An American Progress Note: Disclosures · •With universal healthcare access, people would not be obligated to obtain health insurance, but everyone would have the opportunity to

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An American Progress Note:A Health Reform Update for Healthcare Professionals

B. Cameron Webb, MD, JDHospitalist and Assistant Professor of Medicine

Division of General, Geriatric, Palliative & Hospital Medicine

Director, Health Policy and EquityDepartment of Public Health Sciences

University of Virginia School of Medicine

Medicine Grand Rounds Friday, June 28, 2019

Department of MedicineUniversity of Virginia School of Medicine

Disclosures• I have no actual or potential conflicts of interest in relation to this presentation.

• In 2016, I spent six months working in the White House for the Obama administration as they worked to implement/execute the Affordable Care Act.

• In 2017, I spent six months working in the White House for the Trump administration as they worked to repeal/replace the Affordable Care Act

Healthcare – Front and Center Chief Complaint:

• One decade after debating health reform at the start of the Obama administration, the American healthcare system is still sick.

• How should we fix it?

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Chief Complaint: Presentation Overview

SubjectiveCurrent Attitudes on the State of American Healthcare

Subjective - Patients

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• Gallup’s annual Healthcare poll (November 1-11, 2018)• Telephone interviews with a random sample of –1,037

adults, ages 18+, living in all 50 U.S. states and the District of Columbia.

• Gender: 586 men | 451 women


Subjective - Patients Subjective - Patients

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Subjective - Patients Subjective - Patients

Subjective - Patients Subjective - Physicians

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Subjective – Physicians

• Pilot survey distributed via email in August/September 2018 to 1,000 physicians in the AMA Physician Masterfile

• 129 respondents (12.9% response rate)• Gender: 62.6% male, 35.88% female

• Age: 92.36% > 40 years old

• Race/Ethnicity: 70.8% white | 10.22% Asian | 7.3% Hispanic | 4.38% Black

• Political leanings: 43.5% liberal | 32.8% conservative | 17.6% moderate

• Specialty: • 36.4% primary care

• 24.0% office-based subspecialties

• 11.6% surgical specialties,

• Practice location: 58.1% outpatient-based | 41.9% inpatient-based

Subjective - Physicians

• Healthcare spending in the U.S. continues to rise steadily, far outpacing healthcare spending in other countries that are similarly large and wealthy. As a physician, what level of concern do you have regarding this trend?

Conservative Liberal Moderate Total

Extremely Concerned

26(63.4%)

44(75.9%)

15(71.4%)

85(70.8%)

Somewhat Concerned

11(26.8%)

10(17.2%)

5(23.8%)

26(21.7%)

Slightly Concerned

2(4.9%)

3(5.2%)

1(4.8%)

6(5.0%)

Not at all Concerned

2(4.9%)

1(1.7%)

0(0.0%)

3(2.5%)

Total 41(34.2%)

58(48.3%)

21(17.5%)

120(100%)


• In the past year, approximately how many of your patients faced out-of-pocket healthcare costs that were a significant barrier to their care? In this case, "barrier" is defined as something that negatively impacts the way your patients seek or receive care.


All 0(0.0%)

1(1.7%)

1(4.8%)

2(1.7%)

Most 7(16.7%)

8(13.9%)

2(9.5%)

17(14.0%)

Many 17(40.5%)

32(55.2%)

14(66.7%)

63(52.1%)

Few 13(31.0%)

14(24.1%)

2(9.5%)

29(24.0%)

None 3(7.1%)

1(1.7%)

0(0.0%)

4(3.3%)

Don’t know 2(4.8%)

2(3.4%)

2(9.5%)

6(5.0%)

Total 42(34.7%)

58(47.9%)

21(17.4%)

121(100%)


• How would you grade the quality of care provided to the general public in the U.S. healthcare system?


Poor quality 3(7.1%)

2(3.4%)

0(0.0%)

5(4.1%)

Fair quality 4(9.5%)

16(27.6%)

6(28.6%)

26(21.5%)

Good quality 13(31.0%)

24(41.4%)

8(38.1%)

45(37.2%)

High quality 17(40.5%)

11(19.0%)

6(28.6%)

34(28.1%)

Exceptional quality

5(11.9%)

5(8.6%)

1(4.8%)

11(9.1%)

Total 42(34.7%)

58(47.9%)

21(17.4%)

121(100%)

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• Listed below are some past or proposed policy changes. Please choose the option that most closely matches your attitude regarding the following: Transitioning to a system where a single public agency (“single payer”) organizes the healthcare financing?


