Health%20Insurance

1
Health Insurance

• Shannon Harr
• Camille Pane, MD
• Chris Maher
• Lauren OConnor
• Tom Miller

2
Overview

• Insurance
• History of National Health Insurance
• HR 676
• Healthy Americans Act
• Florida Quality Care Act

3
Insurance

• Insurance
• A contract (policy) in which an individual or
  entity receives financial protection, or
  reimbursement, against losses from an insurance
  company, which pools clients risks to make
  payments more affordable, in exchange for a
  premium.

4
Cost-Sharing

• Pool money together
• Share the risk

5
Delivery Financing Self-Pay
Patients
Payment
Providers
Services
6
Delivery Financing 3rd Party
3rd Party Payers
Payments For Covered Services
Premiums Taxes
Claims
Ins. Coverage
Patients
Providers
Services
Payment (Deductibles,
coinsurance, copays)
7
What does all this Really Mean?

• Premium Amount YOU pay every month
• Ex You pay 250 every month for your insurance
  plan
• Deductible Amount YOU pay after receiving a
  service, up to a specified yearly maximum
• Ex Procedure costs 1000, you pay 500
• Coinsurance YOU pay after receiving a service
• Ex Procedure costs 1000, you pay 30 or 300
• Copayment Amount YOU pay every time you are seen
  by a provider

8
Insurance Who is Paying?
9
Government Health Insurance

• Government Health Insurance
• Medicare
• Medicaid
• Military health care
• TRICARE/CHAMPUS
• CHAMPVA
• The Department of Veterans Affairs (VA)
• SCHIP
• State-specific plan
• Indian Health Service

10
Private Health Insurance

• Private Health Insurance
• Employment-based plans
• Direct-purchase plan
• Managed Care
• HMO
• PPO
• POS

11
47 M Uninsured
12
History National Health Insurance

• (1974) President Nixon introduced a National
  Health Insurance Program
• Employers would be required to provide private
  insurance for their employees, a separate
  government system would provide the same benefits
  for the rest of the population.
• Watergate scandal diverted focus
• Ford withdrew the administration's plan saying it
  would make inflation worse.

13
History National Health Insurance Continued

• (1993) Clinton Plan
• Envisioned creating large regional purchasing
  alliances that would enroll public and private
  employees, the self-employed, the unemployed, and
  Medicare and Medicaid patients.
• 1,364 page bill was very complicated and it was
  bad timing with regards to the markets

14
Universal Coverage

• Personal mandates and subsidies
• Every American have health insurance that meets
  some minimum standard, the gvnt. provides
  subsidies or tax credits to the poor to enable
  them to purchase insurance
• Single-payer
• Imagine Medicare extended to cover all age groups
  but includes coverage for dental services,
  long-term care, prescription drugs, and more
  comprehensive mental health care.
• Universal Vouchers
• Combines publicly funded social insurance for
  basic care with competition. Individuals and
  families would have free choice of plans and
  freedom to purchase additional services with
  their own after-tax dollars.

15
HR 676

• 110th Congress
• A bill to provide for comprehensive health
  insurance coverage for all United States
  residents, and for other purposes.

16
Sponsors

• Introduced by John Conyers, D-MI
• Other sponsors
• Kucinich
• Rangel

17
Eligibility

• All residents of the U.S. and its territories
• No mention is made of legal/illegal immigrant
  status
• Individuals will be presumed eligible if they
  present for services, but will then need to
  complete an application

18
Benefits

• Primary care prevention
• Inpatient outpatient care
• Emergency care
• Prescription drugs
• DME
• Long term care
• Mental health substance abuse services
• Dental care (non-cosmetic)
• Chiropractic care
• Vision care correction
• Hearing services including hearing aids

19
Benefits/Portability

• Benefits available anywhere in the U.S. through
  licensed clinicians
• No deductibles, copayments, coinsurance
• Private insurers may not sell coverage that
  duplicates the basic benefit package
• Insurers may, however, sell plans that provide
  benefits not offered through the basic benefit
  package

