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Kevin Grumbach, MD Department of Family and Community Medicine

University of California, San Francisco

Overview •  Context for health reform

•  Key features of the Patient Protection and Affordable Care Act

•  Beyond health insurance reform: health delivery reform

The Elusive Goal of Coverage Number of Nonelderly Uninsured Americans, 2000 – 2009

39.6 40.9 43.3 44.7 45.5

43.0 44.4 46.5 45.0 45.7

50.0

0

25

50

2000 2001 2002 2003 2004 2004 2005 2006 2007 2008 2009

2000-2004 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 2000 through 2004, and 2004 though 2009. SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2001-2010 ASEC Supplements to the CPS.

18,000 deaths annually due to uninsurance

(Institute of Medicine)

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Uninsured Rates Among Nonelderly by State, 2008-2009

<14% Uninsured (13 states & DC) 14 to 18% Uninsured (20 states) National Average = 18.1%

SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2009 and 2010 ASEC Supplements to the CPS., two-year pooled data.

AZ

WA

WY

ID

UT

OR

NV

CA

MT

HI

AK

AR

MS

LA

MN

ND

CO

IA

WI SD

MO KS

TN

NM OK

TX

AL

MI

IL OH

IN

KY NC

PA

VA WV

SC

GA

FL

ME

NY

NH

MA

VT

NJ

DE

MD

RI

DC

CT

>18% Uninsured (17 states)

NE

Universal Coverage: Limited Menu of Options

•  Tax people for coverage under a public plan or public health service

•  Mandate employers to pay for private insurance for their employees

•  Mandate individuals to enroll in private insurance

•  Can use tax system to subsidize employment-based and individual private plan coverage

Patient Protection and Affordable Coverage Act: Key Coverage Measures

•  Mandates on individuals and employers with 20+ employees to purchase private insurance if not publicly insured and citizen or legal resident

•  Tax subsidies for small employers and individuals (citizens and legal residents)

•  Insurance market reform (e.g., no exclusions for pre-existing conditions)

•  Health Insurance Exchanges

Patient Protection and Affordable Coverage Act: Key Coverage Measures

•  Expansion of Medicaid – States required to make all citizens and legal

residents <133% poverty level eligible for Medicaid – No more categorical eligibility criteria (eg, dependent

children, disability) – Federal government funds cost of newly enrolled

•  CBO estimates will cover 32M of ~50M uninsured

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Other Measures •  Gradually closes Medicare Part D “donut hole”

•  Eliminates cost-sharing for – Medicare covered preventive services

recommended by U.S. Preventive Services Task Force

Coverage Gaps Remaining

•  Undocumented immigrants •  Low-mid income individuals and families unable

to afford mandates even with subsidies

Supreme Court Decision June 2012 •  Upheld individual mandate

– Justified by federal government’s power to tax – Not justified by commerce clause

•  Rejected federal government’s authority to require state’s to implement Medicaid expansion – Must be voluntary – California will implement Medicaid expansion

•  Revised CBO Analysis July 2012: 25M more insured (down from 33M more)

House Minority Leader John Boehner Advice to President Obama

Sept 9, 2009

“I hope he’s been listening to the American people, because I think over the course of August they’ve raised their voices loud and clear that they don’t want this massive government takeover of our health-care system.”

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AMA Campaign vs Medicare Bill “Write those letters now. Call your friends, and tell them to write them. If you don't, this program I promise you will pass just as surely as the sun will come up tomorrow. And behind it will come other federal programs that will invade every area of freedom as we have known it in this country, until, one day, as Norman Thomas said, we will awake to find that we have socialism. And if you don't do this, and if I don't do it, one of these days, you and I are going to spend our sunset years telling our children, and our children’s children, what it was once like in America when men were free.”

Socialist Socialist Socialist Not a Socialist

“Whatever happens, the Government better not get involved with my Medicare.”

PP&ACA: Coverage Timeline • High risk health insurance pools for individuals

with no insurance due to pre-existing conditions (7/2010)

• Expansion of dependent coverage for young adults up to age 26 (9/2010)

• Elimination of provisions that allow health insurers to cap lifetime benefits or deny coverage to children based on pre-existing conditions (9/2010)

• Expansion of Medicaid (2014)

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PP&ACA: Coverage Timeline • Individual health insurance mandate (2014) • Subsidized health insurance exchanges for the

uninsured to purchase insurance (2014) • Elimination of provisions that allow health

insurers to deny coverage based on pre-existing conditions, etc. (2014)

• Employer requirements related to provision of health care coverage or payment of a penalty (2014)

What about the Affordable part of the Affordable Care Act?

Per Capita Total Current Health Care Expenditures, U.S. and Selected Countries, 2008

$2,966

$3,295

$2,804

$4,713

$2,683

$3,728

$2,750

$3,632

$3,359

$3,610

$3,595

$2,858

$3,865

$3,677

$3,758

$7,164

$0 $1,000 $2,000 $3,000 $4,000 $5,000 $6,000 $7,000 $8,000

United States

United Kingdom

Sweden

Spain

Norway^

New Zealand

Netherlands^

Italy

Ireland

Iceland*

Germany

France

Finland

Canada^

Belgium^

Austria

Source: Organisation for Economic Co-operation and Development. OECD Health Data 2010, from the SourceOECD Internet subscription database updated June 2010. Copyright OECD 2010, http://www.oecd.org/health/healthdata. Data accessed on 07/02/10.