Favor 8(19.0%)

44(75.9%)

12(57.1%)

64(57.0%)

Oppose 33(78.6%)

9(15.5%)

7(33.3%)

49(43.0%)

Neither Favor Nor Oppose

1(2.4%)

5(8.6%)

2(9.5%)

8(6.6%)

Total 42(34.7%)

58(47.9%)

21(17.4%)

121(100%)

ObjectiveA Look at the Data Describing the Current State of Affairs

Vitals

SOURCE: OECD Health Statistics 2018.

National Health Expenditures

$$$$$$$$$$$$$$$$$$$$$

$3.5 trillion

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What is a Trillion?

30,000 BCE

ONE MILLION SECONDS AGO

ONE BILLION SECONDS AGO

ONE TRILLION SECONDS AGO

=

=

=

11.57 days ago

31.7 years ago

31,709.8 years ago

Areas of Greatest Spending GrowthType of Service/Product

Hospital Care

Physician/Clinical Services

Retail Prescription Drugs

Other Health, Residential, and Personal Care Services

Nursing Care Facilities

Dental Services

Home Health Care

Other Professional Services

Non-durable Medical Products

Durable Medical Equipment

% Share

33%

20%

10%

5%

5%

4%

3%

3%

2%

2%

% Growth

4.6%

4.2%

0.4%

5.6%

2.6%

3.2%

4.3%

4.6%

2.2%

6.8%

Total Spent 2017

$1.1 trillion

$694.3 billion

$333.4 billion

$183.1 billion

$166.3 billion

$129.1 billion

$97.0 billion

$96.6 billion

$64.1 billion

$54.4 billion

Out-of-Pocket Expenditures Out-of-Pocket Expenditures

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Prescription Drug Spending Health Insurance Premiums

Life Expectancy Mortality

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Years of Potential Life Lost (YPLL)

https://data.oecd.org/healthstat/potential-years-of-life-lost.htm

Years of Potential Life Lost (YPLL)

https://www.countyhealthrankings.org/app/virginia/2019/measure/outcomes/1/map

County YPLL

Albemarle 3,800

Fluvanna 6,400

Greene 6,700

Louisa 7,200

Nelson 9,000

Top U.S. Performers (10th percentile)

5,400

Quality of Care Insurance Status

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Insurance Status Uninsured Rates

Uninsured Rates

AssessmentThe Differential for What’s Wrong with American Healthcare

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1. Healthcare Spending Overload, Chronic

What is Driving Expenditures?

Growth in Expenditures

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Prices vs Use Healthcare is not a “Normal” MarketStandard Supply & Demand Model1. The main interested parties are the

buyers and sellers in the market.

2. Buyers are good judges of what they get from sellers.

3. Buyers pay sellers directly for the goods and services being exchanged.

4. Market prices are the primary mechanism for coordinating the decisions of market participants.

5. The invisible hand, left to its own devices, leads to an efficient allocation of resources.

Healthcare Market Features1. Third parties—insurers, governments,

and unwitting bystanders—often have an interest in healthcare outcomes.

2. Patients often don’t know what they need and cannot evaluate the treatment they are getting.

3. Healthcare providers are often paid not by the patients but by private or government health insurance.

4. The rules established by these insurers, more than market prices, determine the allocation of resources.

5. In light of the foregoing four points, the invisible hand can’t work its magic, and so the allocation of resources in the healthcare market can end up highly inefficient.

What to Do With THIS Market?

• It’s the Nature of the Beast. Regulate!• Bureaucracy is to Blame. De-regulate!

2. Inadequate Outcomes / Value

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3. Healthcare Access Deficiency, Chronic

Understanding “Access”

• “Universal access” vs “universal coverage”• Republicans tend to focus on ensuring that people have access to health

insurance.• Democrats tend to focus ensuring that people have health insurance.


• Healthcare reform hinges on the answer to one basic question: Is healthcare a right or a market product?

• Republicans are using the word “access” to describe a consumer-driven model for healthcare. Access means that there are sufficient facilities and providers for everyone, but this approach enables individuals to decide how much they want to pay for health insurance and how much coverage they want.

• On the other side of the spectrum, Democrats use the phrase “universal coverage” to define healthcare as a right, which by definition demands a viable option for every individual. This approach uses government-dictated directives to ensure that healthcare is available to everyone.


• With universal healthcare access, people would not be obligated to obtain health insurance, but everyone would have the opportunity to do so. This mindset aims to repeal the burden of mandatory healthcare premiums and allows healthcare to be dictated by the consumer instead of the government.

• There is concern that this method of health insurance delivery will create a barrier for people who cannot afford the services that they could theoretically obtain. Some theorize that, if consumers have more options in the private healthcare marketplace, then they have the opportunity to shop around for coverage and potentially lessen the financial burden.

