US Health Care System: Its impact on your future practice and
patients Nancy Cooper Coordinator, Health Policy Fellowship March
27, 2014 1
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Medicine is the #1 industry in the US We have the best
Technology Infrastructure Medical schools Physicians 2
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CMS Office of the Actuary 2011 & Kaiser Family Foundation
report, Health Care 4
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White House Office of Management and Budget 2010 5
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6 Half of all children born after 2000 will live to be 100 One
in three will develop Type II diabetes The Lancet Oct 1, 2009 and
National Diabetes Fact Sheet, Jan 26, 2011
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Emphasize acute care over wellness and prevention Fee for
service payment encourages quantity over quality Health disparities
among racial and ethnic minorities Outcomes are poorer than
countries which spend much less 7
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"In the United States today, we give you all the care you can
afford, whether or not you need it, as opposed to all the care you
need, whether or not you can afford it." Arthur Kellerman, MD, MPH,
Emory Medical School 8
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Understanding the US Health Care System(s): Evolution or
Intelligent Design? 9
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50% Private Insurance Employer-based group insurance or Single
policy or Out of Pocket 10
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50% State and Federal Government Insurance Medicare (elderly)
Medicaid (destitute) Childrens Health Insurance Program (CHIP)
Veterans Affairs Indian Health Service Federal Employees Health
Benefit Program
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Emergency rooms Public hospitals Federally Qualified Health
Centers (FQHCs) 145 OR Migrant worker health centers $61 B per year
in uncompensated care Urban Institute: Health Care Spending Under
Reform: Less Uncompensated Care and Lower Costs to Small Employers
1/2010 http://findahealthcenter.hrsa.gov/Search_HCC.aspx 12
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$880 billion budget Medicare $524 B Medicaid $243 B fed$ Total
CMS $ 767 B www.hhs.gov Kaiser Family Foundation 3/17/11 13
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Serves 47 million people over age 65 >650,000 in CO Four
Parts Part A: Hospital costs Part B: Physician Services Part C:
Medicare Advantage Part D: Rx www.hhs.cms.gov Kaiser State Health
Facts/Medicare/Oregon. Accessed 10/13 14
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Also pays $9B for Graduate Medical Education (GME) med school
enrollment increasing but cap on federally-funded residency slots
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"Youve got... 10,000 new seniors, baby boomers, becoming
eligible for the entitlement programs"... everyday for the next 18
years. Rep. Cantor, R-VA House Majority Leader Representative Eric
Cantor, April 27, 2011, PoliticFact, Richmond Times Dispatch
4/27/11 17
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... Enrollment will increase from 47 million to approx 74
million number of beneficiaries over age 80 will triple.
Congressional Budget Office 2/1/12 18 The Silver Tsunami
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Health care for 60 million eligible poor > 133% FPL Pregnant
women, children, moms Medically needy (aged, blind, disabled) and
nursing home care 618,000 in CO (2010) $343 billion per year 2/3 is
federal match (FMAP) 1/3 paid by states Kaiser State Health
Facts/2009 data 3 out of 5 kids are born on Medicaid 19
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Takes up >25% of most state budgets Increases in
unemployment = increases in eligibility (but decreased state
revenue) Fairly generous benefits (mental health, dental and
vision) but access problems due to low reimbursement 20
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Separation of powers Senate and House: Checks and balances
Reactive rather than proactive Compromise the key to passing policy
Congress is currently highly partisan Change is slow and
incremental 24
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Approval rating: 9% Even Congress Hates Congress Its so bad
sometimes I tell people Im a lawyer, Senator Lindsey Graham
(R-S.C.). I dont want to be associated with a body that in the eyes
of your fellow citizens seems to be dysfunctional. Were below
sharks and contract killers, added Rep. Trey Gowdy (R-S.C.).
Politico, October 26, 2011/January 2012
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26 US Government Income and Outlay, based on historical tables
from the White House Office of Management and Budget (Table 1.1).
*2012 is estimated by OMB.
http://www.whitehouse.gov/omb/budget/Historicals
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I love change except for the part about doing things
differently anonymous There is nothing more difficult to carry out,
nor more doubtful of success, nor more dangerous to handle, than to
initiate a new order of things. For the reformer has enemies in all
those who profit by the old order, and only lukewarm defenders in
all those who would profit by the new order. Machiavelli Rule of
Reform 27
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1. Yes 2. No 3. Dont know 29
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1. Yes 2. No 3. Dont know 31
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32 "The America I know and love is not one in which my parents
or my baby with Down syndrome will have to stand in front of
Obama's 'death panel' so his bureaucrats can decide, based on a
subjective judgment of their 'level of productivity in society,'
whether they are worthy of health care. Sarah Palin 8/7/09
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1. Yes 2. No 3. Dont know 33
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1. Yes 2. No 3. Dont know 35
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1. Yes 2. No 3. Dont know 38
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1. Yes 2. No 3. Dont know 39
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1. Yes 2. No 3. Dont know 40
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1. Yes 2. No 3. Dont know 41
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1. Yes 2. No 3. Dont know 42
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1. Yes 2. No 3. Dont know 43
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65 18 Health Care On Demand Very Poor Near Poor Uninsured Dual
Eligibles Underinsured Medicare Medicaid Work. Poor Very Rich
Middle Class Upper- Mid Class Retiree Benefits CHIP Employer-
Provided Managed Care Health Care System: Before the ACA Age Income
Adam Sheingate, Professor, John Hopkins University Political
Science Department, August 2012
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65 18 Health Care On Demand Very Poor Near Poor Dual Eligibles
Medicare Work. Poor Very Rich Middle Class Upper- Mid Class CHIP
Employer- Provided Managed Care Health Care System: After ACA Age
Income Medicaid Health Exchanges Medicaid Expansion Underinsured
Uninsured Retiree Benefits Circa 2012: Medicaid Exp., Health Exch.
Adam Sheingate, Professor, John Hopkins University Political
Science Department, August 2012
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Cover up to 35 million more people Individual Mandate (SCOTUS
considers the fine a tax) Employer Mandate Insurance Regulation
Kids covered on parents policy to age 26 No exclusion for
pre-existing conditions Health Insurance Exchanges and subsidies
Changes to Medicaid State can choose to include adults > 137% of
FPL 46
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Fill in donut hole in Medicare Rx Reduce Hospital readmissions
Reduce Medicare premiums Increase Medicare preventive services
Increase access to Medicaid services Increase access and quality
for dual eligibles 47
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Incentive payments for Patient Centered Medical Home $44,000
bonus payment for adoption and meaningful use of HIT 10% bonus to
primary care physicians and surgeons working in Health Profession
Shortage Areas (HPSAs) Accountable Care Organizations responsible
for quality and costs; can earn shared savings Cut reimbursement to
Medicare providers No payment for preventable readmissions Reduce
payment updates for hospitals, home health and SNFs Value-based
purchasing performance and quality Bundled payment for an episode
of care Cut reimbursement to Medicare Advantage (MA) plans
Independent Payment Advisory Board to reduce rate of spending
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Invite speakers on key issues AOA Dept Gov. Relations AACOM
Dept Gov. Relations Former HPF and TIPS Fellows Educate yourself
Monitor, analyze and advocate for issues Educate elected officials
about key issues Attend DO Day on the Hill or Visit State Capitol
AACOM Health Policy Internship Training in Policies Studies Program
OGME II and III 49