1. February 27, 2009 9:00 – 3:00 PM Mission Valley Hilton, San Diego, CA Health Reform: Exploring the Models A panel and audience participation forum 1

2. Thank you to our Sponsors Foundations

3. Thank you to our sponsors Business

4. Thank you to our Sponsors Community Organizations

5. Thank you to our Sponsors Healthcare Providers

6. Introductions  Keynotes:  Moderator:  Panel: 6   Rosemarie Day, Deputy Director & COO MA Health Insurance Connector Authority   Jonathan Cohn, Senior Editor The New Republic   Irma Cota, Executive Director   North County Health Ser vices (SDHCC Board Member)   Robert E. Hertzka, MD (SDHCC Board Chair)   Gregory E. Knoll, esq (SDHCC Board Vice Chair)   Vincent Mudd (CEO, Sdoi) – Chamber Board)   Jan C. Spencley, Executive Director, SDHCC

7. Agenda 9:15 Welcome and IntroductionsRobert E. Hertzka, MD 9:40 Background - Purpose Issues – Data Snapshots Jan C. Spencley 10:40 Model for Achieving Near Universal Coverage in Massachusetts: Two Years Later Rosemarie Day 11:30 Break - Lunch Buffet 12:00 International Models of Coverage & Care Implications for Reforming the US Healthcare System Jonathan Cohn 1:15 Break 1:30 Q&A - Moderated Discussion Panel Audience Irma Cota 2:45 Summary Next Steps Jan C. Spencley Robert E. Hertzka, MD 7

8. San Diegans for Healthcare Coverage Our Mission To bring diverse constituencies together to identify and pursue strategies for expanding health care coverage and access to health care in the region  Education  Consensus Building  Advocacy and Outreach 8

9.   Improving Access to Healthcare (IAH) Project formed by Board of Supervisors in 1999 to evaluate and pursue strategies to expand health coverage in the region. Efforts discontinued due to State waivers.   IAH formed SDHCC in 2001 to maintain diverse coalition to continue to pursue expansion of health care coverage   SDHCC created Business Healthcare Connection (BHC) as subsidiary to establish operations, business relationships and outreach in preparation for longer-term demonstration project   SDHCC and BHC conducted series of Business and Labor Roundtable forums and focus groups to work towards and establish consensus principles and elements of reform. (2003-2005)   Roundtable series resulted in the development of the San Diego Healthcare Connection (SDHC) demonstration pilot project, co- sponsored by the Regional Chamber (2006-8) San Diegans for Health Care Coverage (SDHCC) Background 9

10.   SDHC demonstration pilot legislation (SB51 –Ducheny) did not advance due to Governor and legislative leadership comprehensive reform proposals (2007-8)   SDHCC Board determined to maintain and expand coalition and continue to build consensus, educate and advocate for health reform, meaningful health coverage and access (2008).   Current forum series to build on consensus achieved through information, dialogue and polling.   Focus today on Models of coverage and care   Key outcome from today is to identify model preferences across constituency groups for incorporation into SDHCC Principles and Required Elements for Health Reform. 10

11.   Shared responsibility for developing reforms and program oversight (government, business and individuals)   Shared responsibility for funding (government, business and individuals)   All citizens and legal residents should have access to basic, meaningful, minimum coverage and care   Minimum, basic benefit structure with option to purchase broader coverage, including healthy behavior incentives and disease management and education (see handout)   Cost containment (transparency, care guidelines, evidence based)   Premium share and co-insurance based on family income   Incentives for employers to provide coverage   Adequate provider reimbursement (no cost shifting)   Program evaluation and adjustment (measurement and course correction)   Administrative simplicity (eliminate fragmentation of programs, easy enrollment methods, administrative burdens and overhead) SDHCC Consensus Principles and Elements for Health Reform Highlights 11 ( See Detailed Handout )

12. Audience Response System  If you do not have a Keypad, you should have a PINK version of the questions to respond to.  Pick up your Keypad – You will use the Letters to respond  Each Question and its Response Options will be displayed on Both Screens. They will be read through one time.  Select the response that MOST closely reflects your perspective  A few questions have a PAPER SURVEY corollary so that you can provide more precise input (with evaluation form)  You will have 15 seconds to respond once the question and the response options have been read (Timer on ARS Screen)  Please answer All Questions – it will record only one response. The last answer entered during the 15 seconds will be the response recorded.  Responses are not identified by individual  Your Constituency registration allows us to assess and identify preferences, issues and consensus positions across constituencies 12

13. ARS 1 Question: Constituency Group 13 Using your keypad, from the list below, select the constituency group that you most appropriately represent today. A.Broker-Agent/Health Plan/Insurance B.Foundation or Community Based Organization C.Business (owner, association) D.Labor E.Consumer (advocates, organizing project, etc) F.Healthcare Provider G.Government Agency H.Other

