Unpacking the Alternatives. Mitchell Stein. LinkedIn:

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1 Unpacking the Alternatives Mitchell Stein LinkedIn:

2 25+ years of health care experience Started at MetLife working on long-term care insurance, then spent over 15 years at Mercer Consulting in their healthcare practice Lived in Maine for past ten years during which time I ve worked at Health Dialog, Consumers for Affordable Health Care and the Institute for Clinical and Economic Review. Currently an independent consultant Who am I?

3 Many ways to skin a cat We sometimes get stuck in a rut we have a solution so we think it s the only one ACA depends on threelegged stool Individual mandate Guaranteed issue Subsidies/low costs

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5 If not for three legs, the stool collapses They work together to assure affordable coverage. Taken together they guarantee the largest possible risk pool everyone pays in all the time so funding is available when needed But are there other ways to accomplish the same goal?

6 Individual Mandate (Red) It s the leg that assures everyone is part of the system. But are there other ways to keep everyone in the system? One option is the continuous coverage requirement Instead of a penalty for those who are not covered, a penalty is applied if you seek coverage after having been without for a certain period Proposed penalties for not having continuous coverage: Surcharge for a set period of time Waiting period before pre-existing conditions are covered No hardship exemption (there is for the mandate where there is no penalty if cost of coverage too high) Remember, system doesn t work if we allow enrollment from the back of an ambulance

7 Individual Mandate (cont.) There are other options to mandate: Auto Enrollment everyone is enrolled in a basic plan (really hard to do) Pre-funded HSA (carrot instead of stick) Larger subsidies (carrot instead of stick)

8 Guaranteed Issue (Blue) But it s not enough to have everyone want to buy, you have to make sure they can buy, and can buy something meaningful that s the second leg, guaranteed issue, EHB, etc. For our purposes today we re going to skip options to this leg

9 To talk about this piece, I m going to take a minute or two and turn you all into actuaries Affordability (Green) Here s the secret to insurance everyone pays in even when they don t need help, so that there are enough funds available when they do need help. That s it the rest is simply elaboration

10 The reason we need the elaboration, is health reform can get messy Affordability (cont.) In the individual market, even with the mandate, there are not always enough people in the pool to keep premiums low. This brings us to our next topic keeping premiums low through risk adjustment mechanisms

11 Affordability (cont.) There are several risk adjustment options Some were part of the ACA Some are used in Medicare Part D Some have been tried by the states There are pros and cons to each but the basic goal is to bring additional money into the system (risk pool) leading to reduced premiums

12 Source: Stabilizing Individual Health Insurance Markets With Subsidized Reinsurance

13 Out of scope There are alternatives to single payer that achieve the goal of universal coverage. As noted by Atul Gawande in the New Yorker piece published yesterday: Few want the system we have, but many fear losing what we ve got. And we disagree profoundly about where we want to go. Do we want a single, nationwide payer of care (Medicare for all), each state to have its own payer of care (Medicaid for all), a nationwide marketplace where we all choose among a selection of health plans (Healthcare.gov for all), or personal accounts that we can use to pay directly for health care (Health Savings Accounts for all)? Any of these can work. Each has been made to work universally somewhere in the world. They all have their supporters and their opponents. We disagree about which benefits should be covered, how generous the financial protection should be, and how we should pay for it. We disagree, as well, about the trade-offs we will accept: for instance, between increasing simplicity and increasing choice; or between advancing innovation and reducing costs. Is Health Care a Right?

14 Mitchell Stein Contact Info LinkedIn: Blog: Weekly pharmacy newsletter I write for the Institute for Clinical and Economic Review: