health care reform in half an hour-detailed

Health Care Reform in the United States

WILLIAM M. SAGE, MD, JDTHE UNIVERSITY OF TEXAS AT AUSTIN

APRIL 2012

America’s Health Care Cost Problem

Approximately $3.5 trillion aggregate annual cost

Spending over $8,000 per capitaPremium for family coverage=$12,106 in

2007 Rising much faster than wages A year's salary at minimum wage= $12,168

More than half is publicly funded, amounting to a substantial part of government spending

International Spending on Health:1980–2006

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000United StatesGermanyCanadaNetherlandsFranceAustraliaUnited Kingdom

Data: OECD Health Data 2008, June 2008 version.

Average spending on health per capita ($US PPP*)

* PPP = Purchasing Power Parity.

THE COMMONWEALTH

FUND

THE COMMONWEALTH

FUND

Publication: R. E. Leu, F. F. H. Rutten, W. Brouwer et al., The Swiss and Dutch Health Insurance Systems: Universal Coverage and Regulated Competitive Insurance Markets, The Commonwealth Fund, January 2009

What is a potential solution to U.S. federal health care spending?

1. Preventing any growth in pension spending (social security)

2. Eliminating politicians’ pet projects (“pork” or “earmarks”)

3. Cutting back all discretionary federal spending

4. Renting out the U.S. military to other countries

What is a potential solution to U.S. federal health care spending?

1. Preventing any growth in pension spending (social security)

2. Eliminating politicians’ pet projects (“pork” or “earmarks”)

3. Cutting back all discretionary federal spending

4. Renting out the U.S. military to other countries

Federal Budget Trends

Health and State Budgets

Components of total state spending, fiscal 2006

Medicaid, 21.5%Elementary/secondary education, 21.4% (largest until ‘03)Higher education, 10.4% (2nd largest until 1990)Transportation, 8.1%Corrections, 3.4 %Public assistance, 1.8%All other expenditures, 33.4%

Source: NGA/NASBO Dec. 2007 Survey

America’s Health Care Access Problem

47 million Americans (15%) did not have health insurance in 2006

Institute of Medicine estimates that 18,000 Americans die every year from lack of care

There are large racial, ethnic, and socioeconomic disparities in diagnosis, treatment, and medical outcomes

Number of Nonelderly Uninsured Americans,1994 – 2006

40.6 41.743.1 43.9

42.1 40.943.3 43.0

44.446.545.544.7

40.0 39.6

44.80

25

50

Previous Method 1999 Revised Method 2004 Revised Method

* The Census Bureau periodically revises its CPS methods, which means data before and after the revision are not comparable. Comparison across years can be made between 1994 and 1999, 1999 through 2004, and 2004 though 2006.SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.

‘94 ‘95 ‘96 ‘97 ‘98

'99*

‘00 ‘01 ‘03‘02

’04* ‘05

39.8

‘06

Patient Protection and Affordable Care Act of 2010

Title I: “Quality, Affordable Care for All Americans” Insurability reforms

Title II: “Role of Public Programs” Affordability reforms

Title III: “Improving the Quality and Efficiency of Health Care” Delivery system reforms

Title IV: “Prevention of Chronic Disease and Improving Public Health” Health reforms

Title V: “Health Care Workforce” Education reforms

Uninsured Nonelderly vs. All Nonelderly,by Family Poverty Level, 2006

36%17%

29%

17%

19%

16%

16% 49%

Uninsured All Nonelderly

46.5 Million 260.0 Million

Under 100%

100% - 199%

200% - 299%

300% +

NOTES: The Federal Poverty Level for a family of four in 2006 was $20,614 (according to the U.S. Census Bureau’s poverty threshold). Family size and total family income are grouped by insurance eligibility. Data may not total 100% due to rounding. SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.

Uninsured Rates Among Nonelderly by State, 2005-2006

<13% Uninsured (13 states)13 to 17% Uninsured (18 states & DC)National Average = 18%

SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of the March Current Population Survey, 2006 and 2007, two-year pooled data.

