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The Obama Health Care Reform Proposal

The Obama Health Care Reform Proposal. Bill Evans Department of Economics and Econometrics. Three topics in this topic. What issues must comprehensive health care reform confront? Outline the Obama proposal Suggest some likely consequences. Confusing at the moment.

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The Obama Health Care Reform Proposal

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  1. The Obama Health Care ReformProposal Bill Evans Department of Economics and Econometrics

  2. Three topics in this topic • What issues must comprehensive health care reform confront? • Outline the Obama proposal • Suggest some likely consequences

  3. Confusing at the moment • Campaign proposal but no legislation yet • Some parts adopted in stimulus plan • HealthCare Dialogue Coalition (18 groups) will release their recommendations Monday • But, everything is up in the air as a result of the economy

  4. Kaiser FF Tracking Survey

  5. What issues must health care reform address? • Access • Cost (both the level and rate of change) • Medicare • Tax equity

  6. Access • Uninsurance is a persistent issue • Dimensions of the problem (2007) • 45.7 million people • 9 million children • Fraction uninsured increasing • 12.6% in 1987 • 15.3% in 2007

  7. What issues must health care reform address? • Access • Cost (both the level and rate of inflation) • Medicare • Tax equity

  8. Data for 2007 $2.2 trillion on HC $7,400 per capita 16.2% of GDP Projected, 2018 $4.4 billion $13,100 per capita 20.3% of GDP Expenditures on Medical Care

  9. 90% more than Canada 145% more than the UK

  10. Individual plan $4,704 total Family plan $12,690 Average Annual PremiumsCovered Workers, 2008 (KFF)

  11. Are high expenditures a bad thing? • A key driver of health care costs is technology • MRIs/CT scans, angioplasty, anti-psychotropic drugs, hip/knee replacements, neo-natal intensive care, treatments for AIDS, statin drugs (Lipitor) • All not available 20-30 years ago. Now, commonplace

  12. If you want to cut costs, where do you look? • Administrative/overhead • 3% in Canada (single payer) • 1.5% in Medicare • 30% in US system in total • Chronic conditions • Unnecessary care

  13. Per Capita Medicare Spending by Hospital Referral Region, 2006 $9,000 to 16,352 (57) 7,500 to < 8,000 (53) 5,310 to < 7,000 (75) 8,000 to < 9,000 (79) 7,000 to < 7,500 (42) Not Populated

  14. What issues must health care reform address? • Access • Cost (both the level and rate of inflation) • Medicare • Tax equity

  15. 2007 44.1 million recipients $432 bill. exp. 3.2% of GDP 16% of fed. budget 2040 86 million recipients 7.6% of GDP 30% of fed. budget Medicare

  16. Future problems • Funding • Medicare trust fund • General revenues (75%) • Medicare Trustees predict • Costs > revenues by 2011 • Trust fund exhausted by 2019 • Declining ratio of workers/enrollees means taxes must be raised

  17. What issues must health care reform address? • Access • Cost (both the level and rate of inflation) • Medicare • Tax equity

  18. Tax System Equity • EPHI health insurance is a tax-free fringe benefit • Greatly reduces the cost to consumers of purchasing insurance • Has encouraged the growth of EPHI • Most people w/ private insurance get is through their employers • 170 million have EPHI

  19. Inequalities • Tax break only available to people who receive insurance from their firm • Higher income families have higher tax rates so the tax benefit to them is greater • Costs Fed. Govt. over $243 billion/year • Regressive tax

  20. Tax Benefit of EPHI • A family w/ $70,000 in income • 36.4% marginal tax rate • 25% federal • 3.4% state (Indiana) • ~8% Social Security and Medicare • Want to purchase $12,000 policy in AFTER TAX DOLLARS

  21. Without tax advantage: • Receive $18,897 in income • Pay 36.4% or $6,897 in taxes • $12,000 left over for health insurance • Net benefit of tax deduction is $6,897

  22. Obama/Biden Plan for a Healthy America

  23. Overview • Plan builds out from existing EPHI • Tries to fill in the gaps in coverage • Heavy emphasis on trying to reduce costs to make health care more affordable • Plan has not been formally proposed so some details sketchy

  24. Access • Expansion of SCHIP/Medicaid • Must provide HI for children • No enforcement specified • Tax credits for small businesses that provide EPHI • “Pay or play” for businesses • Must spend minimum fraction of labor costs on HC or pay that amount as a tax (5 or 6%)

  25. Access (continued) • National Health Insurance Exchange • Similar to MA connector • Policies similar to those offered to congress and federal employees • Available to individuals, small businesses, self-employed • National Plan • Offered by the Federal government • Designed to provide competition to pvt. ins.

