Introduction to U.S. Health Care Daniel Prinz September 2, 2015 Hartman et al., National Health Spending In 2013 Micah Hartman, Anne B. Martin, David Lassman, Aaron Catlin, and the National Health Expenditure Accounts Team, National Health Spending In 2013: Growth Slows, Remains In Step With The Overall Economy, Health Aairs 34(1):150-60, January 2015. Overall trends US healthcare spending increased by 3.6% in 2013 US healthcare spending was 17.4% of GDP in 2013, and has been steady as a share of GDP since 2009 the growth is spending decelerated by 0.5% from 2012 to 2013 main reason: slower private health insurance and Medicare spending growth slower spending growth is also attributable to slower growth in hospital care spending, investments in medical and structure and equipment, and spending for physician and clinical care private health insurance spending growth decelerated: slower growth in hospital services, physician, and clinical services Medicare spending growth decelerated: slower growth in enrollment ACA: lower FFS payment updates ACA: adjustments in Medicare Advantage benchmark payment rates federal budget sequestration typically GDP growth and healthcare spending growth converge a few years after the end of a recession, stabilizing healthcare's share of GDP national health spending growth can generally be disaggregated into: 1
economywide price ination changes in population shifts in age and sex mix of population residual: use and intensity of services currently: relatively high growth in residual but slow growth in prices due to payment adjustments, MLR requirements, and private insurance rate reviews under ACA and budget sequestration Impact of ACA and budget sequestration negative spending impact of ACA: productivity adjustment of FFS payments reduced Medicare Advantage base rates increased Medicaid prescription drug rebates MLR requirement for private insurers positive spending impact of ACA: early Medicaid expansion initiatives temporary increase in Medicaid PCP payments reducing the size of the doughnut hole in Medicare Part D implementation of drug industry fees budget sequestration: 2% reduction in spending on Medicare benets reduced funding for federal research, federal public health activities, and some other federal programs By source of insurance Medicare: slower enrollment growth ACA changes sequestration Private health insurance: low overall enrollment growth continuing shift to enrollment in consumer-directed high-deductible plans other benet design changes low underlying benet cost trends ACA: MLR requirement and rate review 2
By spending type OOP spending: faster growth improved economy higher cost sharing for group health insurance increased enrollment in consumer-directed plans (higher deductibles, higher copayment) hospital spending: private health insurance: increased cost-sharing requirements, shift towards higher-deductible plans Medicare: ACA productivity adjustment reductions in inpatient readmissions, overall lower use, sequestration physician and clinical services: Medicare: decline in physician fee schedule Medicaid: temporary increases in PCP payments retail prescription drugs: Looking ahead 2012 had the patent cli: drugs accounting for $35 billion in sales went o-patent expensive new specialty drugs increased utilization of newly available cheap generics growth in Part D enrollment increased subsidies for expanding number of Part D enrollees reaching the catastrophic phase of the benet key question looking ahead: will health spending growth accelerate as economic conditions improve signicantly? changes coming up: ACA Marketplaces ACA Medicaid expansion shift to private coverage with high deductibles 3
Sommers, Long, and Baicker, Changes in Mortality After Massachusetts Health Reform Benjamin D. Sommers, Sharon K. Long, and Katherine Baicker, Changes in Mortality After Massachusetts Health Care Reform: A Quasi-experimental Study, Annals of Internal Medicine 160(9):585-93, May 2014. Summary 2006 Massachusetts health reform provided near-universal insurance coverage and increased access to care (similar to ACA) study evaluates whether reform lead to changes in mortality (all-cause and from conditions amenable to medical care) Methods dierence-in-dierences pre-reform: 2001-2005, post-reform: 2007-2010 propensity score matching of county-age-race-sex cells to counties from other, non-reform states Results healthcare-amenable mortality decreased in Massachusetts relative to the comparison counties, consequently overall mortality decreased too other causes of death showed minimal changes coverage and access improved number needed to treat was 830 adults gaining insurance to prevent 1 death per year 4
Kaiser Family Foundation, Summary of the Affordable Care Act Individual mandate require US citizens and legal residents to have coverage those who don't have coverage pay a penalty Requirement to oer coverage with some exceptions, companies will have to enroll their employees in employer-oered health insurance (employees may opt out) Medicaid expansion under-65 people with incomes up to 133% of FPL are eligible federal nancing some states are opting out of expansion CHIP increased match rate Premium and cost-sharing subsidies premium credits to purchase insurance in exchanges and cost-sharing subsidies for people with incomes in the 100-400% FPL range Taxes to nance provisions increase in Medicare Part A tax from 1.45% to 2.35% on earnings over $200,000 ($250,000 for joint lers) 3.8% tax on unearned income for higher-income taxpayers excise tax on employer-sponsored insurance above $10,200 ($27,500 for family coverage) limit FSA contributions at $2,500 annual fee on pharmaceutical manufacturing sector ($3 billion in 2015) annual fee on health insurance sector ($11.3 billion in 2015) 2.3% excise tax on the sale of taxable medical devices 5
