Norma final power point


Published on

  • Be the first to comment

  • Be the first to like this

No Downloads
Total views
On SlideShare
From Embeds
Number of Embeds
Embeds 0
No embeds

No notes for slide
  • Is something missing from this diagram? What about the impact of grassroots efforts and the current economic and health care cost crisis. Where do those two issues fit in?
  • Major issues within the health care system are costs, insurance coverage (uninsured, underinsured), and the strained delivery system Key point on uninsurance: Half of young (19-29 year old) working adults offered health insurance by employer versus 75% of workers over age 30. They often work in part-time jobs that do not offer coverage, or in firms that have waiting periods or no insurance coverage offered to their employees. Clarify that our costs are higher than other countries and our lack of insurance results in lack of access to primary care, disparities in outcomes for minorities, limited English proficient, and low-income populations. The line of argument that the U.S. health care is expensive because it is the “best in the world” does not appear to hold water, as will be shown through comparisons of outcomes, life expectancy, etc when compared to other industrialized countries.
  • The U.S. spends more than any other country in the world, on a per person basis, for health care. It represents over 16% of GDP now, and should surpass 20% by 2015. Our rate of increase has gone up drastically since the late 80s. The rate of increase was slightly better from 1995 to 2000 when managed care was seen as the “cost savior”, but has ticked up sharply at an unprecedented rate since them. We see these cost increases in both cost of services and the premiums paid by employers and individuals for health insurance premiums.
  • Per capita spending data shows that we almost double other countries in terms of spending per person, and we spend much more on both inpatient, outpatient, pharmacy, and nursing home care. Despite data that shows the U.S. has lower rates of hospitalization, we spend more on inpatient stays than any other country. Our reliance on outpatient procedures does not appear to help in terms of cost savings. Even though the U.S. is not a “government-run” health system, we spend more than Japan, Germany, and France in direct government spending. In Japan, Germany, and France the residents put money into a “social security” type of pool that supports their health care system and regulates the delivery of health care. In Canada, tax dollars into provincial governments result in the higher government spending for health care. However, all 4 countries spend much less on health care than we do, which these percentages do not show. It is probable that the 32% of government spending in the U.S. exceeds the government/social security spending in most of the other 4 comparison countries.
  • Spending on health care is concentrated among select members of the population. The elderly and chronically ill represent a large portion of health care spending, as you can see the top 1% of the U.S. population is responsible for using health services (22% of all costs in 2002), while the bottom 50% of the population resulted in only 3% of all health care spending. In California, the top 20% of the Medicaid population (aged, disabled, and chronically ill) represent almost 80% of the health spending in Medicaid. Many U.S. residents do not use health care at all, which is also not appropriate.
  • This slide indicates that the elderly and low-income spend much more of their income on health care than other age and income groups. It appears to confirm that the elderly and medically needy spend more out of pocket than their younger, insured, and higher income counterparts as a percentage of their annual income. The burden of our health care problems often falls on the poor and the elderly, regardless of insurance status.
  • Does our system make any sense? It appears to be based on a combination of incremental and comprehensive changes that began near the beginning of the 20 th century: Workers’ Comp, growth of almshouses and pest houses that became hospitals, self-pay health care, employer-based insurance during and after World War Two, disease monitoring and epidemiology since the days of cholera, Medicare and Medicaid, responses to specific diseases like HIV/AIDS, SCHIP, etc… We truly have a “system” patched together by various payers and interest groups that do not embody a well-planned system. However, this web of intertwined systems have many gaps, especially for the uninsured, other vulnerable populations (like the chronically ill or people with limited English proficiency), recent war veterans, the homeless, our young people (aged 19-29), and people who do not have generous health care benefits. This question is to be posed to the entire class, 15 minute discussion of the barriers: What are the barriers to receiving care for people who are uninsured, who have employer-based insurance, who have less generous health benefits, the poor, disabled, etc. Give examples of groups that are not able to get the health care they need – it really turns out that everyone has challenges, regardless of income or insurance status – whether it relates to an HMO not allowing for a specialty visit or needing to use the ER for primary care due to uninsurance. Bring up concept of employer-based insurance and why we have that system, and who is left out of that system. Also, bring up issue of increasing employer-based premium and how people’s employers are passing along added costs to their workers, or doing other things to cut costs (i.e. less generous benefits, higher deductibles and co-pays, waiting periods for benefits, etc). Two-tiered system results in rationing care, even if we do not usually hear it framed that way. Opponents of health care reform often say that universal health care will bring about rationing – in actuality, we are rationing care in the U.S. right now along social class, employee type, health status, and racial/ethnic lines.
