Will the Midterm Elections Transform Our Health System? · 2018-10-04 · Will the Midterm...
Transcript of Will the Midterm Elections Transform Our Health System? · 2018-10-04 · Will the Midterm...
Will the Midterm Elections Transform Our Health System?Daniel Derksen, M.D. | October 3, 2018 | Duvall Auditorium, Tucson, ArizonaAssociate VP for Health Equity, Outreach & Interprofessional Activities Walter H. Pearce Endowed Chair & Director, Center for Rural Health
• I do not represent the positions of the UA or the Arizona Board of Regents.• I will express my personal opinions based on
more than 30 years of experience as a family physician and in applied health policy to inform the public, providers, and policymakers. • I cite primary source data in this presentation &
the handout posted at: http://crh.arizona.edu
Daniel Derksen, M.D. Statement
Dan Derksen, MD
Dan Derksen, M.D.UAHS Associate Vice President
for Health Equity, Outreach & Interprofessional Activities
March 1, 2017 CNN Town Hall Question
“How will you make sure the country doesn’t return to having 48 million people without health insurance?”
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New YorkerWorld View
UAHS World View?
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YouAreHere!
You Are
Here!
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Arizona Hispanic Center of ExcellenceCenter for Elimination of Border Health Disparities
Office of Diversity and Inclusion
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UA Arthritis CenterState Office of Rural Health
Center for Rural HealthArizona Center on Aging
Opioid Assistance and Referral LineW. Region Public Health Training Center
Area Health Education CentersAZ Poison Control & Information Center
Arizona’s Smokers’ HelplineAZ Telemedicine Program
Banner University Medical Center
Center for Innovation in Brain ScienceCenter for Population Science & Discovery
UA Cancer CenterPrevention Research Center
Academic
Silos
Shawn Braley
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What’s past is prologueShakespeare: The Tempest
Eight Years Ago
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Affordable Care Act Signing March 2010https://www.washingtonpost.com/graphics/national/obama-legacy/obamacare.html
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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https://www.politico.com/story/2013/06/arizona-medicaid-expansion-jan-brewer-092723
AZ Pre-ACA Health Coverage 2013Payer Source Arizonans % AZ Pop
Medicaid + CHIP (AHCCCS + KidsCare) 1,320,000 20%
Uninsured 1,225,000 19%Total AZ Population 6,458,000 100%
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AZ Health Coverage 2018Medicaid + CHIP 1,689,000 24%
Uninsured 725,000 10%Total AZ Population 7,016,000 100%
Medicaid/AHCCCS+CHIP: Medicaid/CHIP July 2018: https://www.medicaid.gov/state-overviews/stateprofile.html?state=arizona
Arizona ACA Impact
AZ #5 in Health Sector Job Growth
Since 2010
AZ #13 in Uninsured
Decline
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 and 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
DC NY WV RI CT OR VT MOMS DE KY MN AR TN MT OH ND PA MEMA ID LA MD IA IN US AK NC UT NM KS SC AL WI CA WYWA OK TX MI NJ GA FL VA AZ NE SD HI CO NV IL NH
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
While Arizona’s Federal Medical Assistance Percentage (FMAP) is high
(69%), its federal spending is 8th lowest
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U.S. Coverage: >40% Public# covered in millions (%)
Private Health Insurance1
Employer Sponsored ESI
Individual Purchase (Non-Group)
179 (54%)157(43%)22 (11%)
Medicaid + CHIP2 73 (22%)Medicare3 59 (18%)Uninsured 28 (8.8%)
Total Population4 328 (100%)Note: 9 million Americans have both Medicaid and Medicare (dual eligible)1.2016 KFF Data at: https://www.kff.org/other/state-indicator/total-population2. https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.html3. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/CMS-Fast-Facts/index.html4. US Census 2018 U.S. Population: https://www.census.gov/popclock/
