Health Care Reform: How It Happened & Where It Leads

Transcription

1 Health Care Reform: How It Happened & Where It Leads Jacob S. Hacker Stanley Resor Professor of Political Science Director, Inst. for Social and Policy Studies

2 What it does: Prohibits insurers from denying coverage for pre-existing medical conditions; limits underwriting Covers a projected 32 million more Americans by 1. Expanding Medicaid; almost entirely federally financed 2. Creating a state exchanges for individuals and small businesses to buy insurance with subsidies for middleand lower-income Americans. Most Americans required to have insurance 3. Regulating employment-based insurance; employers with 50 or more employees penalized if do not cover workers Establishes Independent Payment Advisory Board (IPAB) to contain Medicare and private spending Reduces drug expenses for Medicare beneficiaries

3 Agenda Looking at American health care from 10,000 feet How did we get here? Why now? What now? From political history to policy Where next?

4 Looking at American health care from 10,000 feet

5 $8,000 $7,000 $6,000 $5,000 $4,000 $7,285 United States Non-US Average Non-US Average Medical Inflation in Excess of Economic Growth ( ) Share of Citizenry Covered by Public Programs (2007) 0.73% 97.30% $3,000 $3,182 $3,317 $2,347 United States 2% 27.30% $2,000 $1,000 $0 Health Spending Per Capita (US$) Public Health Spending Per Capita (US$) Non-U.S. nations are all OECD nations except Czech Republic, Hungary, Italy, Korea, Mexico, New Zealand, Poland, Slovak Republic, Slovenia, and Turkey. Government expenditures per capita are not available for Belgium and the Netherlands. Data for Portugal are from 2006 rather than Source: Chapin White, Health Affairs, Jan/Feb 2007; OECD health expenditure dataset.

6 Ellen Nolte and C. Martin McKee, Measuring The Health Of Nations: Updating An Earlier Analysis, Health Affairs, 27, no. 1 (2008): Copyright 2003 by Project HOPE, all rights reserved.

7 How did we get here??!! Politics, politics, politics 1. American political institutions make largescale social reform extremely difficult 2. Failure to enact universal health insurance in the past has had enduring legacies ( path dependence ) Well-financed private interests Hugely expensive medical complex Most Americans have (sometimes inadequate/insecure) coverage

8 Why Now?

9 Percent covered by private employer insurance 72% 68% 64% 60% 56% 52% The Great Risk Shift in Health Care 69.0% Over 15 percentage point decline 54.9% Private employerprovided health insurance Source: Economic Policy Institute, State of Working America, 2006/2007

10 Workplace Health Coverage for Recent College Graduates 85% 80% Percent covered 75% 70% 65% 60% 55% Source: Economic Policy Institute.

11 97% 100% 90% Cumulative Growth, % 60% 40% 29% 21% 20% 0% Family Premiums Single Premiums Wages Overall Inflation

12 Underinsured in America: Three in Ten Nonelderly Adults Nearly six in ten postponed needed medical care because of the cost. Nearly four in ten had to put off home or car maintenance or repairs due to medical expenses. A third had to dig deep into their savings to pay for medical care. More than one in five made job-related decisions based mainly on their health care needs. Median family income: $58,000. Just as likely to be white as the well insured, nearly as well-educated, and just as likely to work full-time and in large or medium-sized companies. Source: Consumer Reports National Research Center Survey, May 2007, which sampled 2,905 Americans between ages 18 and 64.

13 Do you think it is the responsibility of the federal government to make sure all Americans have health care coverage? 29% Yes No 71% Source: Gallup Poll, Jan/Dec Non-responses (3%) omitted.

14 Do you think the federal government should guarantee health insurance for all Americans? 30% Yes No 70% Source: CBS/NYT, February Non-responses (9%) omitted.

