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ThecaseforHealthcarereformandACA
AndresBarkil-Oteo
DepartmentofPsychiatryYaleUniversity
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Outline
Why?:ThecurrentstateofhealthandhealthcareinUSA What?:IntrotoHealthInsurance How?:IntroducFontotheAffordableCareAct(ACA)
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Valueinhealthcare
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International Comparison of Spending on Health, 19802009
*PPP=PurchasingPowerParity.
Data:OECDHealthData2011(database),version6/2011.
Averagespendingonhealthpercapita($USPPP*)
TotalexpendituresonhealthaspercentofGDP
4
0
1,000
2,000
3,000
4,000
5,000
6,000
7,000
8,000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
United States
Canada
Germany
France
Australia
United Kingdom
0
2
4
6
8
10
12
14
16
18
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
2006
2008
United States
France
Germany
CanadaUnited Kingdom
Australia
CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
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7.2 7.0 6.9 6.8 7.0 6.8 6.8 6.9 6.7 6.8
10.3
11.1
10.29.9 9.9 9.6
10.110.8
10.0 9.9
5.3 5.1 5.0 4.9 4.8 4.7 4.7 5.0 5.0 5.0
0
4
8
12
1998
1999
2000
2001
2002
^
2003
2004
^
2005
2006
2007
U.S. average Bottom 10% states Top 10% states
NaFonalaverageandstatedistribuFon InternaFonalcomparison,2007
2.02.5 2.6 2.7
3.1
4.0
5.1
6.8
Icelan
d
Swed
enJapa
n
Finlan
d
Norw
ay
Denm
ark
Cana
da
Unite
dStat
es
CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
Infant Mortality RateInfantdeathsper1,000livebirths
^Denotesyearsin2006and2008NaFonalScorecards.
Data:NaFonalandstateNaFonalVitalStaFsFcsSystem,LinkedBirthandInfantDeathData(AHRQ20032008;Mathewsand
MacDorman,2011);internaFonalcomparisonOECDHealthData2011(database),Version06/2011.
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IsUSHealthReallytheBestintheWorld?
Of13countries,theUnitedStatesranksanaverageof12th(secondfromtheboom)for16availablehealthindicators
13th(last)forlow-birth-weightpercentages 13thforneonatalmortalityandinfantmortalityoverall 11thforpostneonatalmortality 13thforyearsofpotenFallifelost(excludingexternalcauses) 11thforlifeexpectancyat1yearforfemales,12thformales 10thforlifeexpectancyat15yearsforfemales,12thformales 10thforlifeexpectancyat40yearsforfemales,9thformales 7thforlifeexpectancyat65yearsforfemales,7thformales 3rdforlifeexpectancyat80yearsforfemales,3rdformales
Starfield2000JAMA
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Kaiser:TheUninsuredaprimer
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TheUninsured
Uninsuredadultshavea25percentgreatermortalityriskthanadultswithcoverage
Lackofhealthinsuranceisassociatedwithasmanyas44789deathsperyearmorethanthosecausedbykidneydisease
Wilperetal2009
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Data: U.S. Census Bureau, 200001 (revised) and 201011 Current Population Survey ASEC Supplement.
Percent of Adults Ages 1964 Uninsured by State
CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
19992000 20092010
19%22.9%
Lessthan14%
14%18.9%
23% or more
WA
OR
ID
MT ND
WY
NV
CAUT
AZNM
KS
NE
MN
MO
WI
TX
IA
IL IN
AR
LA
AL
SC
TN NC
KY
FL
OH
MI
WV
PA
NY
AK
MEVTNH
MA
RI
DE
DC
HI
CO
GAMS
OK
NJ
SD
VA
CT
MD
WA
OR
ID
MT ND
WY
NV
CAUT
AZNM
KS
NE
MN
MO
WI
TX
IA
IL IN
AR
LA
AL
SC
TNNC
KY
FL
OH
MI
WV
PA
NY
AK
MEVTNH
MA
RI
DE
DC
HI
CO
GAMS
OK
NJ
SD
VA
CT
MD
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1 or More Full-
Time Workers,
61%
No Workers,
24%
Part-Time
Workers,
16%
NonelderlyUninsuredbyamilyWorkStatus,2010
Datamaynottotal100%duetorounding.