  • Medical Bankruptcy and foreclosures: A Harvard Study (Himmelstein, 2005) found that medical bills were cited in half on all personal bankruptcies, many of which were experienced by families WITH health insurance coverage.
  • While the percentage of the uninsured has remained stable at between 15-16%, the number continues growing. Currently, it is estimated that there are over 47 million uninsured, and that number comes from data collected prior to our current economic downturn and surge in unemployment. In addition, this chart shows that Medicaid has been bearing the brunt of insurance provision as private insurance coverage has decreased by 10% since 1984. Only about 69% (now closer to 66%) of the population has private insurance, in comparison to over 83% in 1980. The percentage of people able to buy private insurance on their own appears to decrease too, with 9% in individually purchased private coverage in 1980 dwindling to 6% in 2004.
  • The individual market (private purchase) is relatively small, so our system is dominated by Employer-Based insurance and Government Payers. People can be “dually eligible” for Medicare and another insurance program. For example, someone who has an employer-based pension with health care benefits may have dual coverage from Medicare and a private source (Kaiser, Blue Cross, etc). Other, low-income, Medicare beneficiaries can qualify for Medicaid. (there is more detail on this in the Resource Guide)
  • This chart shows the rate of increase in premiums, we haven’t had a drop in premiums in over 20 years. Also, small employers face larger % changes due to lower levels of negotiating power. The annual premium that a health insurer charges an employer for a health plan covering a family of four averaged $12,700 in 2008. Workers contributed nearly $3,400, or 12 percent more than they did in 2007.2 The annual premiums for family coverage significantly eclipsed the gross earnings for a full-time, minimum-wage worker ($10,712). Percentage of premium increases (10%+) over the last few years is much higher than Medical Services Inflation (3-4% per year)
  • Medicare, Medicaid, and SCHIP are all aimed at insuring people who cannot afford coverage or would otherwise be unable to get insurance due to disability, age, medical needs, and overall cost. They represent almost half of the health care expenditures for the population.
  • There is concern, much like Social Security, that Medicare will not be able to handle all of the aging baby boomers and rising health care costs.
  • Birthweight outcomes in the U.S. are worse than the typical industrialized country, and even though they have trended downward over the past 35 years, the U.S. is still much higher than other countries with universal health care systems.
  • The U.S. has a higher cancer incidence rate, and higher obesity and HIV rates than any other OECD country. However, we have lower smoking rates than other OECD countries. We also have the highest homicide rate behind Mexico.
  • The use of PPS and lower Medicaid fee schedules has resulted in providers needing to subsidize their government-funded care with commercial insurance billing (aka COST SHIFTING). When negotiating contracted rates, private physicians and hospitals must negotiate a high enough rate from commercial sources to compensate for the relatively lower rates from Medicaid and Medicare. Now, with managed care, it is growing harder to negotiate high enough rates to compensate.
  • Medicare and Medicaid often result in financial losses, especially if a hospital is not in a state with high enough inpatient Medicaid rates. California is notorious for paying about 80% of cost, while Medicare pays 90%, and private insurers (negotiated rates) tend to be 100-110% of cost. Not a lot of room for a hospital to stay financially solvent. This puts hospitals with a high Medicare, Medicaid, and Uninsured caseload in a predicament.
