Oberlander

The Path to Universal Coverage:Can Health Reform Succeed?HCW Lunch & LearnMay 16, 2007: 

The Path to Universal Coverage: Can Health Reform Succeed? HCW Lunch & Learn May 16, 2007 Jonathan Oberlander Department of Social Medicine Department of Health Policy & Administration UNC-Chapel Hill

The Odd Couple: 

The Odd Couple

Familiar Headlines: 

Familiar Headlines “Number of Uninsured Escalates” “ No Relief in Sight for Health Costs” “Health Insurance Gap Surges as Political Issue” “Coalition Unveils Plan to Cover the Uninsured” “Talk of Universal Health Care Grows” “States Take Initiative on Health Care Reform” “Candidates Outline Ideas for Universal Health Care”

Cycle of U.S. Health Reform: 

Cycle of U.S. Health Reform Discover Crisis in Health System Identify and Debate Solutions Do Nothing or Not Much Ignore Issue Rediscover Crisis in Health System

Roadmap: 

Roadmap Rediscovering a Crisis Cost Control Covering the Uninsured The Future of Health Reform

Slide7: 

Rediscovering the Crisis

Slide8: 

Source: KCMU and Urban Institute

Slide9: 

Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits: 2005

The Future: Up, Up, and Away: 

The Future: Up, Up, and Away Source: Uwe Reinhardt

Slide13: 

II. Cost Control

Private Sector Strategies to Control Costs: 

Private Sector Strategies to Control Costs

A Brief History of Private Sector Cost Control Efforts in Two Words: 1990s: Managed2000s: Directed: 

A Brief History of Private Sector Cost Control Efforts in Two Words: 1990s: Managed 2000s: Directed

Promise of HSAs/Consumer-directed health care: 

Promise of HSAs/Consumer-directed health care Control costs by reducing excess demand and unnecessary medical care (“skin in the game”) Make people responsible for their health care behavior Portability; move away from employer-based system

Problems with HSAs: 

Problems with HSAs Regressive tax policy Regressive health policy Concentration of health care costs Supply-side backlash

Other Magic Bullets/Acronyms to Control Costs: 

Other Magic Bullets/Acronyms to Control Costs Electronic Medical Records (EMR) Pay for performance (P4P)

Slide19: 

III. The Politics of Health Reform & Covering the Uninsured

The Health Reform Debate: 

The Health Reform Debate Vs.

Why is Health Reform So Hard to Pass?: 

Why is Health Reform So Hard to Pass? Interests (NHE=SEI) Institutions Ideology Indifference

Public Sector Strategies to Expand Coverage:The Federal Government: 

Public Sector Strategies to Expand Coverage: The Federal Government

A long time ago,In a capital not so far awayThe Clinton health plan diedand took with it any political enthusiasm for comprehensive reformUS health policy thus entered the galaxy of incrementalism and inaction, where it remains todayIs there hope for reform?: 

A long time ago, In a capital not so far away The Clinton health plan died and took with it any political enthusiasm for comprehensive reform US health policy thus entered the galaxy of incrementalism and inaction, where it remains today Is there hope for reform?

The Trouble with Incrementlaism: 

The Trouble with Incrementlaism

Health Reform Solutions, 1993: 

Health Reform Solutions, 1993 Single Payer Employer Mandate Individual Mandate Expand Public Programs Tax Credits for Private Insurance

Since 1994 health policy analysts have been hard at work developing new solutions to cover the uninsured. The results are in…..: 

Since 1994 health policy analysts have been hard at work developing new solutions to cover the uninsured. The results are in…..

Health Reform Solutions, 2007: 

Health Reform Solutions, 2007 Single Payer Employer Mandate Individual Mandate Expand Public Programs Tax Credits for Private Insurance

Bush Health Reform Plan 2007: 

Bush Health Reform Plan 2007 * New standard tax deduction for health insurance for individual and employer-based insurance: $15,000 families $7,500 individuals * Health insurance to be treated as taxable income and above those amounts will be taxed

Income Tax Distribution of Uninsured: 

Income Tax Distribution of Uninsured 55% (0% tax bracket) 16% (10% tax bracket) 23% (15% tax bracket) 5% (27% tax bracket) 1% (30%-39% tax bracket) Source: S. A. Glied and D. K. Remler, The Effect of Health Savings Accounts on Health Insurance Coverage (New York: The Commonwealth Fund, April 2005).