SOURCE:KCMU/UrbanInsFtuteanalysisof2011ASECSupplementtotheCPS.
Total = 49.1 million uninsured
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Uninsured and Underinsured Adults
11
Percent of adults ages 1964 who are
uninsured or underinsured
26 28 28
91614
0
25
50
75
100
2003 2007 2010
Underinsured*
Uninsured during year
CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
Insured all year, not underinsured
Underinsured*
Uninsured during year
Millions of adults ages 1964 who are
uninsured or underinsured, 2010
102
29
52
Total: 184 million**
35
42 44
* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income;medical expenses equaled 5% or more of income if low-income (
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Underinsured
62.1%ofallbankruptcieshaveamedicalcause. Mostmedicaldebtorswerewelleducatedandmiddleclass;threequartershadhealthinsurance.
Theshareofbankruptciesaributabletomedicalproblemsroseby50%between2001and2007
Youloosecoveragewhenyouloosejob,youloosethehealthinsurancewhenismostneeded!
Himmelsteinetal2009
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uchsNEJM2012
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Iatrogenicevents
USesFmates 12000deaths/yearfromunnecessarysurgery 7000deaths/yearfrommedicaFonerrorsinhospitals 20000deaths/yearfromothererrorsinhospitals 80000deaths/yearfromnosocomialinfecFonsinhospitals 106000deaths/yearfromnon-error,adverseeffectsofmedicaFons TheaveragenumberesFmatedis225000deathsperyear AdmissiontoahospitalisthethirdleadingcauseofdeathintheUnitedStates,aerdeathsfromheartdiseaseandcancer.
Starfield2000JAMA
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Numberofdeathsforleadingcausesofdeath
1-Heartdisease:599,413
2-Cancer:567,628
3-Chroniclowerrespiratorydiseases:137,353
4-Stroke(cerebrovasculardiseases):128,842
5-Accidents(unintenFonalinjuries):118,021
CDCesFmatesfor2010
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Numberofdeathsforleadingcausesofdeath
Modified
1-Heartdisease:599,413
2-Cancer:567,628
3-Iatrogeniccausesduringhospitaladmissions225,000
4-Chroniclowerrespiratorydiseases:137,353
5-Stroke(cerebrovasculardiseases):128,842
6--Accidents(unintenFonalinjuries):118,021
CDCesFmatesfor2010
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Anyroomforimprovement?
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Overall Health System Performance
Exhibit 1EXECUTIVE SUMMARY
Source: Commonwealth Fund Scorecard on Local Health System Performance, 2012.
Top Quartile
Second Quartile
Third Quartile
Bottom Quartile
Not Populated
Overall Performance
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isheretalNEJM2009
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Sutherlandetal2009NEJM
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DifferenFalofmedicarespending
PaFentsinthehighestspendingregionsspendmoreFmeinthehospitalhavemorefrequentphysicianvisitsandundergomoreMRIproceduresCT
scans.DiscreFonarydecisionsbyphysiciansseemtoaccountformostof
theregionalvariaFoninspending(Sutherlandetal2009NEJM)
Medicarewillbe$660billionintheholeby2023.Reducingannualgrowthinpercapitaspendingfrom3.5%(thenaFonalaverage)to2.4%(therate
inSanrancisco)wouldleaveMedicarewithahealthyesFmatedbalance
of$758billion,acumulaFvesavingsof$1.42trillion(isheretal2009
NEJM)
Sutherlandetal2009NEJM
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Whataboutoutcomes?
Skinneretal2006HA
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Sutherlandetal2009NEJM
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Chronic Disease Under Control: Diabetes and Hypertension
85
49
76
55
72
29
Diabetes under control* High blood pressure under
control**
Private Public Uninsured
*Refers to diabetic adults whose hemoglobin A1c is
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Use of Electronic Medical Records
17
28
46
97 97 96 95 94 94
7268
37
99
0
25
50
75
100
2000 2006 2009 NETH NZ NOR UK AUS ITA SWE GER FRA CAN
International Comparison, 2009
AUS=Australia; CAN=Canada; FRA=France; GER=Germany; ITA=Italy; NETH=Netherlands; NZ=New Zealand; NOR=Norway;SWE=Sweden; UK=United Kingdom.
Data: Commonwealth Fund International Health Policy Survey of Physicians.
Percent of primary care physicians using electronic medical records
Source:CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
United States
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Whatisgoingonhere?
