February 27, 2009 9:00 – 3:00 PM

Mission Valley Hilton, San Diego, CA

Health Reform: Exploring the Models

A panel and audience participation forum

11

Thank you to our SponsorsFoundations

Thank you to our sponsorsBusiness

Thank you to our SponsorsCommunity Organizations

Thank you to our SponsorsHealthcare Providers

Introductions Keynotes: Keynotes:

Moderator: Moderator:

Panel:Panel:

66

Rosemarie Day, Deputy Director & COOMA Health Insurance Connector Authority

Jonathan Cohn, Senior EditorThe New Republic

Irma Cota , Executive Director North County Health Ser vices (SDHCC Board

Member)

Robert E. Hertzka, MD (SDHCC Board Chair) Gregory E. Knoll, esq (SDHCC Board Vice Chair) Vincent Mudd (CEO, Sdoi) – Chamber Board) Jan C. Spencley, Executive Director, SDHCC

Agenda9:15 Welcome and Introductions Robert E. Hertzka,

MD

9:40 Background - PurposeIssues – Data Snapshots

Jan C. Spencley

10:40 Model for Achieving Near Universal Coverage in Massachusetts: Two Years Later

Rosemarie Day

11:30 Break - Lunch Buffet

12:00 International Models of Coverage & CareImplications for Reforming the US Healthcare System

Jonathan Cohn

1:15 Break

1:30 Q&A - Moderated Discussion•Panel•Audience

Irma Cota

2:45 Summary Next Steps

Jan C. SpencleyRobert E. Hertzka, MD

77

San Diegans for Healthcare CoverageSan Diegans for Healthcare Coverage

Our Mission Our Mission To bring diverse constituencies together to identify To bring diverse constituencies together to identify

and pursue strategies for expanding health care and pursue strategies for expanding health care coverage and access to health care in the regioncoverage and access to health care in the region

EducationEducation Consensus BuildingConsensus Building

Advocacy and OutreachAdvocacy and Outreach

88

Improving Access to Healthcare (IAH) Project formed by Board of Supervisors in 1999 to evaluate and pursue strategies to expand health coverage in the region. Efforts discontinued due to State waivers.

IAH formed SDHCC in 2001 to maintain diverse coalition to continue to pursue expansion of health care coverage

SDHCC created Business Healthcare Connection (BHC) as subsidiary to establish operations, business relationships and outreach in preparation for longer-term demonstration project

SDHCC and BHC conducted series of Business and Labor Roundtable forums and focus groups to work towards and establish consensus principles and elements of reform. (2003-2005)

Roundtable series resulted in the development of the San Diego Healthcare Connection (SDHC) demonstration pilot project, co-sponsored by the Regional Chamber (2006-8)

San Diegans for Health Care Coverage (SDHCC)

Background

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San Diegans for Health Care Coverage (SDHCC)

Background

SDHC demonstration pilot legislation (SB51 –Ducheny) did not advance due to Governor and legislative leadership comprehensive reform proposals (2007-8)

SDHCC Board determined to maintain and expand coalition and continue to build consensus, educate and advocate for health reform, meaningful health coverage and access (2008).

Current forum series to build on consensus achieved through information, dialogue and polling.

Focus today on Models of coverage and care Key outcome from today is to identify model preferences across

constituency groups for incorporation into SDHCC Principles and Required Elements for Health Reform.

1010

Shared responsibility for developing reforms and program oversight (government, business and individuals)

Shared responsibility for funding (government, business and individuals) All citizens and legal residents should have access to basic, meaningful,

minimum coverage and care Minimum, basic benefit structure with option to purchase broader

coverage, including healthy behavior incentives and disease management and education (see handout)

Cost containment (transparency, care guidelines, evidence based) Premium share and co-insurance based on family income Incentives for employers to provide coverage Adequate provider reimbursement (no cost shifting) Program evaluation and adjustment (measurement and course correction) Administrative simplicity (eliminate fragmentation of programs, easy

enrollment methods, administrative burdens and overhead)

SDHCC Consensus Principles and Elements for Health Reform

Highlights

1111(See Detailed Handout)

Audience Response SystemAudience Response System If you do not have a Keypad, you should have a If you do not have a Keypad, you should have a PINKPINK version of the version of the

questions to respond to.questions to respond to. Pick up your Pick up your KeypadKeypad – You will use the – You will use the LettersLetters to respondto respond Each Question and its Response Options will be displayed on Each Question and its Response Options will be displayed on Both Both

Screens. Screens. They will be read through one time.They will be read through one time. Select the response that Select the response that MOSTMOST closely reflects your perspectiveclosely reflects your perspective A few questions have aA few questions have a PAPER SURVEY PAPER SURVEY corollary so that you can corollary so that you can

provide more precise inputprovide more precise input (with evaluation form) (with evaluation form) You will have You will have 15 seconds15 seconds to respond once the question and the to respond once the question and the

response options have been read (response options have been read (Timer on ARS ScreenTimer on ARS Screen)) Please answer Please answer All Questions – All Questions – it will record only one response. The it will record only one response. The

last answer entered last answer entered during the 15 seconds will be the response during the 15 seconds will be the response recordedrecorded..

