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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 15

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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 41

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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 48

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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

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50 Generate Discussion

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51 coopern@ohio.edu