Thepathwaystobeerhealthdonotgenerallydependonbeerhealthcare
Inthoseinstancesinwhichhealthcareisimportant,toomanyAmericansdonotreceiveit,receiveittoolate,orreceivepoor-qualitycare.
Beerhealth(lowermortalityandahigherleveloffuncFoning)cannotbeachievedwithoutpayinggreateraenFontopoorAmericans
Schroeder2007NEJM
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TruthorficFononinternaFonalhealthcaresystems
Wastefulsystemsrunbybureaucrats RaFoncarewithlimitedchoiceandwaiFnglists Itsallsocializedmedicine ThosesystemsaretooforeigntoworkintheUS
TRReidThehealingofAmerica2009
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Wastefulsystemsrunbybureaucrats?
1920s:nonforprofit,hospitalsrun,samepremiumforallmembers,allapplicantswereenrolledandpaidthesamepremium
1945:orprofitenteredthemarket:chargingmorepremium,denyingcoverage
TheUnitedStatesistheonlyadvanceddemocracywithforprofithealthinsuranceindustry
TRReidThehealingofAmerica2009
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h)p://,nyurl.com/3ohmvjd
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orbes2011h)p://,nyurl.com/7duz7ta
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RaFoncarewithlimitedchoiceandwaiFnglists?
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Waiting Time to See Doctor When Sick or Need Medical
Attention,
Among Sicker Adults, 2008
80
71
62 61 59
53
43
36
0
25
50
75
100
NETH NZ FRA UK GER AUS US CAN
Sicker adults met at least one of the following criteria: health is fair or poor; serious illness in past two years; or was hospitalizedor had major surgery in past two years. AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands;NZ=New Zealand; UK=United Kingdom; US=United States.
Data: 2008 Commonwealth Fund International Health Policy Survey.
Percent of adults who could get an appointment on the same or next day
when sick or needed medical attention
Source:CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
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Access Problems Because of Costs, 2010
5 6
10 10 1113 14
15
22
25
33
0
25
50
UK NETH SWE SWIZ NOR FRA NZ CAN AUS GER US
* Did not get medical care because of cost of doctors visit; skipped medical test, treatment, or follow-up because of cost;or did not fill Rx or skipped doses because of cost.AUS=Australia; CAN=Canada; FRA=France; GER=Germany; NETH=Netherlands; NZ=New Zealand; NOR=Norway;
SWE=Sweden; SWIZ=Switzerland; UK=United Kingdom; US=United States.
Data: 2010 Commonwealth Fund International Health Policy Survey.
Percent of adults who had any of three access problems* in past year because of costs
Source:CommonwealthundNaFonalScorecardonU.S.HealthSystemPerformance,2011.
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Itsallsocializedmedicine!
h)p://,nyurl.com/7832fc3
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Itsallsocializedmedicine!
Beginningin1952theTrumanAdministraFon,throughederalSecurityAdministratorOscarEwing,hadbegunadvocaFngmedicalcareforthe
agedwhatwouldbecomeMedicare.ThiswasaretreatfromTrumans
earliercallsforuniversalhealthcareforallAmericans.Theimplacable
opposiFonoftheAMAandotherpressuregroupsmadeuniversalhealth
careanimpossibletask
Opera,onCoffeecup:LedbytheWomansAuxiliarytotheAmericanMedicalAssocia,on,wasanall-outefforttosFmulateasmanyleersto
Congressopposingsocializedmedicineanditsmenaceasproposedinthe
bill
h)p://,nyurl.com/7832fc3
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Itsallsocializedmedicine!
"Theterm['socializedmedicine']waspopularizedbyapublicrelaFonsfirmworkingfortheAmericanMedicalAssociaFonin1947todisparage
PresidentTruman'sproposalforanaFonalhealthcaresystem.Itwasa
label,atthedawnofthecoldwar,meanttosuggestthatanybody
advocaFnguniversalaccesstohealthcaremustbeacommunist.Andthe
phrasehasretaineditspoliFcalpowerforsixdecades
TRReidThehealingofAmerica2009
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ThosesystemsaretooforeigntoworkintheUS
orthemajorityofAmericanswhogettheirinsurancethroughtheiremployer,weareGermany.
orveterans,weareEngland orSeniors,weareCanada ortheuninsured,weareCambodia
TRReidThehealingofAmerica2009
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How?