  • Public Hospitals and CHCs are often in a precarious position due to having large # of uninsured, Medicaid, and underinsured private patients where the costs of providing care are higher than the revenue received for the care. Cost shifting is not possible as it is in the private market, so they rely on grants and subsidies from federal, local, and state governments in the form of DSH payments, indigent/uncompensated care pools, etc.
  • In addition, a 1% increase in unemployment results in a 3-4% decrease in tax revenue, so the state and federal government is actually less likely to be able to deal with the added expenditures to Medicaid and SCHIP spending caused by the additional unemployed, uninsured population.
  • Incremental changes: Adoption of RBRVS payment system in 1983 and on, expanding community health centers rather than dealing with insurance status, adoption of managed care, etc. Are we headed for another incremental reform? Nothing at all? Who favors the status quo?
  • Discuss issues around ADVERSE SELECTION and CROWD OUT
  • Concern About Cost Shifting led to use of individual mandate Baucus’s argument is that guaranteed issue insurance products would attract the sick and high-cost members of society and cause adverse selection and higher premiums. Therefore, requiring everyone to purchase coverage will ease premium costs and spread out risk.
  • Norma final power point

    1. 1. The U.S. Healthcare SystemThe U.S. Healthcare SystemPrepared byNorma Perry
    2. 2. Reform Occurs When and WhereReform Occurs When and WhereProblem, Policy, and Politics MeetProblem, Policy, and Politics Meet• Kingdon’s Model of Agenda Setting says:PoliticalStream PolicyStreamProblemStreamWindow ofOpportunity
    3. 3. Reform Occurs When and WhereReform Occurs When and WhereProblem, Policy, and Politics MeetProblem, Policy, and Politics Meet• Kingdon’s Model of Agenda Setting says:PoliticalStream PolicyStreamProblemStreamWindow ofOpportunityGrassrootsmobilizationCost Crisis, Economy,Rising Unemployment
    4. 4. The Health Care System is Broken:The Health Care System is Broken:There is a Cost to Doing NothingThere is a Cost to Doing NothingCosts are out-of-control:• $2.4 trillion spent on health care in 2008– Represents 16.6% of Gross Domestic Product– By 2015, it is projected be 20% of GDPHealth Insurance Coverage is in Crisis:• 47 million people are uninsured (15.5%)– 52 million people are considered medically disenfranchised (i.e.they do not have a usual source of care, even if they areinsured)– 13.2 million (28%) of the uninsured are aged 19-29The Delivery System is Strained:• Disparities in quality and access– Medical errors, birth weight outcomes, hospital readmit rates,and waiting times for ER visits and specialty care indicate thatwe do not have the best health care system in the world.
    5. 5. Health Care Costs in the U.S.Health Care Costs in the U.S.
    6. 6. Source: The Commonwealth Fund, calculated from OECD Health Data 2006.Health Care Spending per Capita,1980-2004- adjusted for cost of living differences -U.S.: $12,357per person,20% of GDPby 2015
    7. 7. Health Spending in the U.S. Compared toHealth Spending in the U.S. Compared toOther Industrialized Countries, 2003Other Industrialized Countries, 2003Source: Organisation for Economic Cooperation and Development Health Data (OECD), 20061,5511,0531,1141,0562,473843670666675709509467581454766- 500 1,000 1,500 2,000 2,500 3,000 3,500 4,000 4,500 5,000 5,500U.S.JapanGermanyFranceCanadaPer Capita Health Spending (in U.S. Dollars)Inpatient Outpatient AncillaryHome Health Pharmacy Nursing Home
    8. 8. Source: Yu & Ezzati-Rice, Medical Expenditure Panel Survey Statistical Brief #81, AHRQ, May 2005.22%49%64%97%0%10%20%30%40%50%60%70%80%90%100%Top 1% Top 5% Top 10% Top 50%Percentage of Population Ranked by SpendingPercentageofExpendituresHalf of the Population Uses Very Little Health Care:Half of the Population Uses Very Little Health Care:97% of all health spending is concentrated in half of the population!
    9. 9. Health Care CoverageHealth Care Coveragein the the U.S.
