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Health Care Reform  in the United States     WILLIAM M. SAGE, MD, JDTHE UNIVERSITY OF TEXAS AT AUSTIN           APRIL 2012
America’s Health Care Cost Problem Approximately $3.5 trillion aggregate annual cost Spending over $8,000 per capita Pr...
International Spending on Health:1980–2006                          Average spending on health per capita ($US PPP*)      ...
THE                                                                                                                       ...
What is a potential solution to U.S.      federal health care spending?1.   Preventing any growth in     pension spending ...
What is a potential solution to U.S.      federal health care spending?1.   Preventing any growth in     pension spending ...
Federal Budget Trends
Health and State BudgetsComponents of total state spending, fiscal 2006Medicaid, 21.5%Elementary/secondary education, 21.4...
America’s Health Care Access Problem 47 million Americans (15%) did not have health  insurance in 2006 Institute of Medi...
Number of Nonelderly Uninsured Americans,                  1994 – 2006                     Previous Method             199...
Patient Protection              and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”   ...
Uninsured Nonelderly vs. All Nonelderly,            by Family Poverty Level, 2006             300% +            19%   200%...
Uninsured Rates Among Nonelderly               by State, 2005-2006                                                        ...
Patient Protection              and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”   ...
America’s Health Care Value Problem Fragmented, variable, poor quality health care delivery  Lack of preventive care  P...
Lack of Insurance Undermines Preventive and Chronic                              CarePercent of adults                    ...
Poor Coordination: Nearly Half Report Failures to Coordinate                              Care  Percent U.S. adults report...
Patient Protection              and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”   ...
The problem“The American public cannot have it both ways. They must decide what is more important – money  and time– or co...
Patient Protection              and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”   ...
Obesity Trends* Among U.S. Adults                         BRFSS, 1985 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1986 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1987 for 5’ 4”              (*BMI ≥30, or ~ 30 lbs. overw...
Obesity Trends* Among U.S. Adults                         BRFSS, 1988 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1989 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1990 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1991 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1992 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1993 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1994 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1995 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1996 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1997 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1998 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                         BRFSS, 1999 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lb...
Obesity Trends* Among U.S. Adults                        BRFSS,overweight for 5’ 4” person)              (*BMI ≥30, or ~ 3...
Obesity Trends* Among U.S. Adults                        BRFSS, 2001 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lbs...
Obesity Trends* Among U.S. Adults                     BRFSS, 2002                 (*BMI ≥30, or ~ 30 lbs. overweight for 5...
Obesity Trends* Among U.S. Adults                        BRFSS, 2003 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lbs...
Obesity Trends* Among U.S. Adults                        BRFSS, 2004 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lbs...
Obesity Trends* Among U.S. Adults                        BRFSS, 2005 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lbs...
Obesity Trends* Among U.S. Adults                        BRFSS, 2006 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lbs...
Obesity Trends* Among U.S. Adults                        BRFSS, 2007 for 5’ 4” person)              (*BMI ≥30, or ~ 30 lbs...
Patient Protection              and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”   ...
Health Care Reform in Half an Hour-detailed
Health Care Reform in Half an Hour-detailed
Health Care Reform in Half an Hour-detailed
Health Care Reform in Half an Hour-detailed
Health Care Reform in Half an Hour-detailed
Health Care Reform in Half an Hour-detailed
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Health Care Reform in Half an Hour-detailed

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Health Care Reform in Half an Hour-detailed

  1. 1. Health Care Reform in the United States WILLIAM M. SAGE, MD, JDTHE UNIVERSITY OF TEXAS AT AUSTIN APRIL 2012
  2. 2. America’s Health Care Cost Problem Approximately $3.5 trillion aggregate annual cost Spending over $8,000 per capita Premium for family coverage=$12,106 in 2007  Rising much faster than wages  A years salary at minimum wage= $12,168 More than half is publicly funded, amounting to a substantial part of government spending
  3. 3. International Spending on Health:1980–2006 Average spending on health per capita ($US PPP*) $7,000 United States $6,000 Germany Canada Netherlands $5,000 France Australia $4,000 United Kingdom $3,000 $2,000 $1,000 $0 80 82 84 86 88 90 92 94 96 98 00 02 04 06 19 19 19 19 19 19 19 19 19 19 20 20 20 20* PPP = Purchasing Power Parity.Data: OECD Health Data 2008, June 2008 version.