Private insurance changes create state-based health insurance exchanges consumer operated and oriented plans (CO-OP) benet tiers: bronze, silver, gold, platinum, catastrophic establish essential benet package temporary high-risk pool for individuals with pre-existing conditions who have been uninsured 85% minimum MLR for large group market 80% minimum MLR for individual and small group markets dependent coverage up to age 26 prohibit lifetime spending limits prohibit rescinding coverage 6
2003: Kaiser Family Foundation, A Primer on Medicare What is Medicare? Medicare was established in 1965 (Social Security Act, Title XVIII) for people over 65 expansions: 1972: people under 65 with permanent disabilities receiving SSDI and people with ESRD 2001: people under 65 with ALS Medicare Modernization Act created Part D launched in 2006 social insurance program that provides health insurance to over-65 people and some under-65 people with permanent disabilities enrollment: 55 million (46.3 million 65+ and 9 million <65 with permanent disabilities) helps pay for a variety of services, including hospitalizations, physician visits, prescription drugs, post-acute care, SNF, home health care, hospice, preventive services working people contribute Medicare payroll taxes eligibility at 65, regardless of income or health status 14% of federal budget, just over 20% of personal healthcare expenditures spending growth slowed over last years, expected to grow below private insurance per person Part A: Hospital Insurance (HI) Program inpatient hospital, SNF, some home health services, hospice funded through 2.9% tax (1.45% employee + 1.45% employer) + 0.9% for higher-income taxpayers enrollment: 55 million Part B: Supplemental Medical Insurance (SMI) Program physician, outpatient, some home health, and preventive services funded through general revenues + beneciary premiums enrollment: 51 million 7
Part C: Medicare Advantage (MA) Program allows beneciaries to enroll in private plans (e.g., HMO, PPO) covers Part A and B services, and in most cases Part D services enrollment: 15.7 million Part D: Outpatient Prescription Drug Benet created by the Medicare Modernization Act (MMA) in 2003; launched in 2006 voluntary benet through private plans two types: standalone PDPs and MA-PD plans monthly premium + cost sharing enrollment: 42 million Other issues low-income subsidy to help low-income beneciaries employer-sponsored retiree coverage or Medigap policies can help with cost-sharing expenses Medicare Part D doughnut hole (to be closed) Medicare Advantage: increasing number of enrollees regulated benet designs bidding process risk-adjusted payments from Medicare to insurers dual-eligible beneciaries: 10 million people eligible for both Medicaid and Medicare, some of the most vulnerable populations for most providers, traditional Medicare pays FFS; exact payment rules vary by type of service some reforms/experiments: ACOs, bundled payments, medical homes, hospital readmission reduction initiatives Medicare spending is skewed: concentrated on a small number of beneciaries 8
Kaiser Family Foundation, Medicaid Moving Forward Role of Medicaid health insurance coverage for 33 million children and 19 million adults in low-income families + 16 million elderly and persons with disabilities assistance to Medicare beneciaries: 10 million elderly and disabled (21% of Medicare beneciaries) long term care assistance: 1.5 million institutional + 2.9 million communitybased residents support for healthcare system + safety net: 16% of national health spending and half of long term care spending support for state capacity for health coverage ACA Changes before ACA federal funding and requirement for coverage of children, pregnant women, parents of dependent children, individuals with disabilities, people 65+ states can cover more if they choose prior to ACA, low-income, childless adults largely excluded from Medicaid ACA change: establish eligibility for nonelderly adults at 138% FPL some states are not adopting this expansion 9
Kaiser Family Foundation and Health Research & Educational Trust, Employer Health Benets 2014 employer-sponsored insurance covers about 149 million nonelderly Americans this is the 16th annual survey of private of nonfederal public employers with three or more workers Key ndings of the 2014 survey modest increase in the average premiums for family coverage (estimate: 3%) no statistically signicant increase in single coverage premiums (estimate: 2%) covered workers generally faced similar premiums and cost-sharing in 2014 as they did in 2013 the percentage of rms oering health benets and the percentage of workers covered are statistically unchanged (estimates: 55% and 62%) some employers are implementing incentives to inuence workers not to enroll themselves and/or their spouses in employer-sponsored plans Premiums and contributions average premium: $6,025 for single coverage and $16,834 for family coverage modest increase in the average premiums for family coverage (estimate: 3%) no statistically signicant increase in single coverage premiums (estimate: 2%) 2004-2014: 69% increase in premium for family coverage (2004-2009: 34%, 2009-2014: 26%) Plan enrollment PPO plans are most common (58%) 20% in high-deductible plans with a saving options (HDHP/SO) 13% in HMOs 10
8% in POS plans less than 1% in indemnity plans Cost sharing most covered workers face additional out-of-pocket costs 80% have a general annual deductible (mean for those with a deductible: $1,217) the deductible was almost unchanged between 2013 and 2014 but has been increasing since 2009 other types of cost sharing: copayments: ~75% pay copayments for oce visits, ~15% pay copayments for hospitalization coinsurance: ~20% pay coinsurance for oce visits, ~60% pay coinsurance for hospitalization workers at larger rms have smaller deductibles cost sharing for drugs varies by type of drug and coverage tier 11