    10. 10. Do We Even Have a “System”:Do We Even Have a “System”:Filling in the GapsFilling in the Gaps• Financing and Structure of the System are Intertwined• Different Components of the Health Care System arefinanced and regulated in different ways– Public Health Activities– Care for the Uninsured– Government Programs– Hospitals– Community Health Centers– Free Clinics– Private Physician Offices– Medical Groups– TriCare/CHAMPUS/Military– Employer-based Insurance– Individually-PurchasedInsurance– Indian Health Services– HIV/AIDS-related care– Insurance Companies– Veterans’ Affairs (VA)Health Care– Workers’ Compensation– Children’s Health Care
    11. 11. The Challenges of Basing a SystemThe Challenges of Basing a Systemon Employer Provided Insuranceon Employer Provided Insurance• As health care costs increase, employers are faced withdifficult choices:– Reducing benefits or not offering– Reducing choice of potential plans– Offering high deductible, catastrophic plans– Establishing different requirements for health benefitparticipation• Minimum hours, waiting periods, workers must higherpercentage of employer-negotiated premium• Employers negotiate directly with insurers for benefitsand premiums– Smaller employers have less leverage due to smaller risk pool– Can represent a significant cost when workforce and retireesage, get sicker, and ultimately use more health care
    12. 12. Sources of Commercial InsuranceSources of Commercial Insurance• Group (Employer-Based)– In the past, commercial insurance was knownas “Major Medical” – Benefits similar toMedicare Part A– Currently, employer-based insurance benefitsare more comprehensive• Individually Purchased (Non-Group Market)– Premium and Benefits based on risk profile ofthe individual policyholder– Tends to be more expensive for the individual– Limitations due to pre-existing conditions
    13. 13. Insurance Status in the U.S., 2007Insurance Status in the U.S., 2007Type of Coverage Number (millions) PercentPrivate 201.7 67.9%Employment Based 177.2 59.7%Individual 27.1 9.1%Government 80.3 27.0%Medicare 40.4 13.6%Medicaid/SCHIP 38.3 12.9%Uninsured 47.0 15.8%Note: Percentages exceed 100% because type of coverage is not mutually exclusive;individuals can have more than one category of coverage.Source: U.S. Census Bureau Analysis of March 2007 Current Population Survey
    14. 14. Main Governmental Sources ofMain Governmental Sources ofHealthHealth InsuranceInsurance CoverageCoverage• Two programs were voted into law in June of1965 and implemented in July of 1966.– Title XVIII (Medicare) and XIX (Medicaid) of the SocialSecurity Act– Medicare is “social insurance”• Designed for people with disabilities or the elderly who meetspecific requirements, lifetime benefit– Medicaid is a “welfare program”• Designed for needy people who are categorically eligible (nota guaranteed benefit)• State Children’s Health Insurance Program(SCHIP)– Created in 1997 as part of the Balanced Budget Act
    15. 15. The Uninsured: At Serious RiskThe Uninsured: At Serious Risk• The uninsured in the U.S. face huge obstacles whenattempting to access health care:– Many private providers will not accept them• The burden is placed on community health centers, publichospitals, and emergency rooms– Difficult to find medical home– Some are considered uninsurable due to pre-existingconditions, but cannot qualify for Medicaid– Cannot afford full cost of visits• This can lead to medical bankruptcies and foreclosures• There is some evidence that cost-shifting has resulted in theuninsured being billed for full charge, even higher thancommercially insured patients
    16. 16. Source: Kaiser Family Foundation, 2006Note: All respondents are under age 65
    17. 17. Health Care DeliveryHealth Care Delivery
    18. 18. U.S. Life Expectancy in 2003 LowerU.S. Life Expectancy in 2003 Lowerthan Countries that spend far lessthan Countries that spend far lessOrganisation for Economic Cooperation and Development Health Data (OECD), 200674.878.6 78.4 76.772.768.675. 83.877.6 76.979.9830102030405060708090U.S. Japan Sweden France Mexico Hungary Denmark AustraliaLifeExpectancyinYearsMale Female
