Health Reform and the Health Reform and the Delivery System: A Delivery System: A Discussion of the Discussion of the

Policymaking ProcessPolicymaking Process

Jack O. Lanier, Jack O. Lanier, DrPH, MHA, FACHEDrPH, MHA, FACHE

CEOCEORichmond Behavioral Health Richmond Behavioral Health

AuthorityAuthority1

Class Learning ObjectivesClass Learning Objectives►Describe and discuss components of PPACA.Describe and discuss components of PPACA.►Describe key components of health Describe key components of health

economics and social choice.economics and social choice.►Explain the role of public opinion in the Explain the role of public opinion in the

policymaking process.policymaking process.►Describe a model for policymaking in the Describe a model for policymaking in the

U.S.U.S.►Assess students’ opinion of Governments’ Assess students’ opinion of Governments’

role in access to health care.role in access to health care.

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Health Care For Health Care For Americans:Americans:

The “Patient Protection The “Patient Protection and Affordable Care and Affordable Care

Act”Act”(P.L. 111-148)(P.L. 111-148)

2010-2018 2010-2018

Five Key Components of Five Key Components of PPACA:PPACA:

Health Insurance ReformHealth Insurance Reform

Coverage Reform – parityCoverage Reform – parity

Quality ReformQuality Reform

Payment ReformPayment Reform

Information TechnologyInformation Technology

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Behavioral Health Reform: Three Notable Publications

http://link.brightcove.com/services/player/bcpid1875349721?bctid=608833805001

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Significant Provisions of Significant Provisions of PPACAPPACA

Impact on Individual Population Impact on Individual Population GroupsGroups Young AdultsYoung Adults

26 and younger may remain on parents’ policy26 and younger may remain on parents’ policy

Insurance may be costly, but must stay coveredInsurance may be costly, but must stay covered

The ElderlyThe Elderly Receive free preventive services under MedicareReceive free preventive services under Medicare

Medicare Advantage Plan - insurer may cut extra Medicare Advantage Plan - insurer may cut extra benefits or increase co-paymentsbenefits or increase co-payments

Small-Business OwnersSmall-Business Owners 25 workers or less - may be eligible for tax credit to 25 workers or less - may be eligible for tax credit to

help buy coveragehelp buy coverage

After 2010, may be eligible for only 2 years of tax After 2010, may be eligible for only 2 years of tax credits to help purchase coveragecredits to help purchase coverage

Impact of New Insurance Impact of New Insurance Coverage on AmericansCoverage on Americans

32 mil more adults nationwide covered.32 mil more adults nationwide covered.

In Virginia, 300,000 individuals predicted In Virginia, 300,000 individuals predicted to receive new benefits.to receive new benefits.

Of the 32 mil, 10.5 mil have mental Of the 32 mil, 10.5 mil have mental health or substance use conditions; 60% health or substance use conditions; 60% qualify for Medicaid.qualify for Medicaid.

Approx. 8% of individuals may have sub-Approx. 8% of individuals may have sub-stance use issues and never been served.stance use issues and never been served.

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Virginia’s Response to Mandatory Virginia’s Response to Mandatory Coverage & State-run Insurance Coverage & State-run Insurance

ExchangesExchanges In March, VA AG Cuccinelli sued U.S. Govt.In March, VA AG Cuccinelli sued U.S. Govt.

Claim: U.S. Constitution “Commerce Clause” Claim: U.S. Constitution “Commerce Clause” can’t compel people to buy insurance.can’t compel people to buy insurance.

2010, Va. GA passed law not to compel residents 2010, Va. GA passed law not to compel residents to purchase health insurance.to purchase health insurance.

Gov. Bob McDonnell has endorsed lawsuit, Gov. Bob McDonnell has endorsed lawsuit, saying the federal law could cost Va. in excess of saying the federal law could cost Va. in excess of $1.5 bil in health costs between 2017 and 2022.$1.5 bil in health costs between 2017 and 2022.

