Health Policy & the Midterm Elections...Health Policy & the Midterm Elections Dan Derksen, MD at the...
Transcript of Health Policy & the Midterm Elections...Health Policy & the Midterm Elections Dan Derksen, MD at the...
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Health Policy & the Midterm ElectionsDan Derksen, MD at the 45th Annual Rural Health ConferenceHealth in Context: Addressing Rural Strengths & Challenges
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Arizona Center for Rural HealthThe AzCRH Mission is to improve the
health & wellness of rural and vulnerable populations.
http://crh.arizona.edu
Center Programs:State Office of Rural Health
Rural Hospital Flexibility ProgramSmall Rural Hospital Improvement Program
First Responders InitiativePrescription Misuse/Abuse Initiative
Navigator Consortium
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Arizona Nonpartisan Health Policy Collaboration: This Year
Dan Derksen, MD
Legislature Unanimously Passes AZ Opioid Epidemic Act Gov. Ducey Signs 1/26/18
HB 2235 Dental
Therapists
HB 2324 CHW VoluntaryCertification
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Education Is a Social Determinant of Health
Dan Derksen, MD
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Five Years Ago
Brewer wins Medicaid expansionBy Kyle Cheney & Jason Millman 06/13/2013
AZ Gov. Jan Brewer muscled to victory in her Medicaid expansion crusade, outmaneuvering conservative opposition to push through a key piece of President Obama’s agenda.
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Dan Derksen, MD
Adapted by Dan Derksen, MD: https://www.azahcccs.gov/Resources/Downloads/PopulationStatistics/HistoricPopulationData_1986toCurrent.pdfand http://www.kff.org/other/state-indicator/total-
population/?dataView=0¤tTimeframe=2&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D
Pre-ACA 2013 AZ Health CoveragePayer Source Arizonans %AZ Pop
Employer Sponsored Insurance 2,900,000 45%
Medicaid (AHCCCS)+CHIP (KidsCare) 1,320,000 20%
Non-Group Individual Ins. 171,000 3%Medicare 842,000 13%Uninsured 1,225,000 19%
Total Pop. Arizona 6,458,000 100%
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Arizona Health Coverage 2017-18Payer Source # Arizonans %AZ Pop
Employer Sponsored Insurance (2016)1 3,011,000 43%
Medicaid (AHCCCS)2
+CHIP (KidsCare) (7/2018) 1,855,000 25%ACA Marketplace +
Individual (non-group)1 377,000 5%Medicare (04/2018)3 1,245,000 17%
Uninsured4 725,000 10%Total Pop. Arizona5 7,016,000 100%
1.ESI 2016 Kaiser: https://www.kff.org/other/state-indicator/total-population/?dataView=1¤tTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D2.Medicaid/AHCCCS+CHIP: Medicaid/CHIP July 2018: https://www.azahcccs.gov/Resources/Downloads/PopulationStatistics/2018/Jul/AHCCCSPopulationHighlights.pdf3.Medicare AZ Beneficiaries April 2018 (nb: 213,000 are dual, Medicaid+Medicare): https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Dashboard/Medicare-Enrollment/Enrollment%20Dashboard.html4.Derksen 2017-18 estimated uninsured for one year or greater5.July 2017 AZ Population Estimate: https://www.census.gov/quickfacts/AZ
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Arizona ACA Uninsured ImpactsPre-ACA 2010-12: 1.2M of 6.5M (18.5% Uninsured)
Current 2017-18: 0.7M Uninsured of 7M (10%) AZ Pop.