  26. Controlling Cost • $50 billion in IT for health care sector • Expand use of preventive services and disease management • Increase competition in insurance industry • Allow Medicare to bargain Part D prices • Catastrophic reinsurance through the Federal government

  27. Medicare • Reduce expenditures for Medicare Advantage • Prevention/Disease Management • Greater bargaining over health care costs

  28. Tax equity • Subsidies for small business who offer EPHI • Some talk on Capital Hill of eliminating tax-preferred status of EPHI • Obama railed against McCain for proposing • White House has signaled they will support but cannot propose

  29. "And this is your plan, John," he said at one debate. "For the first time in history, you will be taxing people's health-care benefits." Mr. Obama added that the McCain proposal was "radical," "the biggest middle-class tax increase in history," "out of line with our basic values" and that "the choice you'll have is having your employer no longer provide you health care."

  30. What has been adopted? • $19B to encourage health IT investment • Additional $10B over next 2 years for NIH • $1.1B for effectiveness research (AHRQ) • $85B for states to help finance Medicaid

  31. $25B -- 65% of COBRA for unemployed • 9 months • Laid-off between 9/1/2008 and 12/31/2009 • Had insurance • Worked for company >20 employees • Income < $145,000/adult

  32. Incentives/Fines for EMR Investment

  33. Proposed: 2010 Budget Downpayment on Reform • $630 billion over time years • Cost savings • Reduce payments for Medicare Advantage • Increase rebate from pharma. to Medicaid • Higher taxes • Reduce tax rate on itemized deductions for families w/ taxable income >$250,000

  34. Is it enough? • Cost estimates • Vary from $1.2 - $1.7 trillion over 10 years • Big unknowns • Take up rates on new programs • Subsidy for government insurance • Health care costs

  35. Estimated impacts – Access(Lewin Group, 2008) • Cut number uninsured by 26.6 million • Primarily from expansion of Medicaid/SCHIP • Shift 28.7 million onto federal insurance • Companies drop coverage • Those on federal rolls will increase by 48.3 million – roughly 50% increase

  36. Does Preventive Medicine save $? • Intuitively appealing – detect disease before it becomes expensive • Problem: with low incidence rates, screening is costly and low # of cases detected • Cohen et al., NEJM, February 14, 2008 • Reviewed 599 published articles on cost-effectiveness of preventive care

  37. Our findings suggest that the broad generalizations made by many presidential candidates can be misleading. These statements convey the message that substantial resources can be saved through prevention. Although some preventive measures do save money, the vast majority reviewed in the health economics literature do not.

  38. Disease Management? • Again – intuitively appealing • Reduce discretion in use, standardize care, eliminate unnecessary treatment • Lots of experience with DM in managed care • Has DM reduced costs?

  39. American Journal of Medical Care (2007) reviewed 317 studies about DM “there was no conclusive evidence that disease management leads to a net reduction of direct medical costs.”

  40. Health IT/EMR? • Great promise • Reduce paper work/time/medical errors/unnecessary diagnostic tests • Savings alluded to in plan based on RAND estimates • RAND estimates that IT has the potential to reduce costs by $80 billion/year • Only considered studies that showed cost savings • Best case scenario – if it does what is promised

  41. CBO (2008) • In general, investment in EMR is “generally not sufficient to produce significant cost savings” • Significant cost savings have “tended to be connected to relatively integrated health care systems” which the US health care system is not

  42. Summary • Will reduce uninsurance but • Will do so by shifting a lot more onto public programs • Cost savings are greatly exaggerated • Investing heavily in proposals that to date have not demonstrated much savings • Tax equity has been suggested – nothing concrete • So far, the administration is punting on Medicare

  43. My opinion • Must control costs first • Benefits never decline, they only increase • Enacting universal coverage or a massive expansion will generate cost that will never be controlled or cut • To control cost – must deal with Medicare first

  44. MA Reform: Romney (2006) • Most ambitious state reform to date • Many features but….. • Most striking component: Individual mandate • Required by law to carry insurance

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