Va. Medicaid enrollees estimated to increase Va. Medicaid enrollees estimated to increase from 270,000 to 425,000 between 2017 and from 270,000 to 425,000 between 2017 and 2022.2022. 9

““Doctors Urge Cuccinelli to Doctors Urge Cuccinelli to Drop Health-Reform Drop Health-Reform

Lawsuit” Lawsuit” (RTD 06-18-2010)(RTD 06-18-2010)

Washington-based “Doctors for America” Washington-based “Doctors for America” sent letter to AG Cuccinelli to drop suit.sent letter to AG Cuccinelli to drop suit.

Letter argues that litigation (successful or Letter argues that litigation (successful or not) would harm patients by delaying not) would harm patients by delaying funding appropriated to medical schools funding appropriated to medical schools and community health centers, and and community health centers, and medical care to underserved populations.medical care to underserved populations.

Obama administration lawyers filed Obama administration lawyers filed motion to dismiss Virginia’s lawsuit.motion to dismiss Virginia’s lawsuit.

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““Doctors Urge Cuccinelli to Doctors Urge Cuccinelli to Drop Health-Reform Drop Health-Reform

Lawsuit”: Lawsuit”: By the numbers By the numbers (cont’d)(cont’d) 155 Virginia physicians of “Doctors for 155 Virginia physicians of “Doctors for

America” group signed letter to AG America” group signed letter to AG Cuccinelli opposing Virginia’s lawsuit.Cuccinelli opposing Virginia’s lawsuit.

““Doctors for America” has 16,000 Doctors for America” has 16,000 members.members.

Virginia has 30,000 physicians.Virginia has 30,000 physicians.

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Health Spending vs. ResultsAmericans see doctors less, do not live longer,

and are not healthier.

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Health Care Reform:Health Care Reform:Complaints are Never-endingComplaints are Never-ending

A health-care windfall :*D.C. officials are expecting an infusion of cash. a reward for their push to offer nearly universal access to insurance for residents.

*6.2 percent of District residents are uninsured, less than half the national average.

SOURCE: Urban Institute; the Henry J. Kaiser Family Foundation | The Washington Post - April 14, 2010

Added Benefits To Some States:

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A Case to Reform the A Case to Reform the System:System:

Costs, Quality, and CoverageCosts, Quality, and Coverage

A New Approach for Medicare: A New Approach for Medicare: A Plan to Reward QualityA Plan to Reward Quality

Today’s Payment System:Today’s Payment System:► Is Riddled with perverse incentivesIs Riddled with perverse incentives►Rewards volume and high profit margin Rewards volume and high profit margin

services regardless of value, outcomes services regardless of value, outcomes or appropriatenessor appropriateness

►PPACA will reward hospitals for high-PPACA will reward hospitals for high-quality care: a first step to transform quality care: a first step to transform the way the federal government pays the way the federal government pays for health carefor health care

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Financial & Fiscal Realities Financial & Fiscal Realities For State GovernmentsFor State Governments

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Fiscal Realities: POLICY MAKING Fiscal Realities: POLICY MAKING AT THE STATE LEVELAT THE STATE LEVEL

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Public Public OpinionOpinion

People who say they trust government just about always or most of the time

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Public Trust in Government: 1958 to Public Trust in Government: 1958 to 20102010

An Impediment to Policy MakingAn Impediment to Policy Making

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Special InterestsSpecial InterestsIt’s All About MoneyIt’s All About Money

Americans’ Dependency on Americans’ Dependency on Federal Aid Continues to Federal Aid Continues to

IncreaseIncreaseIn 2010:In 2010:►A record 18.3% of total personal income A record 18.3% of total personal income

was payment from government for Social was payment from government for Social Security, Medicare, Food Stamps, Security, Medicare, Food Stamps, unemployment benefits and other programsunemployment benefits and other programs

►Wages accounted for the lowest share of Wages accounted for the lowest share of income – 51.0%income – 51.0%

►Wages declined to a low of 50.5% of Wages declined to a low of 50.5% of personal income in Feb. 2011personal income in Feb. 2011

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Suicidal Politics: Government Promises Suicidal Politics: Government Promises More Than It Can DeliverMore Than It Can Deliver

Americans’ Dependency on Government: 2009Americans’ Dependency on Government: 2009► 46.2 % received at least one federal benefit46.2 % received at least one federal benefit► 46.5 mil – Social Security46.5 mil – Social Security► 42.6 mil – Medicare42.6 mil – Medicare► 42.4 mil – Medicaid42.4 mil – Medicaid► 36.1 mil – Food Stamps36.1 mil – Food Stamps► 3.2 mil - Veterans’ benefits3.2 mil - Veterans’ benefits► 12.4 mil - Housing subsidies12.4 mil - Housing subsidies