  4. 4. THE COMMONWEALTH FUNDPublication: R. E. Leu, F. F. H. Rutten, W. Brouwer et al., The Swiss and Dutch Health Insurance Systems: Universal Coverage andRegulated Competitive Insurance Markets, The Commonwealth Fund, January 2009
  5. 5. What is a potential solution to U.S. federal health care spending?1. Preventing any growth in pension spending (social security)2. Eliminating politicians’ pet projects (“pork” or “earmarks”)3. Cutting back all discretionary federal spending4. Renting out the U.S. military to other countries
  6. 6. What is a potential solution to U.S. federal health care spending?1. Preventing any growth in pension spending (social security)2. Eliminating politicians’ pet projects (“pork” or “earmarks”)3. Cutting back all discretionary federal spending4. Renting out the U.S. military to other countries
  7. 7. Federal Budget Trends
  8. 8. Health and State BudgetsComponents of total state spending, fiscal 2006Medicaid, 21.5%Elementary/secondary education, 21.4% (largest until ‘03)Higher education, 10.4% (2nd largest until 1990)Transportation, 8.1%Corrections, 3.4 %Public assistance, 1.8%All other expenditures, 33.4%Source: NGA/NASBO Dec. 2007 Survey
  9. 9. America’s Health Care Access Problem 47 million Americans (15%) did not have health insurance in 2006 Institute of Medicine estimates that 18,000 Americans die every year from lack of care There are large racial, ethnic, and socioeconomic disparities in diagnosis, treatment, and medical outcomes
  10. 10. Number of Nonelderly Uninsured Americans, 1994 – 2006 Previous Method 1999 Revised Method 2004 Revised Method 50 46.5 44.7 45.5 44.4 43.1 43.9 43.3 43.0 41.7 42.1 40.6 40.9 39.8 40.0 39.6 25 44.8 0 ‘94 ‘95 ‘96 ‘97 ‘9 99* ‘00 ‘01 ‘0 ‘03 ’04* ‘05 ‘06 8 2* The Census Bureau periodically revises its CPS methods, which means data before and after the revision are not comparable.Comparison across years can be made between 1994 and 1999, 1999 through 2004, and 2004 though 2006.SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.
  11. 11. Patient Protection and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”  Insurability reforms Title II: “Role of Public Programs”  Affordability reforms Title III: “Improving the Quality and Efficiency of Health Care”  Delivery system reforms Title IV: “Prevention of Chronic Disease and Improving Public Health”  Health reforms Title V: “Health Care Workforce”  Education reforms
  12. 12. Uninsured Nonelderly vs. All Nonelderly, by Family Poverty Level, 2006 300% + 19% 200% - 299% 16% 49% 100% - 199% 29% 16% 17% Under 100% 36% 17% Uninsured All Nonelderly 46.5 Million 260.0 MillionNOTES: The Federal Poverty Level for a family of four in 2006 was $20,614 (according to the U.S. CensusBureau’s poverty threshold). Family size and total family income are grouped by insurance eligibility. Data maynot total 100% due to rounding.SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.
  13. 13. Uninsured Rates Among Nonelderly by State, 2005-2006 NH VT WA ME MT ND MN MA OR NY ID SD WI RI MI WY CT PA IA NJ NE OH NV IL IN DE UT WV VA CA CO MD KS MO KY NC DC TN OK SC AZ AR NM AL GA MS AK TX LA FL HI <13% Uninsured (13 states) National Average = 18% 13 to 17% Uninsured (18 states & DC) ≥18% Uninsured (19 states)SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of the March CurrentPopulation Survey, 2006 and 2007, two-year pooled data.
  14. 14. Patient Protection and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”  Insurability reforms Title II: “Role of Public Programs”  Affordability reforms Title III: “Improving the Quality and Efficiency of Health Care”  Delivery system reforms Title IV: “Prevention of Chronic Disease and Improving Public Health”  Health reforms Title V: “Health Care Workforce”  Education reforms
  15. 15. America’s Health Care Value Problem Fragmented, variable, poor quality health care delivery  Lack of preventive care  Poor adherence to clinical “best practices”  Frequent medical errors Mediocre population health  Life expectancy at birth ranks 40th in the world  Epidemic obesity and associated chronic disease burden (diabetes, cardiovascular disease)  25% of Americans are obese  45% of Americans have a chronic disease
  16. 16. Lack of Insurance Undermines Preventive and Chronic CarePercent of adults Percent of adults 100 Insured Uninsured100 Chronic Disease Under Control: Receipt of Recommended Screening Diabetes and Hypertension, 1999– 81 80 and Preventive Care,* 2005 80 2004 63 60 53 60 50 46 41 40 32 40 21 20 20 0 0 Total Uninsured Uninsured Insured all all year part year year Diabetes under control** High blood pressure under control*** * Recommended care includes: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu shot within a specific time frame given age and sex. ** Refers to diabetic adults whose HbA1c is <9.0 *** Refers to hypertensive adults whose blood pressure is <140/90 mmHg.