AHCCCS / Medicaid+600,000
AZ Marketplace+165,000
Age 26 on Parent’s Plan+70,000
Open Enrollment11/1-12/15/17
OE-511/1/16-1/31/17
OE-42017
to 2018AZ ACA Marketplace 165,758 196,291 -30,533
AHCCCS-Medicaid Jan 2017
AHCCCS-Medicaid Jan 2018
AHCCCS-Medicaid Jan 2017 to 2018
1,913,627 1,891,491 -22,136
https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Marketplace-Products/2018_Open_Enrollment.html
Jan 2018 at: https://www.azahcccs.gov/Resources/Downloads/PopulationStatistics/2018/Apr/AHCCCSPopulationHighlights.pdfJan 2017 at: https://www.azahcccs.gov/Resources/Downloads/PopulationStatistics/2017/Mar/AHCCCS_Population_Highlights.pdf
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Arizona ACA Economic Impact
AZ #5 in Health Sector Job Growth Since 2010
Uninsured Decline 2009-
15
AZ#13
https://www.azcentral.com/story/money/business/health/2017/01/27/ducey-cites-obamacare-harm-arizona-seeking-repeal-laws-positives-complicate-issue/96998808/
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AZ Hospital Financial Trends SinceMedicaid Restoration and Expansion
AzHHA@https://static1.squarespace.com/static/572a399a1bbee0add26af051/t/5aa86c57f9619a457058032e/1520987224999/January+2018+Hospital+Financial+Reports.pdf
For the 12 months ending Jan 2014 to Jan 2018:• Uncompensated care dropped from 7.9% to 2.4%• Avg. operating margin increased from 3.1% to 5.1%
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Federal Per Capita Medicaid Enrollee Spending by State 2017
0
2,000
4,000
6,000
8,000
10,000
12,000
Data: J. Holahan and M. Buettgens, Block Grants and Per Capita Caps: The Problem of Funding Disparities Among States, Urban Institute, Sept. 2016, available at http://www.urban.org/research/publication/block-grants-and-capita-caps.
Rosenbaum S Commonwealth Fund Mar 2017: http://www.commonwealthfund.org/publications/issue-briefs/2017/jan/medicaids-future-aca-repeal
U.S. AVG.
AZ #8
LowestCost
Dan Derksen, MD
While Arizona’s Federal Medical Assistance Percentage (FMAP) is high (69%), its federal spending is low
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U.S. Health Coverage Now# covered in millions (%)
Private Health Insurance1
Employer Sponsored ESI
Individual Purchase (Non-Group)
179 (54%)157(43%)22 (11%)
Medicaid + CHIP2 79 (23%)Medicare2 59 (18%)Uninsured 28 (8.8%)
Total Population 323 (100%)
Dan Derksen, MD
Note: 9 million Americans have both Medicaid and Medicare, some on Medicare also have private supplemental plans1.2016 KFF Data at: https://www.kff.org/other/state-indicator/total-population/?dataView=1¤tTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D2.https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html
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Publicly Sponsored 2017Medicaid + CHIP + Medicare Cover
40% US pop: 129M/323MMedicaid 72 Million CHIP 7 Million Medicare 59 MillionDual 9 M Medicaid + Medicare
Accessed 03/29/18 at:https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html
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US Medicaid + CHIP Cover 79 Million Americans
25% US pop: 79M/323M
Over half of these enrollees are children
Dan Derksen, MD
Accessed 03/29/18 at:https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html
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Medicaid Also Covers the Disabled, Frail Elderly, Long Term Care
MEDICAID Elderly + Disabled
Of 68 Million on Medicaid in 2016 24% Enrollees
Park, H. NYT 03/07/17: https://www.nytimes.com/interactive/2017/03/07/us/politics/medicaid-reform-impact-on-states.html?_r=0
Of Medicaid’s $566 Billion Costs 63% of Costs
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States Not Expanding Medicaid Have Highest Rural Hospital Closures
Dan Derksen, MD
MAYBE: 3 StatesID, UT, NEYES: 33 States
NO: 14 States
-14 ruralhospitals
-8
-5 -6-5
-5
Medicaid Expansion by State
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85 Rural Hospital Closures Since 2010
http://www.shepscenter.unc.edu/programs-projects/rural-health/rural-hospital-closures/
AL, AZ, CA, FL, GA, IL, KS, KY, LA, MA, ME, MI, MN, MO, NE, NC, NV, OH, OK, PA, SC, SD, TN TX, VA, WI
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Uninsured, CMS Medicaid & Medicare payment policies drive
rural provider fiscal viability
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Hispanic+4 Million
Insured
Black +3MWhite +8.9M
Accessed 02/11/17 at: https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf
Uneven Uninsured Decline by Race & Ethnicity Post-ACA
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Equity is the absence of avoidable or remediable differences among groups of people, whether those groups are defined socially, economically, demographically, or geographically.