National Opinion Research Center: University of Chicago 2011National Opinion Research Center: University of Chicago 2011

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How Americans Spend: $35,083 per How Americans Spend: $35,083 per HouseholdHousehold

Source: The Portland Mercury with Exotic Magazine (2009)Source: The Portland Mercury with Exotic Magazine (2009)

►Shopping - $8,668Shopping - $8,668►Health & Family - $8,026Health & Family - $8,026►Food & Drink - $6,514Food & Drink - $6,514►Home Related Expenses - $6,398Home Related Expenses - $6,398►Getting Around - $5,477Getting Around - $5,477

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National Opinion Research Center National Opinion Research Center SurveySurvey

University of Chicago - 2011University of Chicago - 2011

Americans Consistently Want More Americans Consistently Want More Spending For:Spending For:

►Education – 74 percentEducation – 74 percent►Health Care – 60 percentHealth Care – 60 percent►Social Security – 57 percentSocial Security – 57 percent►Taxes too high – Between half and Taxes too high – Between half and

two-thirdstwo-thirds►2010 – Only 2 % thought taxes too low2010 – Only 2 % thought taxes too low

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Government On The Brink With Government On The Brink With Suicidal PoliticsSuicidal Politics

National Opinion Research Center – Chicago 2011National Opinion Research Center – Chicago 2011

Government:Government:►Consistently promises more than it can Consistently promises more than it can

realistically deliverrealistically deliver►Repeatedly disappoints by providing Repeatedly disappoints by providing

less than people expectless than people expect►Government’s very expansion brings it Government’s very expansion brings it

into disrepute, results in paralyzed into disrepute, results in paralyzed politics and impedes it from acting in politics and impedes it from acting in the national interestthe national interest

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Big Government on the Brink: American Dependency on Federal

Benefits

Samuelson (WP), 2010

16%

14%14%

12%

1%4%

SocialSecurity

Medicare

Medicaid

FoodStamps

Veteren'sBenefits

HousingSubsidies

Federal Benefit Americans Using Benefit (in millions)Social Security 46.5Medicare 42.6Medicaid 42.4Food Stamps 36.1Veteren's Benefits 3.2Housing Subsidies 12.4

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Behavioral Health Reform: Three Notable Publications

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The Legislative & Policy The Legislative & Policy Making ProcessMaking Process

Is access to health insurance Is access to health insurance for all Americans a right or for all Americans a right or a privilege?a privilege?

A.A. A rightA right

B.B. A privilegeA privilege

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Given the known tension between Given the known tension between federal and state governments, which federal and state governments, which legislative body should prevail in the legislative body should prevail in the health care reform debate?health care reform debate?

A.A. FederalFederal

B.B. StateState

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Will provisions of the health Will provisions of the health reform law likely bend reform law likely bend (reduce) the cost curve (reduce) the cost curve over time?over time?

A.A. YesYes

B.B. NoNo

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Which of the four population groups Which of the four population groups described provides the greatest described provides the greatest opportunity to reduce health care opportunity to reduce health care cost and improve quality?cost and improve quality?

A.A. Medicaid and CHIPMedicaid and CHIP

B.B. Employers with fewer than 50 Employers with fewer than 50 employeesemployees

C.C. Medicare recipientsMedicare recipients

D.D. Midsized and larger employersMidsized and larger employers

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A Thought To PonderA Thought To Ponder

““All history is only one long story to the All history is only one long story to the effect: Men have struggled for power effect: Men have struggled for power over their fellow men in order that they over their fellow men in order that they might win the joys of earth at the might win the joys of earth at the expense of others, and might shift the expense of others, and might shift the burdens of life from their own shoulders burdens of life from their own shoulders upon those of others.” – William Graham upon those of others.” – William Graham Sumner Sumner

(1840-1910). An (1840-1910). An AmericanAmerican academic and professor at Yale College academic and professor at Yale College34

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Thank YouThank You

Questions ?Questions ?

Comments?Comments?