The Crazy World of Health Care. Carolyn McClanahan, M.D., CFP

Transcription

1 The Crazy World of Health Care Carolyn McClanahan, M.D., CFP

2 Today s Adventure History of health care big picture Cost of health care big picture Current status of health policy Mitigating health care costs Mitigating long term care costs What can we do next?

3 History of Health Care The Big Picture

4 History Roosevelt Wanted health insurance in New Deal AMA vigorously against compulsory or government sponsored insurance. Had so much he was trying to do, he decided to follow the tide. On occasions the past attempts have been made to put medicine into politics. Such attempts have always failed and always will fail. Tide started swinging toward health care legislation. Then WWII happened

5 History Truman Attempted health reform in first two years, but couldn t get it together. Big opposition VA health system, then the AMA About half the country had private health insurance. This great nation cannot afford to allow its citizens to suffer needlessly from the lack of proper medical care. Sent a bill to Congress but didn t include a method of financing it. Then the Korean War happened. The bill that would become Medicare was written.

6 History Eisenhower Pushed private insurance but attempted reform through high risk reinsurance. Focused on budgets and deficits 9% of single elderly and 14% of elderly couples had insurance that covered medical expenses Kerr-Mills bill provided a stipend for poor elderly to buy private health insurance. It helped 1% of the elderly. Created the tax exemption for workplace health insurance which is why insurance is tied to employment today.

7 History Kennedy Interested more in international affairs. Presented Medicare but didn t push it at first because of a tight election and no legislative backing. Finally presented it, and was voted down by buying off a senator.

8 History Johnson Most important health care president ever Won election in 1964 with both the House and Senate Had momentum behind him with Kennedy assassination so merged Medicare with two plans originally intended to block it. Medicare A Democratic plan to pay hospitals Medicare B GOP plan to pay physicians Medicaid AMA plan to take care of the poor

9 History Nixon Medicare/Medicaid were under way. Wanted a comprehensive health insurance program Put forth CHIP Comprehensive Health Insurance Plan Required all employers provide coverage Limited employee cost sharing Provided generous essential benefits Government provide coverage for those not employed Would have passed except for what happened?

10 History Ford Nothing Carter Decided to focus on welfare reform instead of health reform Reagan Against socialized medicine then proceeded to oversee the largest expansion of Medicare yet.

11 History Bush Offered tax credits for low income individuals to buy health insurance Financed through taking away tax deduction from employer coverage Failed! Clinton Tackled reform without knowing the ropes failed Bush Medicare Modernization Act - Medicare D Obama ACA

12 Cost of Health Care The Big Picture

13 Health care as % of GDP Cost of Health Care United States OECD Average

14 Health care expenditures per person per year United States $327 $1,036 $2,700 $4,559 $7,929 $9,451 Cost of Health Care OECD Average $180 $605 $1,133 $1,791 $3,212 $3, numbers for the U.S.? >$10,000/person/yr 7.76% annual inflation for U.S. 7.02% annual inflation for all OECD countries 6.92% annual inflation for OECD countries ex U.S.

15 Health care expenditures by government % Cost of Health Care United States OECD Average s to 80 s Nixon, Ford, Carter Medicare bloomed unchecked. 80 s 90 s Reagan cut spending, then toward end expanded Medicare Bush gave us Medicare D

16 Health care expenditures by government % Cost of Health Care United States OECD Average s to 80 s Nixon, Ford, Carter Medicare bloomed unchecked. 80 s 90 s Reagan cut spending, then toward end expanded Medicare Bush gave us Medicare D

17 Cost of Health Care Where does the government spend money on health care?

18 Cost of Health Care With all that spending, are we healthier?

19 Cost of Health Care With all that spending, are we healthier?

20 Cost of Health Care With all that spending, are we healthier?

21 Cost of Health Care With all that spending, are we healthier? We are great at rare disease, accidents, cancer We stink at preventive health and common problems What do the healthy countries do who spend less money? Great primary care systems Choose one health care system instead of four

22 Current Health Policy

23 Party Philosophy Democrats coverage over cost Republicans cost over coverage

24 The Affordable Care Act Main goal provide health insurance coverage for everyone Rebuild a primary care system Add focus of prevention and early care of chronic disease Change payment methods to reign in costs Wanted a public option for health insurance to foster competition with private insurers

25 The Affordable Care Act What went wrong? Death by a thousand pin pricks. Coverage expansion took precedence over cost control Made a complicated health insurance system more complicated Lack of Medicaid expansion hurt everyone in nonexpansion states Funding cuts for the good parts of the law didn t rebuild primary care Cost control measures were to happen later in the cycle.

26 The Affordable Care Act What went wrong? Death by a thousand pin pricks. Coverage expansion took precedence over cost control Made a complicated health insurance system more complicated Lack of Medicaid expansion hurt everyone in nonexpansion states Funding cuts for the good parts of the law didn t rebuild primary care Cost control measures were to happen later in the cycle.