15 70% 60% Worried About Health Costs? Obama McCain Percent Voting for 50% 40% 30% 20% 10% % Not Worried (11% of voters) Not Very Worried (22%) Somewhat Worried (33%) Very Worried (33%) * *Do not add to 100 due to non-responses

16 Projected Budget Deficit (-) or Surplus (+): Including and Excluding Health Programs Percent of GDP Projected Deficit Including All Expenditures and Revenues Projected Deficit Excluding Medicare and Medicaid Source: Henry Aaron, The Brookings Institution

17 From Political History to Public Policy

18 Health Care for America ( Shared Risk, through a New National Insurance Pool modeled after Medicare, the Health Care for America Plan, open to any U.S. resident without good workplace or individual coverage; Shared Responsibility, through a requirement that employers (and the self-employed) either purchase comparable coverage for all their workers or make a relatively modest contribution (6% of payroll) Individual Responsibility, through a requirement that uninsured Americans take responsibility by purchasing private coverage or buying into the Health Care for America Plan.

19 15% 4% 1% Coverage of U.S. Nonelderly, 19% 61% Current Law, 2007 Employer Medicaid/SCHIP Other Uninsured Non-Group Source: The Lewin Group using the Health Benefits Simulation Model.

20 1.4% 0.5% Coverage of U.S. Nonelderly, Health Care for 50.7% 47.4% America, 2007 Employer Other Health Care for America Uninsured Source: The Lewin Group using the Health Benefits Simulation Model.

21 The Public Option and Support for an Individual Mandate Requiring everyone to buy and be covered by a private health insurance plan National Oppose 64% to 34% House Swing Oppose 60% to 34% Maine Oppose 55% to 35% Requiring everyone to buy and be covered by a health insurance plan with a choice between a public option and private insurance plans Favor 60% to 37% Favor 50% to 46% Favor 55% to 40% Source: Polls of likely voters conducted by Anzalone Liszt Research and Lake Research Partners for Health Care for America Now in mid- September.

22 Where Next?

23 $1,400,000 $1,200,000 $1,000,000 Average Income (After taxes, including public and private benefits; 2007 dollars) 281% 250% 200% $800, % $600, Percent Change 100% $400,000 59% $200,000 16% 23% 25% 35% 50% $0 Poorest fifth Second fifth Middle fifth Fourth fifth 80th to 99th percentiles Top 1 Percent 0%

24 Cloture Filings to End Senate Filibusters, In all cases where justice or the general good might require new laws to be passed, or active measures to be pursued, the fundamental principle of free government would be reversed. It would be no longer the majority that would rule: the power would be transferred to the minority. James Madison, Federalist #58

25 $4.0 $3.5 $3.0 $2.5 $2.0 $1.5 $1.0 $0.5 $0.0 Lobbying Expenditures (Billions adjusted for inflation) $.4B $1.8B $3.5B _of_corporate_political_activity.pdf

26 250% Unequal Polarization, % 205% House Democrats 150% 100% 89% Senate Democrats Senate Republicans 50% 17% 39% House Republicans % % Increase in Liberalism/Conservatism of Average Party Member Source: Poole-Rosenthal, D-W Nominate Scores,

27 Repeal slide

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31 More Than Six in Ten Disapprove of Cutting Off Funding As Way To Stop Health Reform Whether or not you like the health reform law, would you say you approve or disapprove of cutting off funding as a way to stop some or all of health reform from being put into place? 33% 62% Disapprove of cutting off funding Approve of cutting off funding 6% Don t know/refused Source: Kaiser Family Foundation/Harvard School of Public Health The Public s Health Care Agenda for the 112th Congress (conducted January 4-14, 2011)

32 Chapin White, Health Care Spending Growth: How Different Is The United States From The Rest Of The OECD?, Health Affairs, Vol 26, Issue 1,

33 Source: Jacob S. Hacker, The Case for Public Plan Choice in National Health Reform, December 2009.

34 There is still today a frontier that remains unconquered an America unclaimed. This is the great, the nationwide frontier of insecurity, of human want and fear. This is the frontier the America we have set ourselves to reclaim.