AZ

WA

WY

ID

UT

OR

NV

CA

MT

HI

AK

AR

MS

LA

MN

ND

CO

IA

WISD

MOKS

TN

NMOK

TX

AL

MI

ILOH

IN

KYNC

PA

VAWV

SC

GA

FL

ME

NY

NH

MA

VT

NJ

DE

MD

RI

DC

CT

≥18% Uninsured (19 states)

NE

Patient Protection and Affordable Care Act of 2010

Title I: “Quality, Affordable Care for All Americans” Insurability reforms

Title II: “Role of Public Programs” Affordability reforms

Title III: “Improving the Quality and Efficiency of Health Care” Delivery system reforms

Title IV: “Prevention of Chronic Disease and Improving Public Health” Health reforms

Title V: “Health Care Workforce” Education reforms

America’s Health Care Value Problem

Fragmented, variable, poor quality health care delivery Lack of preventive care Poor adherence to clinical “best practices” Frequent medical errors

Mediocre population health Life expectancy at birth ranks 40th in the world Epidemic obesity and associated chronic disease

burden (diabetes, cardiovascular disease) 25% of Americans are obese 45% of Americans have a chronic disease

Lack of Insurance Undermines Preventive and Chronic Care

5046

53

32

0

20

40

60

80

100

Total Uninsuredall year

Uninsuredpart year

Insured allyear

Receipt of Recommended Screening

and Preventive Care,* 2005

Percent of adults

81

41

63

21

0

20

40

60

80

100

Diabetes under control** High blood pressureunder control***

Insured Uninsured

Chronic Disease Under Control: Diabetes and Hypertension,

1999–2004

* Recommended care includes: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot within a specific time frame given age and sex. ** Refers to diabetic adults whose HbA1c is <9.0 *** Refers to hypertensive adults whose blood pressure is <140/90 mmHg.

Percent of adults

Poor Coordination: Nearly Half Report Failures to Coordinate Care

Percent U.S. adults reported in past two years:

Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.

No one contacted you about test results, or you had to call

repeatedly to get results

Test results/medical records were not available at the time of

appointment

Your primary care doctor did not receive a report back from a

specialist

Any of the above

25

21

19

15

13

47

0 20 40 60

Doctors failed to provide important medical information to other

doctors or nurses you think should have it

Your specialist did not receive basic medical information from

your primary care doctor

Patient Protection and Affordable Care Act of 2010

Title I: “Quality, Affordable Care for All Americans” Insurability reforms

Title II: “Role of Public Programs” Affordability reforms

Title III: “Improving the Quality and Efficiency of Health Care” Delivery system reforms

Title IV: “Prevention of Chronic Disease and Improving Public Health” Health reforms

Title V: “Health Care Workforce” Education reforms

The problem

“The American public cannot have it both ways. They must

decide what is more important – money and time–

or comprehensive, appropriate care.”

A Kentucky physician opposing

retail medical clinics

Patient Protection and Affordable Care Act of 2010

Title I: “Quality, Affordable Care for All Americans” Insurability reforms

Title II: “Role of Public Programs” Affordability reforms

Title III: “Improving the Quality and Efficiency of Health Care” Delivery system reforms

Title IV: “Prevention of Chronic Disease and Improving Public Health” Health reforms

Title V: “Health Care Workforce” Education reforms

Obesity Trends* Among U.S. AdultsBRFSS, 1985

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1986

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1987

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1988

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1989

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1990

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14%

Obesity Trends* Among U.S. AdultsBRFSS, 1991

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1992

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1993

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1994

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1995

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1996

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19%

Obesity Trends* Among U.S. AdultsBRFSS, 1997

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1998

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 1999

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 2000

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% ≥20%

Obesity Trends* Among U.S. AdultsBRFSS, 2001

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

Obesity Trends* Among U.S. AdultsBRFSS, 2002

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2003

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2004

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

Obesity Trends* Among U.S. AdultsBRFSS, 2005

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2006

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Obesity Trends* Among U.S. AdultsBRFSS, 2007

(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)

No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

Patient Protection and Affordable Care Act of 2010

Title I: “Quality, Affordable Care for All Americans” Insurability reforms

Title II: “Role of Public Programs” Affordability reforms

Title III: “Improving the Quality and Efficiency of Health Care” Delivery system reforms

Title IV: “Prevention of Chronic Disease and Improving Public Health” Health reforms

Title V: “Health Care Workforce” Education reforms