Total US Health Expenditures 2009: $2.5 Trillion

Cumulative Changes in Health Insurance Premiums, Workers’ Contribution to Premiums, Inflation, and Workers’ Earnings, 1999-2010

138%

159%

42%

31%

0%

20%

40%

60%

80%

100%

120%

140%

160%

180%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Health Insurance Premiums

Workers' Contribution to Premiums

Workers' Earnings

Overall Inflation

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2010. Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), 1999-2010; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999-2010 (April to April).

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Source: Ezra Klein, Washington Post, March 26, 2013; data from International Federation of Health Plans

Mortality Amenable to Health Care U.S. Rank Fell from 15 to Last out of 19 Countries

76 81

88 84 89 89

99 97 88

97

109 106 116 115 113

130 134 128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fran

ce

Japa

n Aus

tralia

Spa

in

Italy

Canad

a Nor

way

Nether

lands

Swed

en

Greec

e Aus

tria

German

y Fin

land

New Ze

aland

Den

mark

United

King

dom

Irelan

d Por

tuga

l Unit

ed S

tates

1997/98 2002/03

Deaths per 100,000 population*

* Countries’ age-standardized death rates, ages 0–74; includes ischemic heart disease. Source: Commonwealth Fund; E. Nolte and C. M. McKee, Measuring the Health of Nations: Updating an Earlier Analysis, Health Affairs, January/February 2008, 27(1):58–71

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Under the ACA:

Income = $45,906 Premium = $4,361

Under the ACA:

Income = $46,136 Premium = $10,193

PP&ACA: Cost Measures •  Competition within regulated insurance market •  Health IT •  Prevention and health promotion •  Reduce Medicare Advantage private plan payments •  Independent Payment Advisory Board for Medicare •  Innovation Center within the Centers for Medicare and

Medicaid Services •  Insurance overhead limited to 15% for plans in large

group market and 20% for plans in individual and small group markets

•  High premium excise tax

Beyond Insurance Reform: Delivery System Reform

Medical Homes and Accountable Care Organizations

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Dr. Katherine J. Atkinson of Amherst, Mass., has a waiting list for her family practice; she has added 50 patients since November.

In Massachusetts, Universal Coverage Strains Care

April 5, 2008

Bodenheimer T. N Engl J Med 2006;355:861-864

Family Medicine Residency Positions and Number Filled by U.S. Medical School Graduates

Supply of General Pediatricians per 100,000 Children in the US

Source: Shipman SA, Lurie JD, Goodman DC. Pediatrics 2004;113:435.

The President Wants More and Stronger

Primary Care

“It used to be that most of us had a family doctor; you would consult with that family doctor; they knew your history, they knew your family, they knew your children, they helped deliver babies. How do we get more primary physicians, number one; and number two, how do we give them more power so that they are the hub around which a patient-centered medical system exists, right? ” June 8, 2010, Town Hall with Seniors

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Senator Orrin Hatch Senate Finance Committee Roundtable

Reforming America’s Health Care Delivery System April 21, 2009

“The US is first in providing rescue care, but this care has little or no impact on the general population. We must put more focus on primary care and preventive medicine. How do we transform the system to do this?”

July 6, 2009

Randy MacDonald, Sr VP House Ways and Means Hearing April 29, 2009

•  “I will start with the very last question asked by the committee--what is the single most important thing to fix in healthcare? Primary care. Strengthen primary care -- transform it and pay differently using a model like the Patient Centered Medical Home.”

•  Congressman: “And the second issue?”

•  “Well, if you don't fix the first issue and do not have a foundation of powerful primary care then you can do nothing else. You have to fix primary care before you can even begin to address a second issue.”

Joint Principles of the Patient Centered Medical Home

February 2007 American Academy of Family Physicians

American Academy of Pediatrics American College of Physicians

American Osteopathic Association

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•  Rittenhouse & Shortell: 4 Cornerstones of the PCMH

•  Primary Care –  first Contact (access) –  Comprehensiveness –  Continuity –  Coordination

•  Patient-Centered •  New Model Practice •  Payment Reform

Affordable Care Act: Measures to Revitalize Primary Care

•  Physician payment reform –  Medicare fee 10% increase for PC –  Medicaid PC fee increases to Medicare rates (2013-2015)

•  Infrastructure investment and facilitating practice redesign –  CMS Innovations Center –  Medical Home pilot programs –  Primary Care Extension Program –  ARRA HIT incentives and TA

•  Training pipeline –  More NHSC scholarships and loan repayment –  New Primary Care Training Grants

From Medical Homes to Medical Neighborhoods

•  High performing primary care necessary but not sufficient

•  Need the entire system to work together in a coordinated, integrated, patient-centered manner

3° Care

1° Care

2° Care

Medical Neighborhood

Medical Home

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Global Capitation,Vertically Integrated Delivery

System

Fee For Service, Independent

Practices

Stronger Weaker

Cost Control

Accountable Care

Organization

PPO Plans Kaiser Network

HMO Plans (Health Net)

Accountable Care Organizations

•  “Networks of physicians and other providers that could work together to improve the quality of health care services and reduce costs for a defined patient population.” – Health Affairs Brief, 8/13/10

Percentages of U.S. Physician Practices Owned by Physicians and by Hospitals, 2002–2008.

Source:R Kocher, NR Sahni, N Engl J Med 2011; 364:1790-1793

1990s Managed Care Enters the 21st Century

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