Domestic Health Policy

Welcome

Introductions

Faculty: Dr Richard Bruno, Dr Talia Robledo-Gil, Dr Amit Pahwa, Dr Brian Miller

Format: 3 sessions: Oct 6 (3-4pm), Oct 13 (3-4pm), and Oct 20 (3-4:30pm) via Zoom

Goals: Introduce the fundamentals of current US health policy, including the ACA and its public health implications

Objectives:

• Describe how an idea becomes health policy at the state or federal level

• Compare and contrast maintaining or repealing the Affordable Care Act

• Compare and contrast a single-payer versus market-based financing system

Conflict of Interest

Dr Bruno serves as an unpaid board advisor for Physicians for a National Health Program, and unpaid board director for Committee to Protect Medicare, and is employed by a Federally-Qualified Health Center.

Dr Robledo-Gil has no financial conflicts to disclose.

Dr Pahwa has no financial conflicts to disclose.

Dr Miller currently serves as a member of the CMS Medicare Evidence Development and Coverage Advisory Committee and as a member of the UNC-NC State Biomedical Engineering Department Industry Advisory Board. He is a consultant for the Federal Trade Commission and Radyus Research. He has received fees from the Health Resources and Services Administration, the Heritage Foundation, and Oxidien Pharmaceuticals.

Pre-ACA

How did we get here?

Ethical underpinnings of any healthcare system:

Beneficence Non-maleficence Autonomy Justice

Effects of an Unjust Healthcare System

46 million Americans uninsured by 2007

44,789 of them dying unnecessarily that year

(~1 out of 1,000 per Wilper et al, AJPH, 2009)

Some of those voices:

66% of bankruptcies related to medical issues (bills or missed work),

60% had private insurance at the time

Premiums: monthly payment

Deductibles: amt owed before ins kicks in

Co-pays: share paid at time of service

Co-insurance: amt owed after deductible met

The Social Transformation of American Medicine

Harvard sociologist Paul Starr's 1982 seminal work

examines the evolution of the American healthcare landscape as an intricate interplay between doctors, hospitals, and the growing healthcare conglomerates (private health insurance, pharmaceutical/device companies).

Previous Healthcare Reform Attempts

Many have tried, Many have failed

Medicare (1965):

Part A: inpatient, SNF

Part B: providers

Part C: Medicare Advantage (networks of A/B/D coverage)

Part D: drugs

18.9 Million Seniors Enrolled Within 11 Months

Previous Healthcare Reform Attempts

Many have tried, Many have failed

Medicaid (1965):

State/Federal cofinanced for America's poor, passed despite AMA opposition

CHIP (1997):

Expanded coverage for children. Signed into law by President Clinton after failed healthcare reform efforts of 1993

Healthcare Financing vs Delivery

State of American Healthcare

Mix-match, hodge-podge, siloed, and segregated

Insufficient

Labyrinthine

Misprioritized

Healthcare Systems in Other Countries

The single most powerful concept that public health has to offer… Universal coverage is the best way to cement health gains made during the previous decade. It is a powerful social equalizer and the ultimate expression of fairness. --Margaret Chan, Director General of WHO, 2006-2017

Lower Costs

Better Outcomes

Mandate Model for Reform

"RomneyCare" in Massachusetts passed 2006, and led to 98% of residents with insurance (including 99.8% of kids). Romney downplayed his role (and the similarity between RomneyCare and ObamaCare) in his 2012 presidential run

The Heritage Foundation Proposal (1989):

• Universal coverage
• Individual mandate as "personal responsibility"
• Refundable tax credits pegged to income and health status
• Minimum benefit package

Example: Canada's National Health Plan

• Low administrative costs: 16.7% of health spending vs. 31.0% in US
• Lump-sum, global budgets for hospitals (Maryland has this as well)
• Stringent controls on capital spending for new buildings and equipment
• Single buyer purchasing reins in drug/device prices (known as a monopsony)
• Low litigation and malpractice costs (since all future care is already provided)
• Emphasis on primary care (primary care physicians make more, specialists make less)
• Exclusion of private insurers (private plans overcharged US Medicare by $34B in 2012)

Source: Himmelstein & Woolhandler, Arch Intern Med, December, 2012

Functions of the ACA

Insurance Reform

Cover more people:

• Medicaid expansion to people living 138% FPL, federally covered 100% for 3y
• 2020: Federal Poverty Level for one person is $12,760
• 2020: 34 states + DC (and NE, UT later this year) have expanded
• Exchange with subsidies:
• Individual mandate: all eligible people must purchase or face penalty
• Guaranteed issue: plans can't discriminate based on pre-existing condition
• Community rating: risk factors are evaluated for entire market population, (not individuals) to set premium prices, cost difference between elderly:youth plans can only be a maximum of 3:1

Better coverage:

• Preventive services: (USPSTF Grade A/B) are covered without cost-sharing
• Prescription drug coverage: (eliminated "donut hole")
• Insurance company transparency/limits:
• Medical Loss Ratio capped at 15%, otherwise must rebate beneficiaries
• Set controls for Medicare Advantage plans