27 The American Health Care Act What does the GOP prefer? The new versus the old GOP remember Nixon s plan? Individual mandates Subsidies to buy private insurance The new GOP free market system that gets the federal government out of health care My question Would our country accept an individual mandate if insurance was inexpensive and provided good care at a reasonable cost?

28 The American Health Care Act REMEMBER this didn t pass! Repeal the individual and employer mandates now Repeal health plan actuarial values 2020 Repeal premium and cost sharing subsidies 2020

29 The American Health Care Act Modify tax credits between now and 2020 Older pay more, younger pay less In 2020, flat tax credits start adjusted for age Phase out income of $75,000 to $115,000 Premiums for older can be 5x younger currently 3x younger Guaranteed issued insurance and pre-existing conditions covered (and what tanked the plan)

30 The American Health Care Act Let states define essential benefits Create a high risk pool $15 billion for pregnancy care and mental health benefits Repeal funding for the Prevention and Public Health Fund Give community health centers $422 million (the amount taken away from Planned Parenthood)

31 The American Health Care Act Block grants for Medicaid Increase amount eligible for Health Savings Accounts Add optional state work requirements for Medicaid eligibility Repeal ACA taxes

32 The American Health Care Act Nothing has passed yet! What happens next? Who in the heck knows GOP made a promise to repeal Obamacare President Trump made a promise to replace it with something beautiful GOP first attempt proved they couldn t please even close to a simple majority

33 The Latest from HHS An attempt to stabilize premiums Can t sign up for insurance if premiums overdue Open enrollment shortened to November 1 through December 15. Special Enrollment Periods rules are tighter

34 Mitigating Health Care Costs

35 Estimating Health Care Costs Longevity Health status Health care mindset What inflation rate to use?

36 Insurance Medicare Large Group Small Group Individual Market

37 Health Savings Accounts Maximize contributions Use now or later? Saving receipts

38 Health Care Mindset Minimizer or maximizer Find a doctor to match your mindset Paternalistic Informational Collaborative Your Medical Mind Groopman and Hartband

39 Patient Empowerment Be prepared for your appointments. Write out how you are doing, current symptoms, current medication regimen, and even your diet if your medical problem is diet related. If you have complicated issues, ask for a longer appointment, Write down the questions you want answered during your visit.

40 Patient Empowerment Make certain the doctor provides answers in laymen s terms, not medical jargon. Before a visit is over, make sure you know what is going to happen next and why.

41 Patient Empowerment If testing is ordered Ask what the doctor wants to learn from the test Ask how the results may change the approach to treatment. If the doctor cannot provide a clear answer, ask if the test is really necessary. If medication is ordered Understand the benefits and risks How long will you be on the medication What are the alternatives to the medication being prescribed.

42 Patient Empowerment Ask what you can do to improve the situation. Doctors won t often provide the education needed to improve diet related illnesses or home therapy to improve musculoskeletal problems. If they are not able to provide this education, ask for a referral to the appropriate nutritionist or physical therapist. If you are too ill to participate in your health care to this extent, involve your health care surrogate to act for you in this capacity.

43 Mitigating Long Term Care Costs

44 Living Arrangements Has the family discussed in advance Home until death Assisted living Continuing care retirement community (CCRC)

45 Living Arrangements Home until death How close are grocery stores/restaurants? How close is basic medical care? What is the availability for interaction with others What preparations have been made to make the home aging friendly? Are they willing to use technology so family/friends can monitor their well-being? What about DEMENTIA?

46 Living Arrangements Assisted Living Who is going to decide when you move? Continuing Care Retirement Community Start early!

47 Long Term Care Costs Assisted Living Who is going to decide when you move? Continuing Care Retirement Community Start early!

48 Long Term Care Costs

49 Long Term Care Costs

50 Long Term Care Costs Blue Toenail Request Healthy - Five years of 24 home care Albany - $54,912 x 3 homecare workers x 5 years = $823,680 Not healthy use two years Agree to assisted living/skilled care Healthy Three years assisted living and two years skilled care Albany- $61,878 x 3 years assisted living + $132,072 x 2 years skilled care = $449,778 Not healthy use two years skilled care

51 Long Term Care Costs Family agreements Who will provide care If a family member provides care, numbers can be adjusted What consideration will be given to care providers

52 What Can We Do Next?

53 What Do People Want? Should everyone have at least basic care? Economically sound policy Only industrialized nation that doesn t do this

54 Who Should Pay? In U.S., we spend $10,000 per person per year for health care Japan - $4,150 Average OECD country ex U.S. - $3,648 Of that $10,000, taxpayers pay about half, so already more than most countries pay total per person per year

55 What Do People Want? Can we decrease complexity and overhead? We spend 25% to 30% in overhead Other counties 5% to 15% Cutting overhead to 15% would save about $400 billion per year

56 What Do People Want? How about a base of care for the entire country Community Health Centers provide basic medical, dental, and mental health care for < $1,000/person/year Total cost for everyone about $300 billion per year. Many ways to pay for it. Can move to universal health care or a free market system on top.

57 Resources Quest for Simplicity my blog at Forbes Heart of Power Blumenthal and Morone This Town Leibovich An American Sickness - Rosenthal