  17. 17. Poor Coordination: Nearly Half Report Failures to Coordinate Care Percent U.S. adults reported in past two years: Your specialist did not receive basic medical information from your 13 primary care doctor Your primary care doctor did not receive a report back from a 15 specialist Test results/medical records were not available at the time of 19 appointment Doctors failed to provide important medical information to other doctors or nurses you think should 21 have it No one contacted you about test results, or you had to call 25 repeatedly to get results Any of the above 47Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008. 0 20 40 60
  18. 18. Patient Protection and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”  Insurability reforms Title II: “Role of Public Programs”  Affordability reforms Title III: “Improving the Quality and Efficiency of Health Care”  Delivery system reforms Title IV: “Prevention of Chronic Disease and Improving Public Health”  Health reforms Title V: “Health Care Workforce”  Education reforms
  19. 19. The problem“The American public cannot have it both ways. They must decide what is more important – money and time– or comprehensive, appropriate care.” -A Kentucky physician opposing retail medical clinics
  20. 20. Patient Protection and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”  Insurability reforms Title II: “Role of Public Programs”  Affordability reforms Title III: “Improving the Quality and Efficiency of Health Care”  Delivery system reforms Title IV: “Prevention of Chronic Disease and Improving Public Health”  Health reforms Title V: “Health Care Workforce”  Education reforms
  21. 21. Obesity Trends* Among U.S. Adults BRFSS, 1985 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14%
  22. 22. Obesity Trends* Among U.S. Adults BRFSS, 1986 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14%
  23. 23. Obesity Trends* Among U.S. Adults BRFSS, 1987 for 5’ 4” (*BMI ≥30, or ~ 30 lbs. overweight person)No Data <10% 10%–14%
  24. 24. Obesity Trends* Among U.S. Adults BRFSS, 1988 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14%
  25. 25. Obesity Trends* Among U.S. Adults BRFSS, 1989 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14%
  26. 26. Obesity Trends* Among U.S. Adults BRFSS, 1990 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14%
  27. 27. Obesity Trends* Among U.S. Adults BRFSS, 1991 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19%
  28. 28. Obesity Trends* Among U.S. Adults BRFSS, 1992 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19%
  29. 29. Obesity Trends* Among U.S. Adults BRFSS, 1993 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19%
  30. 30. Obesity Trends* Among U.S. Adults BRFSS, 1994 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19%
  31. 31. Obesity Trends* Among U.S. Adults BRFSS, 1995 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19%
  32. 32. Obesity Trends* Among U.S. Adults BRFSS, 1996 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19%
  33. 33. Obesity Trends* Among U.S. Adults BRFSS, 1997 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% ≥20%
  34. 34. Obesity Trends* Among U.S. Adults BRFSS, 1998 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% ≥20%
  35. 35. Obesity Trends* Among U.S. Adults BRFSS, 1999 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% ≥20%
  36. 36. Obesity Trends* Among U.S. Adults BRFSS,overweight for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. 2000No Data <10% 10%–14% 15%–19% ≥20%
  37. 37. Obesity Trends* Among U.S. Adults BRFSS, 2001 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  38. 38. Obesity Trends* Among U.S. Adults BRFSS, 2002 (*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)No Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  39. 39. Obesity Trends* Among U.S. Adults BRFSS, 2003 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  40. 40. Obesity Trends* Among U.S. Adults BRFSS, 2004 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% 20%–24% ≥25%
  41. 41. Obesity Trends* Among U.S. Adults BRFSS, 2005 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  42. 42. Obesity Trends* Among U.S. Adults BRFSS, 2006 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  43. 43. Obesity Trends* Among U.S. Adults BRFSS, 2007 for 5’ 4” person) (*BMI ≥30, or ~ 30 lbs. overweightNo Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%
  44. 44. Patient Protection and Affordable Care Act of 2010 Title I: “Quality, Affordable Care for All Americans”  Insurability reforms Title II: “Role of Public Programs”  Affordability reforms Title III: “Improving the Quality and Efficiency of Health Care”  Delivery system reforms Title IV: “Prevention of Chronic Disease and Improving Public Health”  Health reforms Title V: “Health Care Workforce”  Education reforms

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