Class Learning Objectives

1. Health Reform and the Delivery System: A Discussion of the Policymaking ProcessJack O. Lanier, DrPH, MHA, FACHECEORichmond Behavioral Health Authority

2. Class Learning Objectives • Describe and discuss components of PPACA. • Describe key components of health economics and social choice. • Explain the role of public opinion in the policymaking process. • Describe a model for policymaking in the U.S. • Assess students’ opinion of Governments’ role in access to health care.

3. Health Care For Americans:The “Patient Protection and Affordable Care Act”(P.L. 111-148) 2010-2018

4. Five Key Components of PPACA: • Health Insurance Reform • Coverage Reform – parity • Quality Reform • Payment Reform • Information Technology

5. Behavioral Health Reform: Three Notable Publications

6. http://link.brightcove.com/services/player/bcpid1875349721?bctid=608833805001http://link.brightcove.com/services/player/bcpid1875349721?bctid=608833805001

7. Significant Provisions of PPACAImpact on Individual Population Groups • Young Adults • 26 and younger may remain on parents’ policy • Insurance may be costly, but must stay covered • The Elderly • Receive free preventive services under Medicare • Medicare Advantage Plan - insurer may cut extra benefits or increase co-payments • Small-Business Owners • 25 workers or less - may be eligible for tax credit to help buy coverage • After 2010, may be eligible for only 2 years of tax credits to help purchase coverage

8. Impact of New Insurance Coverage on Americans • 32 mil more adults nationwide covered. • In Virginia, 300,000 individuals predicted to receive new benefits. • Of the 32 mil, 10.5 mil have mental health or substance use conditions; 60% qualify for Medicaid. • Approx. 8% of individuals may have sub-stance use issues and never been served.

9. Virginia’s Response to Mandatory Coverage & State-run Insurance Exchanges • In March, VA AG Cuccinelli sued U.S. Govt. • Claim: U.S. Constitution “Commerce Clause” can’t compel people to buy insurance. • 2010, Va. GA passed law not to compel residents to purchase health insurance. • Gov. Bob McDonnell has endorsed lawsuit, saying the federal law could cost Va. in excess of $1.5 bil in health costs between 2017 and 2022. • Va. Medicaid enrollees estimated to increase from 270,000 to 425,000 between 2017 and 2022.

10. “Doctors Urge Cuccinelli to Drop Health-Reform Lawsuit” (RTD 06-18-2010) • Washington-based “Doctors for America” sent letter to AG Cuccinelli to drop suit. • Letter argues that litigation (successful or not) would harm patients by delaying funding appropriated to medical schools and community health centers, and medical care to underserved populations. • Obama administration lawyers filed motion to dismiss Virginia’s lawsuit.

11. “Doctors Urge Cuccinelli to Drop Health-Reform Lawsuit”: By the numbers (cont’d) • 155 Virginia physicians of “Doctors for America” group signed letter to AG Cuccinelli opposing Virginia’s lawsuit. • “Doctors for America” has 16,000 members. • Virginia has 30,000 physicians.

12. Health Spending vs. Results Americans see doctors less, do not live longer, and are not healthier. 12

13. Health Care Reform:Complaints are Never-ending

14. Added Benefits To Some States: A health-care windfall : *D.C. officials are expecting an infusion of cash. a reward for their push to offer nearly universal access to insurance for residents. *6.2 percent of District residents are uninsured, less than half the national average. SOURCE: Urban Institute; the Henry J. Kaiser Family Foundation | The Washington Post - April 14, 2010 14

15. A Case to Reform the System:Costs, Quality, and Coverage

16. A New Approach for Medicare: A Plan to Reward Quality Today’s Payment System: • Is Riddled with perverse incentives • Rewards volume and high profit margin services regardless of value, outcomes or appropriateness • PPACA will reward hospitals for high-quality care: a first step to transform the way the federal government pays for health care

17. Financial & Fiscal Realities For State Governments

18. Fiscal Realities: POLICY MAKING AT THE STATE LEVEL

19. Public Opinion

20. Public Trust in Government: 1958 to 2010An Impediment to Policy Making People who say they trust government just about always or most of the time 20

21. Special InterestsIt’s All About Money

22. Americans’ Dependency on Federal Aid Continues to Increase In 2010: • A record 18.3% of total personal income was payment from government for Social Security, Medicare, Food Stamps, unemployment benefits and other programs • Wages accounted for the lowest share of income – 51.0% • Wages declined to a low of 50.5% of personal income in Feb. 2011

23. Suicidal Politics: Government Promises More Than It Can Deliver Americans’ Dependency on Government: 2009 • 46.2 % received at least one federal benefit • 46.5 mil – Social Security • 42.6 mil – Medicare • 42.4 mil – Medicaid • 36.1 mil – Food Stamps • 3.2 mil - Veterans’ benefits • 12.4 mil - Housing subsidies National Opinion Research Center: University of Chicago 2011

24. How Americans Spend: $35,083 per HouseholdSource: The Portland Mercury with Exotic Magazine (2009) • Shopping - $8,668 • Health & Family - $8,026 • Food & Drink - $6,514 • Home Related Expenses - $6,398 • Getting Around - $5,477

25. National Opinion Research Center SurveyUniversity of Chicago - 2011 Americans Consistently Want More Spending For: • Education – 74 percent • Health Care – 60 percent • Social Security – 57 percent • Taxes too high – Between half and two-thirds • 2010 – Only 2 % thought taxes too low

26. Government On The Brink With Suicidal PoliticsNational Opinion Research Center – Chicago 2011 Government: • Consistently promises more than it can realistically deliver • Repeatedly disappoints by providing less than people expect • Government’s very expansion brings it into disrepute, results in paralyzed politics and impedes it from acting in the national interest

27. Big Government on the Brink: American Dependency on Federal Benefits Samuelson (WP), 2010

28. Behavioral Health Reform: Three Notable Publications

29. The Legislative & Policy Making Process

30. Is access to health insurance for all Americans a right or a privilege? • A right • A privilege

31. Given the known tension between federal and state governments, which legislative body should prevail in the health care reform debate? • Federal • State

32. Will provisions of the health reform law likely bend (reduce) the cost curve over time? • Yes • No

33. Which of the four population groups described provides the greatest opportunity to reduce health care cost and improve quality? • Medicaid and CHIP • Employers with fewer than 50 employees • Medicare recipients • Midsized and larger employers

34. A Thought To Ponder “All history is only one long story to the effect: Men have struggled for power over their fellow men in order that they might win the joys of earth at the expense of others, and might shift the burdens of life from their own shoulders upon those of others.” – William Graham Sumner (1840-1910). An American academic and professor at Yale College

35. Thank You Questions ? Comments?