After The Court And Election Decisions: What's Next For Healthcare?

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Presentation by Tom Miller, from Reporting on Health's "From the White House to Community Clinics: What Happens Next for Healthcare Reform" webinar 11/8/2012.

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  • Thank you’sTwo years of waiting for courtObamaCare and health policy problems didn’t stopVoters in Nov 2010 sent a message, but it has not gotten throughUnusual law in many ways ---- contorted process, but also a very slow-developing implementationIt takes a while to takeover the private health care system,while trying to hide all the costs, impacts, and long-term goals with false promises, budgeting accounting fictions, political scapegoating, and “whatever it takes” rulemaking --- and get all the rewiring done so it doesn’t compeltely collapseThis issue matters a lot It’s a big one, not just for the near term but how it will shape our future --- our politics, the role of govt, our economy and, oh yes, our health.
  • Consumer demand within a budget constraintPublic vs. private money
  • This morning, I’m going to cover the ground quickly, and hit the highlightsWhere are we? BulletsUrgency to stop before institutionallizatoin and capitulationSlower health spending ----- what a great solution ---- slow eco growth
  • This morning, I’m going to cover the ground quickly, and hit the highlightsWhere are we? BulletsUrgency to stop before institutionallizatoin and capitulationSlower health spending ----- what a great solution ---- slow eco growth
  • Pay or play No LEGAL COMPULSION to actually buy the insurance Before 2014, and after link to state-run exchange?Trying to go below March 2010 level, or at least below 138% FPL laterStates may try tto make BETTER deals Leverage ---- for participation and market share Watch Maine case (just lost yesterday?)CBO – only modest adjustments in enrollment and budget costs forecast guessing at Medicare state takeupFed tax credits for fed exchanges Possible litigatoinMain delivery vehiicle, w/ Medicaid partly stalledMid-Nov implementation ready deadine? Fed-facilitated overrideRuling impact depends on what feds attempt next, to stretch out compuulsion somewhere else Politics was stalled and frozen while waiting for Court Industry -- it’s just business
  • Pay or play No LEGAL COMPULSION to actually buy the insurance Before 2014, and after link to state-run exchange?Trying to go below March 2010 level, or at least below 138% FPL laterStates may try tto make BETTER deals Leverage ---- for participation and market share Watch Maine case (just lost yesterday?)CBO – only modest adjustments in enrollment and budget costs forecast guessing at Medicare state takeupFed tax credits for fed exchanges Possible litigatoinMain delivery vehiicle, w/ Medicaid partly stalledMid-Nov implementation ready deadine? Fed-facilitated overrideRuling impact depends on what feds attempt next, to stretch out compuulsion somewhere else Politics was stalled and frozen while waiting for Court Industry -- it’s just business
  • Pay or play No LEGAL COMPULSION to actually buy the insurance Before 2014, and after link to state-run exchange?Trying to go below March 2010 level, or at least below 138% FPL laterStates may try tto make BETTER deals Leverage ---- for participation and market share Watch Maine case (just lost yesterday?)CBO – only modest adjustments in enrollment and budget costs forecast guessing at Medicare state takeupFed tax credits for fed exchanges Possible litigatoinMain delivery vehiicle, w/ Medicaid partly stalledMid-Nov implementation ready deadine? Fed-facilitated overrideRuling impact depends on what feds attempt next, to stretch out compuulsion somewhere else Politics was stalled and frozen while waiting for Court Industry -- it’s just business
  • Pay or play No LEGAL COMPULSION to actually buy the insurance Before 2014, and after link to state-run exchange?Trying to go below March 2010 level, or at least below 138% FPL laterStates may try tto make BETTER deals Leverage ---- for participation and market share Watch Maine case (just lost yesterday?)CBO – only modest adjustments in enrollment and budget costs forecast guessing at Medicare state takeupFed tax credits for fed exchanges Possible litigatoinMain delivery vehiicle, w/ Medicaid partly stalledMid-Nov implementation ready deadine? Fed-facilitated overrideRuling impact depends on what feds attempt next, to stretch out compuulsion somewhere else Politics was stalled and frozen while waiting for Court Industry -- it’s just business
  • Pay or play No LEGAL COMPULSION to actually buy the insurance Before 2014, and after link to state-run exchange?Trying to go below March 2010 level, or at least below 138% FPL laterStates may try tto make BETTER deals Leverage ---- for participation and market share Watch Maine case (just lost yesterday?)CBO – only modest adjustments in enrollment and budget costs forecast guessing at Medicare state takeupFed tax credits for fed exchanges Possible litigatoinMain delivery vehiicle, w/ Medicaid partly stalledMid-Nov implementation ready deadine? Fed-facilitated overrideRuling impact depends on what feds attempt next, to stretch out compuulsion somewhere else Politics was stalled and frozen while waiting for Court Industry -- it’s just business
  • g fieldOther legal challenges (fed exchange, MOE,Statutory vs reg conflict Employer mandate, state sovereingty Negotiate for big structural M waiversCritical mass?Reconciliation ---- debone and filet mostFirst day vs. first yearNew rulemaking, limited waivers What’s short-term popular Irreversible changes in markets?Avoiding biggest disasters Tactical vs. strategic Customization/standardization continuum
  • It could crash, if not delayed and rewritten for reality
  • Fiscal cliffRebid for more, better careInstalled base, population health
  • Fiscal cliffRebid for more, better careInstalled base, population health
  • After The Court And Election Decisions: What's Next For Healthcare?

    1. 1. After the Court & Election Decisions: What’s Next for Health Care? Tom Miller American Enterprise Institute November 8, 2012
    2. 2. Story Lines to Pursue• Cross-pressures on exchanges• Recalibrating Medicaid expansion Metabolic disorder or fiscal bulimia?• State-level politics• Setting the table for the 2014 “stress test”• Transparency without real prices
    3. 3. Primary Political Scenarios: Ratification, Rejection, or Equivocation?Post-November playing field scenarios• Re-election w/o full congressional control From “rope a dope” to “survive & advance” Reality-based revision or fuller strength dosage? Pottery barn rules
    4. 4. Primary ACA Political Equations: Blame Shifting• States – branch offices, handle dirty work• Keep full costs off-budget
    5. 5. The Ordeal of Change: Politics vs. Markets• Strategic & tactical repositioning• Getting beyond a common rhetoric• National goals, local trial & error• Scalability, replication, adaptation
    6. 6. Pilot Program Prototypes?•
    7. 7. Pilot Program Prototypes?•
    8. 8. Pilot Program Prototypes?•
    9. 9. Don’t Just Look under the Street Light for Lost Keys• Social determinants of health• Broader portfolio of investments• Scope of practice• Competition policy• Telemedicine• Broader use of self-insurance
    10. 10. Choke Points & Leverage• Exchanges (state v. fed)• Medicaid expansion• Renegotiate & rewrite vs. repeal & replace
    11. 11. The Secret Plan for Health Delivery Reform,ACA Implementation, & Affordable Entitlements
    12. 12. Predictive Modeling:Probabilities, Possibilies & Implausibilities• Centripetal, not centrifugal, forces• But changing permanent law alters frame of reference• Accountability: to patients or politicians?• Macroeconomic overrides
    13. 13. Bonus Rounds• Six Picks for Post-Election Health Policyhttp://www.realclearmarkets.com/articles/2012/11/07/six_picks_for_post-election_health_policy_99976.html• When Obamacare Fails: The Playbook for Market-Based Reform (AEI, November 2012)• Beyond Repeal and Replace (AEI project)•http://www.aei.org/issue/health/healthcare-reform/beyond-repeal-and-replace-series

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