    19. 19. The U.S. also faces problemsThe U.S. also faces problemsrelated to:related to:• Health Care Disparities– Racial/Ethnic, Language, and Gender differences in outcomesand access– These differences persist even with insurance coverage• Medical Errors– 44,000 to 98,000 preventable deaths• Emergency Room overcrowding– Waiting Times– Throughput, Discharge Planning, Staffed Bed Supply• Some areas do not have appropriate numbers ofprimary care and specialty physicians (i.e. physicianmaldistribution)• Hospital Re-Admission Rates
    20. 20. The Intersection of Costs,The Intersection of Costs,Coverage, and DeliveryCoverage, and Deliveryof Health Careof Health Care
    21. 21. The Flow of the Dollar• Costs, Payment, Delivery, and Insurance Coverage are completelyintertwined in our system!InsuranceCompanyIndividuallyInsuredGovernmentInsuredEmployeesUninsuredPhysiciansEmployerPubliclyInsuredPayment made to this entityService provided by this entity to individualsSource: Roby DH. 2009 (forthcoming). Impacts of Being Uninsured in Handbook of Health Psychology (edited bySuls, Kaplan, Davidson), Guilford Publications: New York, NY.
    22. 22. Controlling CostsControlling Costs• Government has been a major proponent of costcontrols– Prospective Payment• Use of Diagnosis Related Groups– Managed Care• Capitation (HMO and POS)• Discounted Fee-for-Service (PPO and POS)• How do differential cost controls impacthospitals, clinics, and physician providers?– Lower payments for Medicaid and Medicare– Insurance companies have increased leverage tonegotiate prices due to managed care contracting– Cost Shifting impacts delivery and coverage
    23. 23. Impacts of Medicare ProspectiveImpacts of Medicare ProspectivePayment System (PPS): 1985-2006Payment System (PPS): 1985-2006Cost ShiftingHospital Payment Per Dollar of CareMedicare Medicaid Private1985 $1.020 $0.943 $1.1711990 $0.895 $0.801 $1.2781998 $1.019 $0.966 $1.1582004 $0.919 $0.899 $1.289Source: American Hospital Association/The Lewin Group, Trends Affecting Hospitalsand Health Systems, TrendWatch Chartbook, April 2006.
    24. 24. Government Spending Outpaces PrivateGovernment Spending Outpaces PrivateCompany Spending in our SystemCompany Spending in our SystemSource: National Health Expenditures, Centers for Medicare and Medicaid Services, 20070500,0001,000,0001,500,0002,000,0002,500,0001993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007Spending(inthousands)Total Spending Out-of-Pocket Spending Commercial Health Insurance Public Funds
    25. 25. Billions spent to close the ‘gaps’ inBillions spent to close the ‘gaps’ inMedicaid/Medicare payment andMedicaid/Medicare payment andUncompensated CareUncompensated Care• Disproportionate Share Hospital (DSH) Payments– Medicaid and Medicare DSH– Based on percentage of caseload from uninsured, Medicaid, andMedicare– “Safety Net Financing”– Medicaid DSH administered by states and subject to federalmatch (FMAP)– Often public/county, teaching facilities, large trauma centers• Community Health Centers (Section 330) Funding– Comprehensive Primary Care (FQHC) clinics receive grantsubsidy based on uninsured and Medicaid– Sliding fee scale– Administered by the Bureau of Primary Health Care– 40% of patients are uninsured
    26. 26. Source: Stan Dorn, Bowen Garrett, John Holahan, and Aimee Williams,Medicaid, SCHIP and Economic Downturn: Policy Challenges and Policy Responses, prepared for the KaiserImpact of Unemployment Growth on Medicaidand SCHIP and the Number Uninsured1%Increase inNationalUnemploymentRate=1.0 1.1Increase inMedicaidand SCHIPEnrollment(million)Increase inUninsured(million)&$2.0$1.4$3.4Increase inMedicaid andSCHIPSpending(billion)StateFederal
    27. 27. Why Does the U.S. Spend SoWhy Does the U.S. Spend SoMuch More on Health Care?Much More on Health Care?• Compared to other Industrialized countries, the U.S. has:– Fewer physician office visits per capita– Fewer hospital inpatient admissions per capita– Lower Average Length of Stay (ALOS) per admission– Fewer hospital inpatient days per capita– Higher (but not the highest) use per capita of selected high-tech procedures (MRI, CT, angioplasty, dialysis)• If expenditures = prices x quantity, and quantities are not higher inthe U.S., then prices must be higher!