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Insurance:Threeleggedstool
McDonoughInsidehealthreform2011
Individualmandate
InsurancesubsidiesGuaranteedissue
ACA
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Individualmandate
RAND2012h)p://,nyurl.com/77mmxgw
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Insurancesubsidies
ExpandMedicaidupto133%ofthepovertylevel
CreatenewHealthInsuranceExchangeswhereindividualsandsmallemployerscanpurchasecoverage
Providepremiumsubsidiesupto400%ofthepovertylevel
McDonoughInsidehealthreform2011
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Estimated Health Insurance Coverage in 2019
Congressional Budget Office, 2010
TotalNonelderlyPopulaFon=282Million
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SomeUninsuredWillRemain
CongressionalBudgetOffice(CBO)esFmates23millionuninsuredin2019 Whoarethey?
Immigrantswhoarenotlegalresidents EligibleforMedicaidbutun-enrolled Exemptfromthemandate(mostbecausecantfindaffordablecoverage) Choosetopaypenaltyinlieuofge|ngcoverage
Manyremaininguninsuredwillbelow-income
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Guaranteedissue/Insurancereform
ProhibiFononannualandlifeFmebenefitscap ProhibiFonofrescissions:rescindingcoverageaerapolicyholdergetssick.
AllinsurancepoliciesmustcoverclinicalprevenFvehealthserivceswithAorBraFngs
ParentscankeeptheiradultchildrenontheirhealthinsuranceFlltheyreaches26
CapmedicallossraFoto80% NodiscriminaFonorpreexisFngcondiFonexclusionsbasedonhealthstatus
McDonoughInsidehealthreform2011
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inancingHealthReform,2010-2019
TotalCost=$938Billion
SavingstoFederalDeficit=$124BillionCongressionalBudgetOffice,2010
ederalsavings
Newrevenues
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ACAImplementaFonTimeline
2010
Someinsurancemarketchangesnocost-sharing
forprevenFveservices,
dependentcoveragetoage
26,nolifeFmecaps
Pre-exisFngcondiFoninsuranceplan
SmallbusinesstaxcreditsPremiumreview
2011-2013
Nocost-sharingforprevenFveservicesin
MedicareandMedicaid
IncreasedpaymentsforprimarycareReducedpaymentsforMedicareprovidersand
healthplans
NewdeliverysystemmodelsinMedicareandMedicaid
Taxchangesandnewhealthindustryfees
2014
MedicaidexpansionHealthInsuranceExchanges
Premiumsubsidies InsurancemarketrulesprohibiFonondenying
coverageorchargingmore
tothosewhoaresick,
standardizedbenefits
IndividualmandateEmployerrequirements
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ACAinacFon
2.5millionyoungadultsarenowenrolledintheirparents'healthinsurance
105millionAmericansnolongerfacelifeFmebenefitcapsontheirinsuranceplans
86millionAmericans,includingthoseinMedicareandprivatecoverage,havereceivedfreeprevenFveservicessuchascheck-upsandcancer
screenings
17millionchildrencannolongerbedeniedcoveragebecauseofpre-exisFngcondiFons
3.6millionMedicareseniorshavereceivedsavingsonprescripFondrugsbecauseoftheclosingoftheso-called"donuthole;"in2011
360,000smallemployersusedthesmallemployertaxcredittomakeinsurancemoreaffordablefortheirtwomillionemployees.
JohnMcDonough2011h)p://,nyurl.com/856wj8s
Nearly Half Say They eel Confused About ACA; Three In Ten Angry;
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31%
25%
47%
30 30 3128
31 32
28
3230
34 34 34
30 30
30
3533
31
27 28
55
4442 43
45
53
47
52
43
50
53
46
0%
20%
40%
60%
80%
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb Mar
NearlyHalfSayTheyeelConfusedAboutACA;ThreeInTenAngry;
QuarterEnthusiasFc
Percentwhosaythateachofthefollowingdescribestheirfeelingsaboutthehealthreformlaw:
AngryConfused Enthusiastic
Source: Kaiser Family Foundation Health Tracking Polls
2010
2011
2012
ACA signed intolaw on March 23,
2010
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NowyoucouldbeangryorenthusiasFcbutdefinitelynot
confused!
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END