Responses are Responses are not identified by individualnot identified by individual Your Your ConstituencyConstituency registration allows us to registration allows us to assess and identify assess and identify

preferences, issues and consensus positions across constituenciespreferences, issues and consensus positions across constituencies

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ARS 1 Question: Constituency Group

1313

Using your keypad, from the list below, select the constituency group that you most appropriately represent today.

A.Broker-Agent/Health Plan/Insurance

B.Foundation or Community Based Organization

C.Business (owner, association)

D.Labor

E.Consumer (advocates, organizing project, etc)

F.Healthcare Provider

G.Government Agency

H.Other

ARS Question 2: Universal CoverageUniversal Coverage means that all Americans have Universal Coverage means that all Americans have affordable, basic healthcare coverage and care, affordable, basic healthcare coverage and care, including primary, specialty, hospital, diagnostic including primary, specialty, hospital, diagnostic services and prescriptions.services and prescriptions.

Select One:Select One:

A.A.Strongly AgreeStrongly Agree

B.B.Somewhat AgreeSomewhat Agree

C.C.Somewhat DisagreeSomewhat Disagree

D.D.Strongly AgreeStrongly Agree

A BROKEN SYSTEMTHE CONSEQUENCES

1515

An estimated 137,000 adults died between 2000 - 2006 because they lacked health insurance, including 22,000 in 2006.

Uninsured women who develop breast cancer have a 30 to 50 percent higher risk of dying than women with private coverage.

Uninsured patients with colorectal cancer are about 50 percent more likely to die than patients with private coverage, even when the cancer is diagnosed at similar stages.

Uninsured people are sicker upon admission and significantly more likely to die in the hospital.

Uninsured adults with chronic disease are less likely to receive care to manage their health conditions than those with coverage. uninsured patients have worse clinical outcomes than insured patients.

People without health care coverage are four times more likely to experience an avoidable hospital or ER visit.

The Uninsured Live Sicker and Die Sooner

1616Source: Institute of Medicine

1717

1818

1919

2020

Medi-Cal beneficiaries who faced gaps in coverage were more than 3 x as likely as those with continuous coverage to be hospitalized for chronic illnesses, according to a five year retrospective study published in the Annals of Internal Medicine and 60% more likely to die in hospital ; uninsured were 80% more likely to die (OSHPD).

The Healthcare Delivery SystemThe Healthcare Delivery SystemEroding and At RiskEroding and At Risk

2121Source: A Report on California Hospitals and the Economy, January 2009, California Hospital Association (November 2008 survey)

MORE UNINSURED AND MORE UNINSURED AND UNDERINSUREDUNDERINSURED

2222

2323

Health Insurance Coverage

2-Source: Authors’ estimates based on S. R. Collins, C. White, and J. L. Kriss, Whither Employer-Based Health Insurance? The Current and Future Role of U.S. Companies in the Provision and Financing of Health Insurance (New York: The Commonwealth Fund, Sept. 2007) and analysis of the Current Population Survey, March 2008, by Bisundev Mahato of Columbia University.

2 - 45.7 Million Uninsured, US 2007

Under-65 population

Employer (62%)

Uninsured(17%)

Medicaid(11%)

Medicare(2%)

Military(1%)

Individual(6%)

1-Data: Estimates by The Lewin Group for The Commonwealth Fund.Source: The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way, February 2009.

1 - Uninsured Projected through 2020

Millions

2424

Coverage in San Diego: 2007

2525

The uninsured are increasingly olderSince 2001, the 40 – 64 Age Category Has Increased

Most

Source: CHIS 2007

Modest to Higher Income Are An Increasing Proportion of San Diego Uninsured (2007)

2727Source: CHIS 2007, San Diego

300% FPL +

200-300% FPL

100-200% FPL

0-99% FPL

20% Increase in Underinsured Overall;175% Increase in Those Earning More Than 200% FPL

2828

Total 200% of poverty or moreUnder 200% of poverty

* Underinsured defined as insured all year but experienced one of the following: medical expenses equaled 10% or more of income, or 5% or more of income if low-income (<200% of poverty); or deductibles equaled 5% or more of income.Data: 2003 and 2007 Commonwealth Fund Biennial Health Insurance Survey.

