Myths of US Healthcare: Past, Present, and Future · 5 Myths of US Healthcare: Obamacare,...
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+ 5 Myths of US Healthcare: Obamacare, Trumpcare, and the Future Ashish K. Jha, MD, MPH February 28, 2020
Transcript of Myths of US Healthcare: Past, Present, and Future · 5 Myths of US Healthcare: Obamacare,...
+
5 Myths of US Healthcare:
Obamacare, Trumpcare, and the Future
Ashish K. Jha, MD, MPH
February 28, 2020
+ Agenda
Obamacare: myths 1 and 2
Trumpcare: myth 3
Why US spends so much more: myth 4
What the future will bring: myth 5
+Why myths about
Obamacare?
…
+ What are the facts?
+ Myth #1:
The ACA was a hodgepodge of
policy ideas
+ Let’s imagine it’s 28/02/2010
+Problems of US Healthcare 2010
Problems around access
Problems around costs
Problems around quality
+Problems of access, 2010
47 million (15%) uninsured Americans
Another 30-50 million underinsured
+Who were the uninsured?
Young people
The working poor
Chronically ill (pre-existing conditions)
Undocumented immigrants
+ACA or “Obamacare”
Two bills in one:
Expand Coverage
Fix the healthcare
delivery system
Access Cost & Quality
+ Myth #1:
The ACA was a hodgepodge of
policy ideas
+ACA or “Obamacare”
Expand Coverage
Access
+What did ACA do for coverage?
<26 year can stay on parents’ insurance
Medicaid expansion up to 138% of FPL
Insurance exchanges with subsidies
Community rating
Essential Health benefits
Individual mandate
Insurance Reform
+The ACA & who is not covered
Young people
The working poor
Chronically ill (pre-existing
conditions)
Undocumented immigrants
<26 policy
Medicaid
expansion
Insurance
Reforms/
Exchanges
?
+ Did it work?
+
16.1%
8.6%9.0%
0%
2%
4%
6%
8%
10%
12%
14%
16%
18%
U.S. Uninsured Rate1997-2018
Centers for Medicare & Medicaid Services, KFF
ACA
+ What’s the HC cost problem?
+
$2,035
$2,167
$2,304
$2,414
$2,506
$2,604
$1,800
$1,900
$2,000
$2,100
$2,200
$2,300
$2,400
$2,500
$2,600
$2,700
2005 2006 2007 2008 2009 2010
National Health Expenditures (billions)
U.S. healthcare spending: 2005-10
Centers for Medicare & Medicaid Services
+7%
+6%
+5%
+4%
+4%
+ ACA’s efforts to improve care
delivery
+ The ACA & Delivery Reform
Change how we pay for things
Value-based payments of various types
Hold providers accountable
Accountable Care Organizations
Bundled payments
Enable innovation
CMMI
+ Myth #2:
The ACA slowed HC spending
+ Total U.S. healthcare spending
Centers for Medicare & Medicaid Services
$2,024,000
$3,649,000
$0
$500,000
$1,000,000
$1,500,000
$2,000,000
$2,500,000
$3,000,000
$3,500,000
$4,000,000
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018
National Health Expenditures (millions)
+36% growth
between 2011
and 2018
ACA
+23% growth
between 2005
and 2009
+ Delivery reform
+ Pay-for-Performance programs
Series of hospital and physician P4P programs
Hospital VBP, Readmissions, HACs, etc.
They have largely failed
No impact on costs or quality
Negative effects on safety-net, teaching hospitals
+ But…its not a total myth
+ Bundled Payments, ACOs
Bundles for surgery: about 2% decrease in spending
Somewhat better patient experience
Accountable Care Organizations
2-5% savings compared to non-ACOs
Modestly better patient experience
Dummit JAMA 2016, Joynt et al NEJM 2018, Navathe Health Affairs 2020, Navathe Health Affairs 2018
+ Myth #3:
Trump administration has done
nothing good on health policy
+Headline March 25, 2017
+ Trump years: visible efforts
Lots of efforts to repeal, replace ACA
Each effort has failed
Has been a political disaster for the GOP
No sign that they have a real replacement plan
+ Trump years: less visible efforts
CMS policy efforts
Price transparency rules coming into effect (big deal)
Moving forward on ACOs, Bundles
Pushing interoperability and making IT systems better
Taking on special interests around safety, quality (i.e. TJC)
Etc.
+ Myth #4:
The main problem of US
healthcare is overutilization
+
17.1
12.3
11.3 11.2 11 10.9 10.7
10.1 10.19.6
9.2
0
2
4
6
8
10
12
14
16
18
US CH FR DE SE JP CA DK NL UK AU
Sp
en
din
g o
n h
ea
lth
as
a %
of
GD
P
Total healthcare spending, 2017
+ Why such high spending?
+ Why such high spending?
Fragmentation
Fee-for-service
For-profit greed
Lack of transparency
Not enough “skin in the game”
+
Total Spending = Quantity X Price
+
Total Spending = Quantity X Price
+ But is overutilization the main
problem of US Healthcare?
+ Do we use more care than others?
