every American Insured Act (S.1886); Bingaman/Baldwin/Feingold/Graham’s proposals is Federal/State Partnership Act (S. 325, H.R.506, S.1169); and Stark’s proposal is AmeriCare (H.R.1841). Source: The Lewin Group for The Commonwealth Fund.

1 Out of an estimated total uninsured in 2010 of 48.9 million. 2 Out of an estimated total uninsured in 2010 of 26.7 million in the 15 states. Note: Wyden’s proposal is the Healthy Americans Act (S.334); Enzi’s proposal is Ten Steps (S.1783); Burr’s proposal is the Every American Insured Act (S.1886); Bingaman/Baldwin/Feingold/Graham’s proposal is Federal/State Partnership Act (S. 325, H.R.506, S.1169); and Stark’s proposal is AmeriCare (H.R.1841). Source: The Lewin Group for The Commonwealth Fund. Health Insurance Expansion Bills Change in Health Spending by Stakeholder Group, Billions of Dollars, 2010 Building Blocks WydenEnziBurr Baldwin / Bingaman / Feingold – Graham Stark Total uninsured covered, millions Federal government$103.9($39.6)$176.4$161.3$40.3$188.5 State and local government ($32.7)($29.0)($21.2)($52.9)$19.4($83.6) Private employers$86.0$98.4($77.6)$7.0$34.8$61.5 Households($139.4)($16.2)($13.5)($84.3)($56.7)($224.5) Net health system cost in 2010 (in billions) $17.8$13.7$64.1$31.1$37.7($58.1) Total uninsured not covered, 1 Millions

Conceptual Directions SomeSolutions Make Medicare Available to all Make a two-tiered insurance product available to all (Congressional Care) Regional or Federal Health Insurance Exchanges Some Complaints

Best Government/Worst Government Best GovernmentWorst Government

In the end – no one will love the outcome because this is a value-laden question

A tale of a professor with a broken leg An American Perspective on the Canadian System

A tale of a professor with a broken heart An American Perspective on the Canadian System

When money doesn’t create the barrier… time will take its place What should be covered?

A continuum of payment models Single Payor (Canada) Limited Funds (Germany) Managed Care (UK)

The system is perfectly designed to give you its current results.

The Law of Unintended Consequences Smoke Marlboro?

Conclusion

Gotcha!

Visions of the Future: Healthcare in the Obama era Timothy R. Huerta, MSPA, Ph.D. Director, Center for Healthcare Innovation, Education and Research (CHIER) & Assistant Professor, Rawls College of Business Clinical Assistant Professor, School of Population and Public Health, U. of British Columbia