26 28

49 48

13 16

914

19 24

411

0

25

50

75

100

2003 2007 2003 2007 2003 2007

Underinsured*

Uninsured during year

4235

17

27

6872

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

Uninsured and Underinsured Adults (19-64), 2003 and 2007 by Percent

2929

3030

A Poor Investment:Insured Adults with Deductibles Are More Likely

to Avoid Needed Health Care

16

811 12

2522

12

1719

3127

19

2624

44

0

10

20

30

40

50

Did not fill aprescription

Did not see specialistwhen needed

Skippedrecommended test,treatment, or follow-

up

Had medical problem,did not see doctor or

clinic

Any of the four accessproblems

<$500 $500–$999 $1,000+

Percent of adults ages 19–64 insured all year with private insurance

Source: S.R. Collins, J.L. Kriss et al., Squeezed: Why Rising Exposure to Health Care Costs Threatens the Health and Financial Well-Being of American Families, The Commonwealth Fund, Sept. 2006.

3131

Our patchwork of public coverage is costly and leaves most uninsured with no options

FPLPregnant Women

Children 0-1

Children 6-19

Breast-Cervical

Prostate CA Parents* Disabled ElderlyAll Other Adults

300%

250%

NOT

200% COVERED

133% BreastCervical

100% Prostate

72% Cancer Proposed State Cuts

PACT

*State proposal to terminate eligibility if two full-time working parents, regardless of income level or family size.

WorkingDis abled

Disabled-

Elderly($1,097/$1,524

w/child$934/$1,208

2 adults)

NOT COVERED

NOT COVERED

Children 1-5

AIM

AIM-HF

Healthy Families

Medi-Cal

3232

ARS Question 3: Health Reform

Basic Understanding: Single Payor means that all Americans have basic, universal coverage and that everyone is covered by the same government operated program.

Select OneA. Strongly AgreeB. Somewhat AgreeC. Somewhat DisagreeD. Strongly Disagree

ARS Question 4: Health Reform

3434

Basic Understanding: Single Payor means that all Americans have basic universal coverage through a single government program and have a choice of coverage programs.

Select One:A.Strongly AgreeB.Somewhat AgreeC.Somewhat DisagreeD.Strongly Disagree

ARS Question 5: Health Reform

3535

Both the CHAMPUS AND Medicare Programs have evolved into public - private models of coverage, with a Single Payor (federal) and a choice of private options for coverage. Overall, do you believe the CHAMPUS and Medicare Programs are a good or bad model for expanding coverage?

Select OneA. BadB. GoodC. Good model, but needs improvementD. Do Not Know

ARS Question 6: Health Reform

3636

Several different models of health reform and coverage expansion are under consideration. From your perspective, which of these basic models do you MOST support?

A.Parallel Models (Private/Employer and Public) for near-universal coverage

B.Single Payer, government run program

C.Single Payer, like the Medicare Public-Private model

D.Continue existing pluralistic model (employer, private, public programs)

E.Existing public program expansions only (Medi-Cal and Healthy Families)

THE INCREASING COST OF THE INCREASING COST OF COVERAGECOVERAGE

(AND NOT PROVIDING IT)(AND NOT PROVIDING IT)

3737

3838

22.7%

50.2%

65.5%74.4%

80.6%

3.5%

96.5%

Top 1% Top 5% Top 10% Top 15% Top 20% Top 50% Bottom50%

Percent of Population Ranked by Health Care Spending

15% of Population Account for almost 75% of Annual Expenditures

50% Accounted for 3.5% of Expenditures

Concentration of Health Care Spending in the U.S. 2005

Source: Kaiser Family Foundation calculations using data from U.S. Department of Health and Human Services, Agency for Healthcare Research and Quality, Medical Expenditure Panel Survey (MEPS), 2005.

These are not a static populations – Each year, the composition changes

Average Health Insurance Premiums and Contributions Increases Outpace Wages and

Inflation (1999-2008)

$4,247

$9,325

$1,543$3,354

1999 2008

Employer Contribution

Worker Contribution

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Note: The average worker contribution and the average employer contribution do not add to the average total premium due to rounding.

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999-2008.

$5,791

$12,680

117% Increas

e

119% Increas

e

Over Same Period:-Worker’s Earnings Increased - 34%-Inflation increased - 29%.

4040

4141

National Per-Capita Health Expenditures

1990-2007

$2,813$3,266

$3,618$3,938

$4,297$4,790

$5,148$5,560

$5,952$6,301

$6,649$7,026

$7,421

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

$8,000

1990 1992 1994 1996 1998 2000 2001 2002 2003 2004 2005 2006 2007

Source: Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http://www.cms.hhs.gov/NationalHealthExpendData/ (see Historical; NHE summary including share of GDP, CY 1960-2006; file nhegdp06.zip).