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• With the idea of universal coverage, the goal is for every—or almost every—citizen to have health insurance regardless of the ability to pay.

• This approach regards healthcare as a basic individual right, akin to the right to representation in court during a trial. The Affordable Care Act sought to get the American healthcare system closer to universal coverage via a combination of an individual mandate, an employer mandate, federal health insurance subsidies, and the Medicaid expansion.

Who are the uninsured?

Why are they uninsured? Understanding “Access”

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Plan(s)Reviewing Leading Proposals for How to “Fix” Our Healthcare System

Plans

Medicare for All The Public Option

Medicare Buy-InMedicaid Buy-In Executive Order:

Improving Price & Quality Transparency

Drug PricingSurprise Medical Bills

EO: Healthcare Price Transparency & Quality

• Goal: To help consumers know the prices and quality of a good or service and to make informed decisions about their healthcare.

• Actions: Directs different federal agencies to adopt rules, issue guidance, or develop reports with the goal of increasing the transparency of healthcare price and quality information.

• Effect: NOT a change in law or regulations, but, rather, a directive to draft new rules or guidance.

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• Calls for increased transparency of healthcare price and quality information.

• Requires the disclosure of “actual” prices• “Actual” = charges based on the rates negotiated between insurance

companies and providers (as opposed to list prices charged to patients without insurance)

• Maximizing Access to HDHP-HSAs and Health Care Sharing Ministries

• Research, Quality, and Surprise Medical Bills


Medicare for All

• Every single American would be covered by a government insurance plan, after a short phase-in period.

• Would eliminate employer-sponsored coverage completely. Under these options, all Americans who currently get insurance at work would transition to one big government health care plan.

• Both single-payer options envision Medicare covering more benefits than it currently does.

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Medicare for All

• Both single-payer options envision Medicare covering more benefits than it currently does.

• The Sanders bill, for example, would change Medicare to cover vision, dental, and prescription drugs, as well as long-term care services as nursing homes. It would also cover a wide breadth of women’s reproductive health services including abortion, a feature that would likely draw controversy.

• The House bill covers a slightly different set of benefits but, according to one Democratic House aide, is undergoing revisions to look more similar to the Sanders package. “We want to make sure we’re able to align the coverage services [of our bill] with the Sanders plan,” said the aide, who asked to speak anonymously to discuss the ongoing negotiations.

Medicare for All

• Both Medicare-for-all bills would eliminate cost sharing completely. This means no monthly premiums, no copayments for going to the doctor, and no deductible to meet before coverage kicks in.

• Senate: Sanders’s office has released a list of financing options that generally impose higher taxes on the wealthiest Americans, such as increased income and estate taxes, establishing a new wealth tax on the top 0.1 percent, and imposing new fees on large banks.

• House: Over on the House side, aides say that while they are currently working on revisions to HR 676, that focuses mostly on updating the benefits package —and less on deciding how to pay for the package. They do not currently expect to release a financing plan in early 2019.

Medicare for All Medicare for All

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Medicare for All Medicare for All vs Public Option

Medicare Buy-In & Medicaid Buy-In Medicaid Buy-In

• State Public Option Act (H.R. 1277)• Introduced by Rep. Ben Ray Luján (D-NM3)• To establish a State public option through Medicaid to

provide Americans with the choice of a high-quality, low-cost health insurance plan.

• 46 cosponsors

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Medicare Buy-In

• Medicare Buy-In and Health Care Stabilization Act of 2019 (H.R. 1346)

• Introduced by Rep. Brian Higgins (D-NY26)• To amend title XVIII of the Social Security Act to provide for an option

for individuals who are ages 50 to 64 to buy into Medicare, to provide for health insurance market stabilization, and for other purposes.

• 30 cosponsors

Plans

• Bipartisan “consensus” around:• Addressing the cost of prescription drugs• Addressing Surprise Medical Bills• Protecting patients with pre-existing conditions

AddendumHow to be an effective advocate for your policy preference

Physician Advocacy

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Advocacy in Organizations Legislative Advocacy

• Find your Representative• Find your Senators

• Call, write, and stop by when in D.C.

Administrative Agencies: Notice and Comment

• When agencies create new rules, they must submit them for public comment and respond to all comments before enacting the rule.

Use Your Pen!

• Your hometown newspapers• Large distribution newspapers (NYT, WaPo)• Blogs (KevinMD)

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Questions?

Documents

An American Progress Note: Disclosures · •With universal healthcare access, people would not be obligated to obtain health insurance, but everyone would have the opportunity to