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Medicaid + CHIP Cover 73M 22% of Americans
Over half are children
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Accessed 10/01/2018 for enrollment and pop. estimates as of July 2018: https://www.medicaid.gov/medicaid/program-information/medicaid-and-chip-enrollment-data/report-highlights/index.htmlhttps://www.census.gov/popclock/
Medicaid Also Covers the Blind, Disabled, Frail Elderly, Long Term Care
MEDICAID Blind, 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 - Higher Rural Hospital ClosuresMAYBE: 3 States ID, UT, NEYES: 33 States
NO: 14 States
-14 ruralhospitals
ACA Medicaid Expansion by State
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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 10/02/18 at: https://aspe.hhs.gov/sites/default/files/pdf/187551/ACA2010-2016.pdf
Uneven Decline in Uninsured by Race & Ethnicity Post-ACA
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30%Uninsured
In 2016
2016Uninsured
7%
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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Interaction Institute for Social Change, Artist: Angus Maguire
Shift from Passive Observers to Active Participants
2019 Prelude? Tax Cuts & Jobs Act 12/2017
• Repeals ACA tax penalty for being uninsured in 2019• Increases uninsured by 4M by 2019, 13M by 2027• Destabilizes individual health insurance market• Increases fed deficit $1.5 trillion over 10 years
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46% projected 2019 deficit relates to bills signed in last 12 mo.
https://www.congress.gov/bill/115th-congress/house-bill/1/text?format=txthttps://www.cbo.gov/publication/53300http://www.crfb.org/blogs/fiscal-year-defined-24-trillion-new-debthttps://www.wsj.com/livecoverage/tax-bill-2017/card/1512431352
Tax Cuts & Jobs Act 12/2017
Temporarily lowers individual tax rate Individuals gain +1.6% income overall
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
Permanently lowers corporate tax rate from 35% to 21%
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Repeal the Social Security ActReplace ‘entitlements’ with: •Medicaid Block Grants•Medicare Market Vouchers• Privatize Social Security
Accessed 09/26/18 at:http://abetterway.speaker.gov/_assets/pdf/ABetterWay-HealthCare-PolicyPaper.pdf
House Speaker Paul Ryan
One View of Paying for the Corporate Tax Cut
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?
How Would Arizona Do with a Medicaid /AHCCCS Block Grant?
States faring worse with Medicaid block grants: X Expanded MedicaidX Cost efficient X Rapid growth in low-income elderly
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Park, H. NYT 03/07/17: https://www.nytimes.com/interactive/2017/03/07/us/politics/medicaid-reform-impact-on-states.html?_r=0
U.S.Avg.
2017 American Health Care Act Effects
# Insured Decreasing Over 10 Years -24 M
# Insured Decreasing in 2018 Alone -14 M
Medicaid $$$ Cut to States Over 10 Years -880 B
2019 Preamble? One Vote Short in 2017 of: Almost $1 Trillion in Medicaid Cuts
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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CNN Town Hall March 1, 2017Town Hall March 1, 2017
Town Hall March 1, 2017“We’re not gonna throw anybody off of
health care - as long as that fundamental principle is there, we will be fine.” Sen. McCain
From 3/1/17 At 22min:45sec: https://www.youtube.com/watch?v=19G_xRx9G-c
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McCain Votes NO
July 27, 2017 at: https://www.washingtonpost.com/video/national/mccain-votes-against-skinny-repeal-health-care-bill/2017/07/28/206422e2-7356-11e7-8c17-533c52b2f014_video.html?utm_term=.fb5b87c3c8cc
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“I believe we could do better working together, Republicans and Democrats,
and have not yet really tried” Sen. McCain
Arizona Nonpartisan Health Policy Collaboration in 2018
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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Sen. Barto
Rep. Carter
Education Is a Social Determinant of Health