20
Budget

• Operating budget
• Clinician payments (FFS)
• Global budgets for institutional providers
• Capitation payments
• Administrative costs
• Capital expenditures
• Construction/renovation of health facilities
• Major equipment purchases
• Health professional education budget

21
Funding

• Existing sources of revenue for health care
• Increasing personal tax on top 5 income earners
• Modest progressive excise tax on
  payroll/self-employment income
• Small tax on stock/bond transactions

22
Funding continued

• System savings will provide huge amounts of
• Significantly reduced overhead
• Monopsony purchasing power for medications

23
The Healthy Americans Act of 2007

• guarantees  universal,  private  health  
• insurance  for  ALL Americans.

24
Sponsor

• Senator Ron Wyden (D, OR)
• Senator since 1996
• Served 15 years in U.S. House of Representatives

25
What is HAA?

• A new system in which every American will have
  the power to choose a comprehensive, private
  health insurance plan in the state of their
  residency.
• The insurance will be high-quality yet affordable
  for every American.
• Even if they change, lose, or become too sick to
  work at their job, Americans will always have
  care.

26
How does HAA work?

• The Healthy Americans Act matches insurers with
  health care consumers in a competitive
  environment.
• This competition should drive down prices
• Each state will establish a Health Help Agency
  (HHA)
• These HHAs will lower admin costs
• Also provide unbiased information about competing
  private health insurance plans
• Determine premium reductions
• With these resources, individuals will be able to
  choose which works best for them and their
  families.

27
Governments Responsibility

• Ensure every American has and can afford health
  insurance
• Through the Health Help Agencies
• Lower premiums and tax deductions
• Individuals will need to verify their enrollment
• Done through interaction with state, local, and
  federal government

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Eligibility

• All Americans will be covered
• Individual mandate will be implemented
• Must purchase one of the options given by the
  state of residency
• Menu of health insurance plans
• Coverage must be equal or greater than BC/BS
  Standard Plan used by Congress
• Previous and existing conditions, occupation,
  genetic information, gender and age will NOT
• impact eligibility or price paid for insurance.

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Benefits

• Primary care
• Inpatient outpatient care
• Emergency care
• Prescription drugs
• DME
• Mental health substance abuse services
• Dental care (non-cosmetic)
• Chiropractic care
• Vision care correction
• Hearing services including hearing aids
• Wellness and prevention
• Not covered
• Long-term care

30
How is the insurance Affordable?

• One way is to put more money in peoples
  pockets
• During first two years, employers who currently
  provide health benefits will convert it to higher
  wages.
• Employees will use the increase to purchase their
  own private health insurance

31
How is the insurance Affordable?

• For employers who currently do not provide health
  benefits
• Required to pay Employer Shared Responsibility
  Payments (ESRPs)
• After the initial two years, ALL employers will
  be required to pay the ESRPs.
• These payments will reflect the ability to pay
  according size and type of industry
• Whats wrong with this?

32
Other Types of Funding

• Subsidies will be offered
• Varying up to 400 above the poverty line
• Full coverage provided to those below 100
• Employers will contribute through a set equation
  related to business size and yearly profits.

33
Incentives and Rewards

• Gives insurers financial incentives
• Have them invest in prevention and disease
  management
• Will give individuals more reason to choose their
  plans, to keep healthy, and stay with the same
  insurer
• What if large numbers of individuals leave the
  state?
• Rewards individuals and their families when they
  participate in wellness programs
• Reduce the monthly premiums
• Rewards providers for helping their patients stay
  healthy

34
Cost Containment

• Competition will drive down costs and promote
  quality.
• Taxpayers will not be asked to foot the bill for
  expensive visits to the emergency room, because
• Every individual has adequate coverage
• They will use prevention and wellness services
• Ultimately, the average growth in health care
  spending will slow by 0.86 between 2007-2016.
• Results in savings of 1.48 trillion.
• Did I miss something?
• Average increase in annual rate of health care
  spending around 10
• Will slow by 0.86 b/w 2007-2016 so will be
  equal to 9.14 in 2016
• Yet individuals still have wage raises (after the
  initial spike) of about 3 annually