    28. 28. Profits for Health InsurersProfits for Health Insurers• Profits for health insurance companies and pharmaceuticalcompanies continue to increase– In 2006, the top 18 health insurers made $15 billion in profits– In 2006, pharmaceutical industry profits were 19.6%• 2ndmost profitable industry, behind the oil industry• Insurers profit from privatized government programs– The Medicare Advantage (Part C) program results in $18 billionin overpayment to insurance companies when compared totraditional Medicare Fee-for-Service (FFS)• Outcomes are not better for Medicare HMO enrollees• Rates paid to private insurers are much higher than cost ofMedicare FFS claims
    29. 29. What are we doing wrong?What are we doing wrong?• We are the only major industrial nation that does notprovide comprehensive health benefits to all its citizens• We have the largest private market for health care financingof any nation• We spend more per capita than any other nation, but allowgreater disparity in spending for different portions of ourpopulation• Our political system favors incremental changes, based onmarket-oriented solutions, rather than fundamental reform– From the inception of Medicare/Medicaid, to SCHIP, to present, weare often working within the existing framework and accomplishingsmaller, incremental changes
    30. 30. Opportunities and theOpportunities and theNeed for ReformNeed for Reform
    31. 31. Possible Reforms andPossible Reforms andFuture FinancingFuture Financing• Restructure our Current System– Indirect Subsidies and Consolidation could be used to insureUninsured– There is enough money in the system to care for everyone, but itis not being used efficiently and effectively! (Obama and Baucus)• Market-Based Approach– Consumer Choice – high deductible plans, health savingsaccounts, provider fee transparency (McCain)• Complete Dismantling of Current System– Can universal health care survive in a for-profit system?(Conyers)• Is Universal Insurance required, or Universal Access?– President G.W. Bush’s health care reform efforts were basedupon expanding the safety net (Community Health Centers),rather than insuring the uninsured.
    32. 32. Current Reform ModelsCurrent Reform Models• Policy Choices are numerous, if there is politicalwill and priority given to health care:– Individual Mandate– Employer Mandate– Pay-or-Play Provision– Tax Credits for Health Insurance– Expansion of Safety Net Providers– Health IT (EMR) and Comparative Effectiveness• Designed to create efficiencies and save money on services,avoid duplication– Introduction of Public Health Insurance Plans• Benchmark Plan• Based on community rating, risk adjustment/reinsurance• Will insure those who cannot get other coverage– Pre-Existing Conditions
    33. 33. Where is Reform Occurring?Where is Reform Occurring?• Since Clinton’s failed attempt at universal health care in1994, most efforts have been at the state-level– Massachusetts’ recently passed a universal health care reform• Individual Mandate – requires all residents to have insurancecoverage, while providing subsidies to those who cannotafford to buy on the private market• Health Insurance Connector• Expansion of state Medicaid and SCHIP eligibility plans• Other states have tried and failed– California was close to a compromise to allow for an individualmandate, similar to Massachusetts– Budget problems derailed the reform effort– Hawaii was able to enact an employer mandate in 1974– States are considered “laboratories of democracy”
    34. 34. Problems with State-Level ReformProblems with State-Level Reform• Complications due to:– State Budgets• Current economic situation can derail efforts– ERISA• Employee Retirement and Income Security Act• Federal Law that preempts state laws mandating employerprovision of specific benefits– Centers for Medicare and Medicaid Services (CMS)• Changes to Medicaid or SCHIP state plan require approval ofwaiver or change in federal regulations• G.W. Bush was not supportive of changes in eligibilityrequirements• Obama administration is supportive and actively pursuingexpansions