14. ARS Question 2: Universal Coverage Universal Coverage means that all Americans have affordable, basic healthcare coverage and care, including primary, specialty, hospital, diagnostic services and prescriptions. Select One: A.Strongly Agree B.Somewhat Agree C.Somewhat Disagree D.Strongly Agree

15. A B ROKEN S YSTEM T HE C ONSEQUENCES 15

16.   An estimated 137,000 adults died between 2000 - 2006 because they lacked health insurance, including 22,000 in 2006.   Uninsured women who develop breast cancer have a 30 to 50 percent higher risk of dying than women with private coverage.   Uninsured patients with colorectal cancer are about 50 percent more likely to die than patients with private coverage, even when the cancer is diagnosed at similar stages.   Uninsured people are sicker upon admission and significantly more likely to die in the hospital.   Uninsured adults with chronic disease are less likely to receive care to manage their health conditions than those with coverage. uninsured patients have worse clinical outcomes than insured patients.   People without health care coverage are four times more likely to experience an avoidable hospital or ER visit. The Uninsured Live Sicker and Die Sooner 16 Source: Institute of Medicine

17. 17

18. 18

19. 19

20. 20 Medi-Cal beneficiaries who faced gaps in coverage were more than 3 x as likely as those with continuous coverage to be hospitalized for chronic illnesses, according to a five year retrospective study published in the Annals of Internal Medicine and 60% more likely to die in hospital ; uninsured were 80% more likely to die (OSHPD).

21. The Healthcare Delivery System Eroding and At Risk 21 Source: A Report on California Hospitals and the Economy, January 2009, California Hospital Association (November 2008 survey)

22. M ORE U NINSURED AND U NDERINSURED 22

23. 23 Health Insurance Coverage 2-Source: Authors’ estimates based on S. R. Collins, C. White, and J. L. Kriss, Whither Employer-Based Health Insurance? The Current and Future Role of U.S. Companies in the Provision and Financing of Health Insurance (New York: The Commonwealth Fund, Sept. 2007) and analysis of the Current Population Survey, March 2008, by Bisundev Mahato of Columbia University. 2 - 45.7 Million Uninsured, US 2007 Under-65 population Employer (62%) Uninsured (17%) Medicaid (11%) Medicare (2%) Military (1%) Individual (6%) 1-Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009. 1 - Uninsured Projected through 2020 Millions

24. 24 Coverage in San Diego: 2007

25. 25

26. The uninsured are increasingly older Since 2001, the 40 – 64 Age Category Has Increased Most Source: CHIS 2007

27. Modest to Higher Income Are An Increasing Proportion of San Diego Uninsured (2007) 27 Source: CHIS 2007, San Diego 300% FPL + 200-300% FPL 100-200% FPL 0-99% FPL

28. 20% Increase in Underinsured Overall; 175% Increase in Those Earning More Than 200% FPL 28 Total200% of poverty or more Under 200% of poverty * Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income, or 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income. Data: 2003 and 2007 Commonwealth Fund Biennial Health Insurance Survey. 42 35 17 27 68 72 Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008 Uninsured and Underinsured Adults (19-64), 2003 and 2007 by Percent

29. 29

30. 30 A Poor Investment: Insured Adults with Deductibles Are More Likely to Avoid Needed Health Care Percent of adults ages 19–64 insured all year with private insurance Source: S.R. Collins, J.L. Kriss et al., Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families, The Commonwealth Fund, Sept. 2006.

31. 31

32. Our patchwork of public coverage is costly and leaves most uninsured with no options 32

33. ARS Question 3: Health Reform Basic Understanding: Single Payor means that all Americans have basic, universal coverage and that everyone is covered by the same government operated program. Select One A.Strongly Agree B.Somewhat Agree C.Somewhat Disagree D.Strongly Disagree

34. ARS Question 4: Health Reform 34 Basic Understanding: Single Payor means that all Americans have basic universal coverage through a single government program and have a choice of coverage programs. Select One: A.Strongly Agree B.Somewhat Agree C.Somewhat Disagree D.Strongly Disagree

35. ARS Question 5: Health Reform 35 Both the CHAMPUS AND Medicare Programs have evolved into public - private models of coverage, with a Single Payor (federal) and a choice of private options for coverage. Overall, do you believe the CHAMPUS and Medicare Programs are a good or bad model for expanding coverage? Select One A.Bad B.Good C.Good model, but needs improvement D.Do Not Know

36. ARS Question 6: Health Reform 36 Several different models of health reform and coverage expansion are under consideration. From your perspective, which of these basic models do you MOST support? A.Parallel Models (Private/Employer and Public) for near-universal coverage B.Single Payer, government run program C.Single Payer, like the Medicare Public-Private model D.Continue existing pluralistic model (employer, private, public programs) E.Existing public program expansions only (Medi-Cal and Healthy Families )

37. T HE I NCREASING C OST OF C OVERAGE ( AND N OT P ROVIDING IT ) 37

38. 38 15% of Population Account for almost 75% of Annual Expenditures 50% Accounted for 3.5% of Expenditures Concentration of Health Care Spending in the U.S. 2005 Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2005. These are not a static populations – Each year, the composition changes

39. Average Health Insurance Premiums and Contributions Increases Outpace Wages and Inflation (1999-2008) 39 Note: The average worker contribution and the average employer contribution do not add to the average total premium due to rounding. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2008. $5,791 $12,680 117% Increase 119% Increase Over Same Period: -Worker’s Earnings Increased - 34% -Inflation increased - 29%.