35
Proposed Legislation

• Florida Quality Care Act
• -Group coverage for Floridians until National
  Health Insurance or HR 676 implemented

36
Call to Action

• To stay relevant, Republicans must
• Recognize that universal health coverage is
  necessary
• Come up with a reasonable and rational plan
• Stay true to the values of
• Personal responsibility and accountability
• Fiscal Responsibility and accountability
• The importance of the individual

37
Out of Necessity

• Due to existing laws (EMTALA, etc.) the burden of
  the uninsured continually falls on hospitals and
  physicians
• Not cost-effective or a reasonable allocation of
  resources

38
Comes Innovation

• Require that everyone in the State of Florida
  have health insurance
• Subsidize the insurance for the working poor
• Use Floridas most abundant natural resource
  (tourists) to be the primary funding for this
  program

39
But is it Republican?

• BENEFITS
• Coverage for deserving and eligible Floridians
• Resurgence of the small to mid-sized business
  sector
• Rewards capitalism and competition
• Self-reliance freedom of choice
• Emphasizes responsibility and accountability

• COSTS
• Citizenship requirement (keeping with R. values)
• Coverage is limited to allow for universal
  provision but can be augmented based on
  individual contributions
• (choices still remain)
• Private health insurance drug companies could
  feel a squeeze
• (Or would they?)

40
Target Groups

• Who to Draw In?
• Small to mid-sized business owners employees
• Working Americans on Cusp- no handouts but sense
  of having earned right to healthcare

• Who not to isolate ()
• Big Pharma
• Private Health Insurance Companies

41
Handling Big Pharma

• Emphasize that lower prices throughout industry
  doesnt mean less income
• More insured more medication/rxs
• Better coverage reduces need for generics
• Kick-backs for research endeavors (i.e., focus on
  science, not marketing)
• Blame Canada

42
Private Insurance Cos

• Private insurance is not eliminated
• Insurance is required for all Floridians.
• Florida coverage is optional for those eligible
  but those who choose/prefer private insurance can
  still have it.
• Private insurance can actually expand by focusing
  on benefits not covered by statewide insurance
  system (ie. cosmetic, preventative care etc).
• Become health investment sources for HSA, LTCSA
  and investment options.

43
Long Live the Entrepreneurial Spirit

• Employers
• Relieves burden from those who cant afford to
  offer private insurance for all employees
• Employee contributions and freedom of choice
  eliminates the employer bad guy perception
• Healthier workers are more productive workers
• More quality employees to smaller sector as
  benefit gap diminishes

• Employees
• Continued coverage for self and family reduces
  unemployment fears
• Choose occupations based on motivation/education,
  not benefit packages
• Customization and personal contributions allow
  for independent need and long-term care
  contribution
• Your doesnt die with you

44
Plan Summary

• Provide statewide health insurance coverage for
  the working poor.
• 200 individual deductible, max 400/family to
  offset costs and prevent abuse
• Graduate student tax deductions in amount of
  deductible to encourage higher education
• Freedom to choose facility and provider with
  specialist exception (recommendation required)

45
Features

• No Cards Government invasion of privacy (FL
  license, ID or birth certificate is enough)
• General benefits include 1 annual dental cleaning
  medically necessary dental work, 2 year vision
  screening and 1 pair prescription glasses, mental
  health treatment and counseling, all physical
  health needs done through private physicians (ER
  visits only as necessary).
• Vaccination coverage
• 80 prescription coverage (rest covered by HSA
  etc)

46
Features Cont

• Freedom to contribute to HSA account
• Freedom to contribute to LTCSA
• Freedom to invest in stock market with capital
  gains exemptions up to bracket allowances
  (brackets based on age, dependents, income)

47
More Ideas to Incorporate Individual Funding
Contributions

• HSA Accounts
• annual rollover
• portable
• LTCSA
• tax exempt
• Portable
• Trust
• 10 year max (C.O.L increases)

• Encourage Market Involvement
• allow tax exempt investments

48
More Ideas Financial Benefits for Organizations
Involved

• Limits on liability for health industry
• Limits on malpractice premiums for health workers
• Financial rewards and tax breaks for biomedical
  research

49
Show Me the Money

• How is it going to get paid for?
• This plan must be distinctly Floridian
• Therefore, we use Floridas most abundant natural
  resource which is what?

