Healthcare Reform: The Problems, The Solution and The Lesson of Massachusetts

1. Healthcare Reform:The Problems,The Solutionand The Lesson of Massachusetts Lynn United for Change May 31, 2009 James Recht, M.D.

3. Current State of Care Access Quality Cost

4. Problems with Access to Care % of respondents reporting not getting recommended care, filling prescriptions or seeing a doctor when sick Schoen et al. Chronic Condition: Experiences of Patients with Complex Healthcare Needs in Eight Countries, 2008”, Health Affairs Web Exclusive, 2008

5. The Difference is Insurance % with unmethealth need Joint Canada/U.S. Survey of Health, 2002-3. CDC and Statistics Canada

7. How Many PeopleIs That?

8. 72.8 million people under age 65 temporarily uninsured in 2006 & 2007 % uninsured months Census Bureau Data - Families USA, Sept, 2007

9. Who are the Uninsured? Current Population Statistics, 1999

10. Premiums outstrip earnings! Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2008.

16. Government Assured Insurance OECD, 2004 (2001 Data)

17. Current State of Care Access Quality Cost Medicine’s Dilemmas (1994)

18. Let’s compare…. • United States • Japan • Germany • China • United Kingdom • France • Italy • Canada • Spain • South Korea

19. MRI Units per Million Pop OECD, 2006

21. Practicing Physicians per 1000 Pop OECD, 2006

23. Continuity of Care Commonwealth Fund Survey, 1998

24. Life Expectancy Total Population at Birth OECD, 2006

25. Infant Mortality per 1000 Births OECD, 2006

26. Maternal Mortality per 100,000 Births OECD, 2006

27. % of Pop Daily Tobacco Smokers OECD, 2006

28. % of Pop 65 Years or Older OECD, 2006

29. Current State of Care Access Quality Cost Medicine’s Dilemmas (1994)

30. Total Expenditure on Health per Capita OECD, 2006

31. Out-of Pocket Expenses per Capita $880 $440 OECD, 2006

33. Difference in Health Spending per Capita, US vs. Canada, 2007 Nearly 40% Woolhandler/Himmelstein/Campbell, NEJM 2003;349:768 (Updated) NCHS &CIHI

34. ~$4500 ~$2000

39. Current State of Care Access Quality Cost Medicine’s Dilemmas (1994)

40. Barack Obama • A health insurance system that maintains the current structure of private insurance markets • A supporting role played by a public insurance option (??) • Expanding Access > Controlling Costs

41. Barack Obama • Build on current mix of private and public group insurance • All employers (except small businesses) must provide employee insurance or help pay for it • Medicaid and SCHIP expansion • Individual mandate • National Health Insurance Exchange to help those without insurance through another mechanism buy a private plan or a new public plan • All insurers required to offer plans to all applicants; no exclusion for prior conditions. • Subsidies for small businesses and low income individuals

42. Massachusetts Health ReformNew Coverage 2006: New state agency (Commonwealth Connector) established to broker private insurance plans and assure their adequacy and affordability

44. MA Reform Has Not Achieved Universal Coverage • State claims that as of 6/08, 440,000 residents have gained insurance (67-80% of the state’s uninsured are now insured) • Urban Institute found 2.6% of MA residents uninsured as of mid-2008 • US Census survey 2008: 5.4% uninsured • DOR: 5% of income tax filers uninsured

46. Massachusetts: Required CoverageIncome > $31,212Age = 56 • Annual Premium: $4,080 • $2000 Deductible • 20% Co-Pay After Deductible

49. Obama’s Proposed Cost Controls • Disease prevention programs Vast majority of these programs do not save $1 • Chronic disease management Medicare Health Support Chronic Disease pilot programs show limited success in reducing costs or acute care utilization2 • Pay for Performance No supporting data • Electronic health technology Not necessarily a cost saver • Cohen et al, NEJM 2008 • Cromwell et al, Health Care Financing Review 2008

50. % of Uninsured in Maine 1987 - 2005 Dirigo 9.9% 12.2% 12.3%