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House Rejects Immigration Overhaul Despite Trump’s Late PleaBy Thomas Kaplan | June 27, 2018
WASHINGTON – The House resoundingly rejected a far reaching immigration overhaul on Wednesday…
Dan Derksen, MD
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November Midterm Elections
Dan Derksen, MD
Senate Today 51R-49D35 seats at stake/100Of which 26 D, 9 R
House 435 Seats: 236R-193D, 6 Vacant218 Needed for Majority
What’s at stake for the next two years2019 to 2020?
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What’s past is prologueShakespeare: The Tempest
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Preamble: Tax Cuts & Jobs Act
Temporarily lowers individual tax rate for most Americans
• 95-99th income get 3.1% income gain, drops to 1.1% in 2027
• All: 1.6% gain, drops to 0.3% in 2027https://www.congress.gov/bill/115th-congress/house-bill/1/text?format=txthttps://www.cbo.gov/publication/53300https://www.wsj.com/livecoverage/tax-bill-2017/card/1512431352
Dan Derksen, MD
Permanently lowers corporate tax rate from 35% to 21%
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Prelude of what’s coming 2019-20Tax Cuts & Jobs Act 12/22/17
• Repeals ACA tax mandate (2019) that required individuals to be insured or pay a tax penalty
• Increases uninsured by 4M by 2019, 13M by 2027• Destabilizes individual health insurance market• Increases fed deficit $1.5 trillion over 10 years
https://www.congress.gov/bill/115th-congress/house-bill/1/text?format=txthttps://www.cbo.gov/publication/53300https://www.wsj.com/livecoverage/tax-bill-2017/card/1512431352
Dan Derksen, MD
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Repeal the Social Security ActReplace it with: • Medicaid Block Grants• Medicare Market Vouchers
Accessed 03/15/18 at:http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf
House Speaker Paul Ryan
Dan Derksen, MD
How Can We Afford the Corporate Tax Cut?
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Dan Derksen, MD
?Though I have to say goodbye
Remember me
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American Health Care Act Effects
# Uninsured Increase Over 10 Years 24 M
# Uninsured Increase in 2018 14 M
Medicaid $$$ Cut to States Over 10 Years $880B
Dan Derksen, MD
Preamble to 2019-20? Congress Cutting $1 Trillion from Medicaid
CBO-JCT Cost and Coverage Estimates of the American Health Care Act, 03/23/2017: https://www.cbo.gov/system/files/115th-congress-2017-2018/costestimate/hr1628.pdf
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Undermining Medicaid Coverage via Sec. 1115 Soc. Sec. Act Waivers
States seeking CMS ok for Medicaid work requirements (N=9):
Arkansas, AZ, Indiana, Kansas, Maine, New Hampshire, Utah, Wisconsin
Dan Derksen, MD
https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issu
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Judge Says “No” to KY Medicaid Work Rules
Dan Derksen, MD
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CMS Says “No” to Lifetime Medicaid Limits (Kansas)
Dan Derksen, MD
Arizona pulls back from imposing time limits on AHCCCS enrollmentStephanie Innes | May 13, 2018
http://tucson.com/news/local/arizona-pulls-back-from-imposing-time-limits-on-ahcccs-enrollment/article_7812f83c-3160-5fef-bd1d-aa3ff70a711c.html
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What’s past is prologue
Dan Derksen, MD
November 6, 2018
What to come, in yours and mine to discharge
William Shakespeare: The Tempest Act II
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Dan Derksen, MD
To carry a positive action we must develop a positive vision
Dalai Lama