How Much Reform?: 

How Much Reform? Estimated coverage impact: Bush plan would increase coverage by 2-5 million uninsured Future of employer-based insurance Individual/Non-group Market

The Politics of Changing the Tax Preference: 

The Politics of Changing the Tax Preference Value of tax exclusion for employer-sponsored insurance: $188 billion Estimated increase in federal revenues from Bush proposal to cap that exclusion: $333 billion, 2007-17* Members of Congress Running for Re-election in 2008: 468 Presidents Running for Re-election in 2008: Zero. *JCT estimate: Lewin estimates $153 billion revenue loss 2009-2018.

Public Sector Strategies to Expand Coverage:The States: 

Public Sector Strategies to Expand Coverage: The States

And when all looked lost, health policy analysts deployed a new weapon in the fight for health reformagainst the Empire of rising costs and uninsured…. A weapon so threatening even insurance companies and providers trembled with fear: 

And when all looked lost, health policy analysts deployed a new weapon in the fight for health reform against the Empire of rising costs and uninsured…. A weapon so threatening even insurance companies and providers trembled with fear

Terminator-Care: 

Terminator-Care

States On The March: 

States On The March Maine Massachusetts Illinois Vermont California Pennsylvania

Health Reform Agenda in North Carolina: 

Health Reform Agenda in North Carolina High Risk Pool Children’s Insurance

A Massachusetts Miracle?: 

A Massachusetts Miracle? Universal coverage (or at least more universal) Play or Pay (not very much) Individual Mandate Medicaid expansion Income-related subsidies Purchasing Pool (“the Connector”) Bipartisan Politics

California: Terminator-Care: 

California: Terminator-Care Play or Pay (4% payroll tax for buis.>10 workers) employer mandate Individual Mandate Purchasing Pool Medicaid expansion Provider Taxes Insurers must spend 85% of $ on patient care

Limits of State-led Reform: 

Limits of State-led Reform How universal is universal? ERISA & legal challenges Medicaid waivers Cost control, or lack thereof Financing and affordability

III. Health Reform & the 2008 Elections: 

III. Health Reform & the 2008 Elections

Partisan Divide on Health Care: 

Partisan Divide on Health Care “The time has come for universal health care in America.” --Barack Obama, January 25, 2007 “They're moving toward socialized medicine so fast, it'll make your head spin.” --Rudy Guliani, April 27, 2007

Health Care in the Primaries: 

Health Care in the Primaries

2008 Plans: John Edwards: 

2008 Plans: John Edwards Universal Coverage Play or pay employer mandate Health Markets with Medicare-like option Individual mandate Real financing: roll back tax cuts

IV. The Future of Health Reform: 

IV. The Future of Health Reform

What forces will shape health reform in coming years?: 

What forces will shape health reform in coming years? 2008 elections & Iraq Economy & Budget Medicare State health reforms Middle class & Anxiously insured Business

A Fairer Fight: 

A Fairer Fight Vs.

A Sign of Things To Come?: 

A Sign of Things To Come? “Abandoning the business lobby’s traditional resistance to healthcare reform, a new coalition of 36 major companies plans to launch a political campaign today calling for medical insurance to be expanded to everyone…..” Los Angeles Times, May 7th, 2007

Conclusions: 

Conclusions 1. Employer-based system is fraying and perhaps approaching a crossroads: which way do we go? And do employers become the swing voters in health reform? 2. If you’re looking for signs of hope, pay attention to state efforts, SCHIP renewal, 2008 elections. 3. If you’re a pessimist, you’re in luck: things will continue to get worse, especially for low-and middle-income Americans priced out of health insurance 4. Comprehensive reform may be returning to the national political agenda; but there is no guarantee it will pass. What happens next?...

Famous Health Policy Analyst: 

Famous Health Policy Analyst