+ Theory: Overutilization
We are quick to go to the doctor
+ Doctor visits
12.7
10
8.27.7 7.6
6.6 6.4
5
4.34 3.9
2.9
0
2
4
6
8
10
12
14
JP DE NL CA AU Mean FR UK DK US CH SE
Ph
ys
icia
n v
isit
s p
er
cap
ita
in
a g
ive
n y
ear
+ Theory: Overutilization
Not enough prevention and primary care
leads to too many hospitalizations
+ Hospital discharges
255
173 172166 163
153 149
128 125119
111
84
0
50
100
150
200
250
300
DE AU DK CH FR SE Mean UK US NL JP CA
Dis
ch
arg
es p
er
1,0
00
p
op
ula
tio
n
We spend far fewer days in the hospital
+ Theory: Overutilization
We use too many tests and procedures
+ MRI examinations
131
118
112
105
82 82
70
5653 52
41
0
20
40
60
80
100
120
140
DE US JP FR DK Mean CH CA UK NL AU
Ex
am
inati
on
s p
er
1,0
00
po
pu
lati
on
+ Total knee replacement
226
190
180176
168 166 163
145141
124118
0
50
100
150
200
250
US DE AU CH DK CN Mean FR UK SE NL
Re
pla
ce
me
nt
per
100
,00
0 p
op
ula
tio
n
+ Total hip replacement292
283
237 236 234
216207 204
183
171
136
90
0
50
100
150
200
250
300
CH DE DK FR SE NL Mean US UK AU CN JP
Re
pla
ce
me
nt
per
100
,00
0 p
op
ula
tio
n
+Coronary angioplasty
393
248 248237
217205
193 190172
157
128
0
50
100
150
200
250
300
350
400
450
DE US NL FR Mean SE JP DK AU CA UK
Pro
ce
du
res p
er
10
0,0
00
po
pu
latio
n
+Higher utilization is not the issue
US has fewer hospitalizations, doctor visits
Tests and Procedures a mixed bag:
We do a lot more MRIs, TKRs, and PTCAs
We do fewer hip replacements
Bottom line:
We’re above average on some things
We’re below average on other things
On average, we are pretty average
+ So what is it?
+
Total Spending = Quantity X Price
+ Hypothesis: It’s the prices….
+
$1,443
$939
$837$779
$749$697 $675 $667
$613$566 $560
$466
$0
$200
$400
$600
$800
$1,000
$1,200
$1,400
$1,600
US CH JP UK Mean FR DK DE CA SE AU NL
To
tal P
ha
rma
ce
uti
ca
l S
pe
nd
ing
(U
SD
pe
r c
ap
ita)
Total Drug Spending (USD Per Capita)
+
$844
$483
$383
$233
$85
$0
$100
$200
$300
$400
$500
$600
$700
$800
$900
US New Zealand Switzerland South Africa Spain
CT Scan Abdomen
International Federation of Health Plans 2015
+
$15,930
$6,199 $6,040
$3,814
$2,003 $1,786
$0
$2,000
$4,000
$6,000
$8,000
$10,000
$12,000
$14,000
$16,000
$18,000
US New Zealand Switzerland Australia Spain South Africa
Appendectomy
International Federation of Health Plans 2015
+
$218K
$154K$146K
$134K $133K$124K
$111K $109K $108K
$86K
$0
$50,000
$100,000
$150,000
$200,000
$250,000
US DE CA UK Mean JP FR NL AU SE
Generalist Physician Salaries
+
$316K
$202K$191K $188K $182K $181K
$171K
$153K$140K
$124K
$98K
$0
$50,000
$100,000
$150,000
$200,000
$250,000
$300,000
$350,000
US AU NL CA Mean DE UK FR DK JP SE
Specialist Physician Salaries
+
$74K
$65K $64K
$58K$55K
$53K$51K
$49K
$44K$42K
$0
$10,000
$20,000
$30,000
$40,000
$50,000
$60,000
$70,000
$80,000
US NL AU DK CA DE Mean UK JP FR
Nurse Salaries
+ What’s the HC spending problem?
To quote Uwe Reinhardt: It’s the prices, stupid
Policymakers have almost entire ignored
And that’s why we have made too little progress
+ 2020 shaping up to be the
healthcare election
+Myth #5:
Following the 2020 election, the
US will make finally get national
health reform
+
“I think we should look to
countries like Denmark…”
+ Reality on the ground
+
Republican president
Republican SenateDemocratic president
Republican Senate
Democratic president
Democratic Senate
• Strengthen the ACA
• Stronger subsidies
• Better outreach for
enrollment
• Pushing states to
expand Medicaid
• Introduction of
Medicare For All
• Possible new public
option.
• Strengthening of ACA
• New repeal of ACA
• No replacement means
ACA survives again
• Movement toward state-
based reform
+ 2021 won’t be big HC year
Three issues
1. No political appetite for radical changes
2. HC costs big issue – with specific areas of focus
1. Drugs
2. Out of network billing
3. Dems won’t want to waste big political capital
and GOP has no ideas for replacement!
+ Summary
The ACA has provided a starting point
Elegantly designed to target specific issues
Has increased coverage but not done much on costs
The Trump Administration has been active on C&Q
Continuing many of the ACA ideas
Pushing new ones
Tackling prices will be critical
2021 is not HC revolution – but an evolution towards a
better, more universal system
+ Governance, administrative spending
8%
5%
4% 4%
3% 3% 3%
2% 2% 2%
1% 1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
9%
US DE NL CH Mean CA AU UK SE DK FR JP
Pe
rce
nta
ge
of
he
alt
hc
are
sp
en
din
g