 Healthcare Expenditures Are Projected

to Exceed 20% of GDP by 2022

4242Source: Congressional Budget Office

The Cost of Doing NothingThe Cost of Doing Nothing Increasing negative impacts on individual Increasing negative impacts on individual

health, families, and communitieshealth, families, and communities Increasing Uninsured and UnderinsuredIncreasing Uninsured and Underinsured Access to a healthy Healthcare system Access to a healthy Healthcare system

eroding and at jeopardyeroding and at jeopardy Growth in healthcare costs cannot be Growth in healthcare costs cannot be

sustained resulting in further erosion of sustained resulting in further erosion of coverage and carecoverage and care

Health care as a proportion of GDP Health care as a proportion of GDP threatens US competitive positionthreatens US competitive position

4343

ARS Question 7: Health Reform What is your greatest concern about efforts to expand and reform health care in the United States?

Select One: A. Restructure the system without achieving universal

coverage

B. Increased personal costs (taxes, premiums, copayments)

C. Increased business costs (taxes, premiums)

D. Socialized medicine (government run system)

E. Delays in access to care (not enough providers participating)

F. Limits on coverage (criteria for coverage of high cost services)

G. Restricts innovation and new technology

H. Inadequate reimbursement to providers

I. Overpromised and underfunded system of coverage

(See Paper Survey Corollary)

Rosemarie Day, Deputy Director & COOMA Health Insurance Connector

Authority

A Model for Achieving Universal Coverage A Model for Achieving Universal Coverage

in Massachusetts:in Massachusetts:

Two Years LaterTwo Years Later

4545

ARS 8 Question: Massachusetts Model

4646

Overall, from what you have heard, do you believe that the Massachusetts model will ultimately achieve universal coverage for all its residents?

Select one:

A.Strongly agree

B.Somewhat agree

C.Somewhat disagree

D.Strongly disagree

ARS 9 Question: Massachusetts

4747

In general, do you believe that the vision and parallel public-private model in Massachusetts should be considered for adoption as national model:

Select one:

A.Should be considered

B.It is a start in the right direction, but not enough

C.Too soon to tell

D.Is the wrong model

ARS 10 Question: Massachusetts

4848

What aspects of the Massachusetts model do you find the LEAST appealing?

Select one:

A.Individual mandates

B.Employer mandates

C.Costs

D.Lack of Universal Coverage

E.Administrative Structures

(See Paper Survey Corollary)

ARS 11 Question: Massachusetts

4949

What aspects of the Massachusetts model do you find the MOST appealing?

Select one:

A.Individual mandates

B.Employer mandates

C.Costs

D.Near Universal Coverage

E.Administrative Structures

(See Paper Survey Corollary)

ARS 12 Question: Costs

5050

What do you think is the greatest contributor to the significantly higher adjusted per-capita costs in the United States compared to other industrialized countries?

Select One:A. Excess utilization of services and

pharmaceuticalsB. Cost of care (hospitals, physicians, testing,

etc.)C. Cost of pharmaceuticals D. Cost of uninsured and foregone careE. Costs of research and innovationF. Administrative overhead and profit

Jonathan Cohn, Senior EditorThe New Republic

International Models of Coverage and Care:

Implications for Reforming the US Healthcare System

OrWhat Monty Python can teach Barack Obama about Health

Reform

5151

Question and Answer Period Question and Answer Period GroundrulesGroundrules

Headline your comments (make them Headline your comments (make them brief and succinct) – Time limit of 30 brief and succinct) – Time limit of 30 secondsseconds

Questions should be specific and identify Questions should be specific and identify to whom you wish to address it. to whom you wish to address it.

Responses Responses will be limited to 1 minute will be limited to 1 minute per panel member and maximum of 2 - per panel member and maximum of 2 - 3 responses per question3 responses per question

Please be polite and open to the ideas of Please be polite and open to the ideas of othersothers

5252

ARS Question 22: Follow-up

5353

Several different models of health reform and coverage expansion are under consideration. From your perspective, which of these basic models do you MOST support?

Select One:A. Parallel Models (Private/Employer and Public) for

near-universal coverage

B. Single Payer, government run program

C. Single Payer, like the Medicare Public- Private model

D. Continue existing pluralistic model (employer, private, public programs)

E. Existing public program expansions only (Medi-Cal and Healthy Families)

ARS 23 Question: Costs

5454

What do you think is the greatest contributor to the significantly higher adjusted per-capita costs in the United States compared to other industrialized countries?

Select OneA. Excess utilization of services and

pharmaceuticalsB. Cost of care (hospitals, physicians, testing,

etc.)C. Cost of pharmaceuticals D. Cost of uninsured and foregone careE. Costs of research and innovationF. Administrative Overhead and Profit(See Paper Survey Corollary)