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Undermining Medicaid Coverage withSec. 1115 Soc. Sec. Act Waivers
Seeking CMS ok for work requirements: AR, AZ, IN, KS, KY, ME, NH, UT, WI
CMS approved them for AR, KY, IN, NH
https://www.healthaffairs.org/do/10.1377/hblog20181001.233969/full/https://www.kff.org/medicaid/issue-brief/medicaid-and-work-requirements-new-guidance-state-waiver-details-and-key-issues/
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CMS Denies KS Lifetime Medicaid Limits
Arizona pulls back from imposing time limits on AHCCCS enrollmentStephanie Innes | May 13, 2018
https://www.nytimes.com/2018/06/29/health/kentucky-medicaid-work-rules.htmlhttp://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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Judge Strikes Down Kentucky’s Medicaid Work RulesAbby Goodnough | June 29, 2018
What’s past is prologue
November 6, 2018
What to come, in yours and mine to discharge
William Shakespeare: The Tempest Act II
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37 states begin voting 5 to 45 days before Nov 6
Arizona Voting Starts Oct 10
2018 US Senate 2*51 R49 D
35 Seats Up26 held by D’s
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In 2016 in the U.S.245.5M Eligible to Vote
157.6M Registered to Vote136.8M Voted
http://www.pewresearch.org/fact-tank/2018/05/21/u-s-voter-turnout-trails-most-developed-countries/
*Seats needed to change majority
2018 US House 25*236 R193 D
6 Vac
All 435 Up
87% of Registered Americans Voted 56% of Eligible Americans Voted
2018 CurrentAZ Senate 3*
17 R13 D
2018 CurrentAZ House 6*
35 R25 D
In August 2018 in Arizona1,264,295 (34.8%) Registered Republicans1,256,170 (34.6%) Other1,111,580 (30.6%) Registered Democrats3,632,045 Registered Arizona Voters1
1. 09/23/2018 at: https://azsos.gov/elections/voter-registration-historical-election-data 2. AZ Capitol Times: https://azcapitoltimes.com/news/2018/07/26/nearly-half-of-eligible-voters-in-arizona-dont-cast-ballots/
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*Seats needed to change majority
74% of Registered Arizonans Voted in 201657% of Eligible Arizonans2 Voted in 2016
• Justice Gorsuch Age 51, 2017: Justice Scalia Age 80 (dec.)• Justice Kennedy: Retired Age 82 in July, 30 yrs SCOTUS• Justice Breyer: Age 80, in 25th year on SCOTUS• Ruth Bader Ginsburg: Age 85, in 26th year on SCOTUS
Midterm and the Supreme Court of the United States (SCOTUS)
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•Spiraling drug costs•Losing coverage•Cutting Medicaid, Medicare•Covering ‘pre-existing’ conditions•Shifting costs to elderly Americans with chronic disease - diabetes, hypertension, arthritis, heart disease
Healthcare Is the #1 Voter Concern This Midterm Election
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http://media1.s-nbcnews.com/i/today/z_creative/18416NBCWSJJunePoll6718Release.pdf
•From 2008-15 brand name drug prices rose by 164%, 12X rise in CPI (13.5%)•Prices fall 75% after patents endPolicy Interventions:•Fast track generic applications to FDA• Import off-patent drugs•FTC strict oversight of drug co. mergers
U.S. Drug Prices – Health Policy
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https://www.healthaffairs.org/doi/10.1377/hlthaff.2018.0628https://data.bls.gov/pdq/SurveyOutputServlet?request_action=wh&graph_name=CU_cpibrief
•Allow Medicaid ‘buy-in’ for states (NV)•Manage costs: home, community (ALTCS)•Pay value-based care v fee-for-service•Eliminate steps not adding value: billing, collecting, EHR documenting•Shift from PhRMA & insurance company ‘hold harmless’ policy approaches to:
hold accountable
Innovative Policy Interventions
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Dan Derksen, MD
To carry a positive action we must develop a positive vision
Dalai Lama
Lake Mary
COCOnino National Forest
Día de los MuertosOct 31 to Nov 2
Though I have to say goodbyeRemember me
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Día de los Votos: Nov 6AZ: Register to Vote by Oct 9
Though I have to say goodbyeRemember to vote!
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