    35. 35. Obstacles to ReformObstacles to Reform• Frequently, universal reform efforts have been led byelites– Clinton’s health care plan was written in a “vacuum”, rather thanseeking consensus from political figures• Even proponents of universal health care opposed Clinton’s plan• Interest groups, especially business, are powerful• Campaign financing is loosely regulated• Political Parties are weak and de-centralized• Pharmaceutical companies, the American MedicalAssociation, and other special interest groups have interestin maintaining status quo  Health Care = $$$$• Major Stakeholders and Politicians cannot agree on thebest solution– Universal coverage can have many different forms– Grassroots mobilization could turn the tide• This economic downturn, with its rising unemployment, could createclass of uninsured and underserved that is vocal, motivated, and inserious need of reform
    36. 36. Senator Baucus’ ProposalSenator Baucus’ Proposal• Individual Mandate: All Americans will be required to purchasecoverage if it is available to them• Creation of purchasing pool or “health insurance exchange”• Requirement that carriers accept all applicants regardless of pre-existing health problems.– By bringing everyone into the system, Senator Baucus believes theaverage cost of insuring each American will be reduced.• Allows those between the ages of 55-and-64 to purchase Medicareif they lack access to public insurance programs or a group healthplan.• Expansion of the State Children’s Health Insurance Program toinclude children in families at or below 250 percent of the federalpoverty level ($44,000 for a family of three)• Lift the ban preventing legal immigrants to enroll in SCHIP untilthey’ve been in the country for five years.• Like President Obama, Senator Baucus supports tax credits forsmall businesses that provide health insurance coverage and forindividuals and families, below 400 percent of the federal povertylevel, who purchase their own coverage.
    37. 37. President Obama’s ProposalPresident Obama’s Proposal• Employer Mandate – Large employers would be required to payportion of payroll tax into fund (Pay-or-Play) – 5% or more– Lower costs for businesses by covering a portion of the catastrophichealth costs they pay in return for lower premiums for employees.• Require insurance companies to cover pre-existing conditions so allAmericans regardless of their health status or history can getcomprehensive benefits at fair and stable premiums.• Create a new Small Business Health Tax Credit• Establish a National Health Insurance Exchange to allow individualsand small businesses to buy affordable health coverage.• Subsidy through personal tax credits based on income• Additional steps to create efficiencies and reduce costs:– Health Information Technology (HIT) investment– Disease Management for chronic illness– Limits on overhead; greater transparency– Allow safe pharmaceuticals from other countries– Prevent insurers from overcharging doctors for their malpracticeinsurance– Reduce preventable medical errors.
    38. 38. Reform Occurs When and WhereReform Occurs When and WhereProblem, Policy, and Politics MeetProblem, Policy, and Politics Meet• Kingdon’s Model of Agenda Settting says:PoliticalStream PolicyStreamProblemStreamWindow ofOpportunity
    39. 39. Reform Occurs When and WhereReform Occurs When and WhereProblem, Policy, and Politics MeetProblem, Policy, and Politics Meet• Kingdon’s Model of Agenda Settting says:PoliticalStream PolicyStreamProblemStreamWindow ofOpportunityGrassrootsmobilizationCost Crisis, Economy,Rising Unemployment
    40. 40. Are we there yet?Are we there yet?• It appears that the window of opportunity may be open– Economy is in crisis– Unemployment and loss of insurance are big problems– Reformers need to take advantage of these opportunities• Obama has made health care reform a priority in hisfederal budget plan• Various Interest Groups are getting involved– Coalitions are being developed around different proposals– Broad Based Coalition and Grassroots support will be vital– Those impacted by the health care system (i.e. nurses,physicians, the underinsured and uninsured) need to beinvolved, empowered and given a voice.• Obama has expressed interest in signing health carereform that comes out of the legislative process– Different from President Clinton’s approach