Delivery Reform

Integrated Care:

• Team based: Patient-Centered Medical Home model to help coordinate care/connect to community resources
• ACOs: Accountable Care Orgs accountable for quality, cost, overall care
• Bundled payments: paid to hospitals/providers "on the basis of expected costs for clinically-defined episodes of care"
• Dual eligibles: streamline care for people who qualify for both Medicare/Medicaid
• Care transition: between hospital/subacute/outpt locations to help reduce admissions

Quality Focus:

• Value based payments: pay for performance to hospitals/providers based on measures
• Fraud/abuse prevention: screening, licensing, background checks, claim limits, penalties

Innovation:

• CMMI: funded at $10B/10y to design, implement, and test new payment models
• Prevention fund: $900M for CDC grants to states/local jurisdictions to prevent disease
• Pricing Reform: transparency in costs of services, drug pricing, etc
• FQHCs: increased funding for safety net clinics (many expanded mental/dental health)

Formation of the ACA

Industry insider Liz Fowler (former VP for Public Policy and External Affairs at Wellpoint insurance company, JHSPH PhD '96) was later Chief Health Counsel to Senate Finance Chair Max Baucus (D-MT) and one of the architects of the ACA.

President Barack Obama signs the ACA on March 23, 2010, with a House vote of 219-212 and a Senate vote of 60-39

Dr Margaret Flowers (JHH Peds residency '93) arrested protesting Senate finance committee hearing chaired by Sen Baucus that did not include discussion about single payer.

JHSPH professor Vincente Navarro, PhD has said that the majority opinion of national health insurance has everything to do with repression and coercion by the capitalist corporate dominant class. He argues that the conflict and struggles that continuously take place around the issue of health care unfold within the parameters of class and that coercion and repression are forces that determine policy.

Effects of ACA

Some gains, Some continued losses

Legal Battles

SCOTUS 2012: individual mandate penalty = tax, and Congress has authority to create new tax, so not unconstitutional

SCOTUS 2015: premium tax credits apply to all states, just like gurantee issue/community rating

Congress 2017: tax overhaul bill removed individual mandate penalty, insurance policies dropped, number of uninsured expected to increase by 13 million

SCOTUS 2020: Next month, SCOTUS is scheduled to hear a trial, supported by the Trump administration, that seeks to overturn the ACA. According to KFF: "The loss of these coverage pathways, particularly the Medicaid expansion, would likely lead to disproportionate coverage losses among people of color, which would widen disparities in coverage, access to care, and health outcomes."

Racial disparities

The ACA addresses many racial disparities in its expansion of access.

Yet many outcomes still worse for Black people.

Changes to the ACA

From 2010 - present

The Trump Administration has achieved the following changes to the ACA:

• Deny birth control
• Obstruct enrollment
• Promote Medicare Advantage plans
• Remove penalty for the individual mandate

Potential Options under the ACA

Under Section 1332 written by Sen Ron Wyden (D-OR), states may request a federal waiver to implement a state innovation plan that, "will provide coverage that is at least as comprehensive in covered benefits; at least as affordable (taking into account premiums and excessive cost sharing); cover at least a comparable number of state residents; and not increase the federal deficit."

Keep these considerations in mind when arguing for your team's debate stance.

Areas for Impovement

What policies are being proposed?

You can always count on Americans to do the right thing - after they've tried everything else.

--Sir Winston Churchill

Republican Repeal & Replace Plans

COVID-19 Stimulus Bills

HEALS Act

Trump vs Biden on Healhcare

From Kaiser Family Foundation, synthesized from candidates' campaign webpages

Trump vs Biden on Healhcare

From Kaiser Family Foundation, synthesized from candidates' campaign webpages

Biden's proposal

Includes lower premiums and more subsidies to help people purchase plans

Task force with Bernie Sanders's team to propose most progressive public option that has ever been proposed: 20+ million added to Medicaid and Medicare-like affordable option

From KFF.org

Results of COVID-19 Pandemic

Worsening unemployment has resulted in more uninsured (13% to 31%)

Session 2

Patient Story and Policymaker

Next Tuesday, October 13 from 3-4pm

State Senator

Mary Washington, PhD

Mr MJ

Please dress professionally.

Session 3

Following Tuesday, October 20 from 3-4:30pm

Debate 1:

TEAM A: Protect ACA

(mentored by Dr Robledo-Gil)

vs

TEAM B: Repeal/Replace ACA (mentored by Dr Pahwa)

Debate 2:

TEAM C: Single-Payer

(mentored by Dr Bruno)

vs

TEAM D: Market-Based

(mentored by Dr Miller)

• Structure:
• 5 minutes introduction for each team
• 5 minutes rebuttal for each team
• 2 minutes open back and forth
• 2 minutes conclusion for each team.
• We recommend each team select 2-3 main points in formulating their overall argument.
• Your team mentor will be in touch with guidance, resources, and feedback
• Each team will email to the class a one-pager on their argument the day before (10/19)

Post-Debate

Teams A & B will vote on Debate 2 winner

Teams C & D will vote on Debate 1 winner