50
Tourists

• They come to FL with bags full of money just
  itching to spend it.
• In fact, they spent about 62 Billion in 2005.

51
More Ideas Consumption-Based Funding

• In keeping with the spirit of Floridas tax
  system, all funding for this program will come
  from consumption taxes
• 2 cent gas tax
• Toll increases
• Increased luxury tax

52
Terms

• Moral hazard refers to the possibility that the
  redistribution of risk (such as insurance which
  transfers risk from the insured to the insurer)
  changes people's behavior. For example, a person
  whose has health insurance will be less likely to
  prevent health problems (e.g. drink and party
  too much) because they know the insurance will
  cover any medical expenses.
• Adverse selection refers to a market process in
  which bad results occur due to information
  asymmetries between buyers and sellers the "bad"
  products or customers are more likely to be
  selected. For example, if health insurance rates
  increase, healthy people drop coverage and sick
  people will keep the insurance causing the pool
  of insured to only be sick people.
• With community rating," everyone pays the same
  premium. An insurer using community rating to set
  insurance premiums ignores any differences in
  expected costs among insured groups or people. If
  an insurer uses community rating, but people know
  and use their expected costs to decide whether or
  not to buy insurance, then only the sickest
  people may wind up signing up for insurance.
• Under "modified" community rating, price
  differences could be based on age and sex. The
  remainder of the definition will be the same as
  regular community rating.

53
References

• Fuchs, Emanuel. "Health Care Reform Why? What?
  When? How?." Health Affairs 24 (6)(2005)
  1399-1414.
• "Health Insurance." Health Insurance -
  Wikipedia. 2006. Wikipedia. 28 Mar 2007
  lthttp//en.wikipedia.org/wiki/Health_insur ancegt.
  
• Mahar, Maggie. Money Driven Medicine. New York,
  NY HarperCollins, 2006.
• Tourism's Impact on Florida May be Greater than
  we Know. Florida TaxWatch. March 8, 2007.
  Florida TaxWatch. 28 Mar 2007

54
References

• HAA How It Works. U.S. Senate Website 2006.
  U.S. Senate. 26 Mar 2007
• lthttp//wyden.senate.gov/Healthy_Americans_Act/HA
  A_How_It_Works.pdfgt
• Klein, Ezra. The Healthy Americans Act. The
  American Prospect 2006. Prospect Online. 25 Mar
  2007
• lthttp//www.prospect.org/weblog/2006/12/post_2260
  .htmlgt
• MA Health Care Reform Law of 2006!. Affordable
  Care Today 2006. ACT Website. 27 Mar 2007
• lthttp//www.hcfama.org/act/mahealthreformlaw.aspgt
  

55
References

• Physicians for a National Health Program. Single
  Payer FAQ. Retrieved via http//www.pnhp.org/facts
  /singlepayer_faq.php?pageall on March 5, 2007
• Woolhandler, S., Himmelstein, D.U. National
  Health Insurance Liberal Benefits, conservative
  Spending. Retrieved from Connecticut Coalition
  for Universal Health Care via http//cthealth.serv
  er101.com/national_health_insurance.htm on March
  5, 2007
• Enthoven, A.C., Fuchs, V.R. Employment-Based
  Health Insurance Past, Present and Future.
  Health Affairs. 2006 25(6) 1538-1547.
• Blumenthal, D. Employer-Sponsored Health
  Insurance in the United States--Origins and
  Implications. NEJM. 2006 355(1) 82-88.