40. 40

41. 41 National Per-Capita Health Expenditures 1990-2007 Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2006; file nhegdp06.zip). http://www.cms.hhs.gov/NationalHealthExpendData/

42. Healthcare Expenditures Are Projected to Exceed 20% of GDP by 2022 42 Source: Congressional Budget Office

43. The Cost of Doing Nothing  Increasing negative impacts on individual health, families, and communities  Increasing Uninsured and Underinsured  Access to a healthy Healthcare system eroding and at jeopardy  Growth in healthcare costs cannot be sustained resulting in further erosion of coverage and care  Health care as a proportion of GDP threatens US competitive position 43

44. ARS Question 7: Health Reform What is your greatest concern about efforts to expand and reform health care in the United States? Select One: A.Restructure the system without achieving universal coverage B.Increased personal costs (taxes, premiums, copayments) C.Increased business costs (taxes, premiums) D.Socialized medicine (government run system) E.Delays in access to care (not enough providers participating) F.Limits on coverage (criteria for coverage of high cost services) G.Restricts innovation and new technology H.Inadequate reimbursement to providers I.Overpromised and underfunded system of coverage (See Paper Survey Corollary)

45. Rosemarie Day, Deputy Director & COO MA Health Insurance Connector Authority A Model for Achieving Universal Coverage in Massachusetts: Two Years Later 45

46. ARS 8 Question: Massachusetts Model 46 Overall, from what you have heard, do you believe that the Massachusetts model will ultimately achieve universal coverage for all its residents? Select one: A.Strongly agree B.Somewhat agree C.Somewhat disagree D.Strongly disagree

47. ARS 9 Question: Massachusetts 47 In general, do you believe that the vision and parallel public- private model in Massachusetts should be considered for adoption as national model: Select one: A.Should be considered B.It is a start in the right direction, but not enough C.Too soon to tell D.Is the wrong model

48. ARS 10 Question: Massachusetts 48 What aspects of the Massachusetts model do you find the LEAST appealing? Select one: A.Individual mandates B.Employer mandates C.Costs D.Lack of Universal Coverage E.Administrative Structures (See Paper Survey Corollary)

49. ARS 11 Question: Massachusetts 49 What aspects of the Massachusetts model do you find the MOST appealing? Select one: A.Individual mandates B.Employer mandates C.Costs D.Near Universal Coverage E.Administrative Structures (See Paper Survey Corollary)

50. ARS 12 Question: Costs 50 What do you think is the greatest contributor to the significantly higher adjusted per-capita costs in the United States compared to other industrialized countries? Select One: A.Excess utilization of services and pharmaceuticals B.Cost of care (hospitals, physicians, testing, etc.) C.Cost of pharmaceuticals D.Cost of uninsured and foregone care E.Costs of research and innovation F.Administrative overhead and profit

51. Jonathan Cohn, Senior Editor The New Republic International Models of Coverage and Care: Implications for Reforming the US Healthcare System Or What Monty Python can teach Barack Obama about Health Reform 51

52. Question and Answer Period Groundrules  Headline your comments (make them brief and succinct) – Time limit of 30 seconds  Questions should be specific and identify to whom you wish to address it.  Responses will be limited to 1 minute per panel member and maximum of 2 - 3 responses per question  Please be polite and open to the ideas of others 52

53. ARS Question 22: Follow-up 53 Several different models of health reform and coverage expansion are under consideration. From your perspective, which of these basic models do you MOST support? Select One: A.Parallel Models (Private/Employer and Public) for near- universal coverage B.Single Payer, government run program C.Single Payer, like the Medicare Public- Private model D.Continue existing pluralistic model (employer, private, public programs) E.Existing public program expansions only (Medi-Cal and Healthy Families)

54. ARS 23 Question: Costs 54 What do you think is the greatest contributor to the significantly higher adjusted per-capita costs in the United States compared to other industrialized countries? Select One A.Excess utilization of services and pharmaceuticals B.Cost of care (hospitals, physicians, testing, etc.) C.Cost of pharmaceuticals D.Cost of uninsured and foregone care E.Costs of research and innovation F.Administrative Overhead and Profit (See Paper Survey Corollary)