Strategies for Increasing Healthcare Access

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Strategies for Increasing Healthcare Access
Flávio Casoy (adapted from Kao-Ping Chua and
Vanessa Calderón) Jack Rutledge FellowAmerican
Medical Student Association
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• It takes more than medical school to make a
  physician!

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• AMSA - the nations OLDEST and LARGEST
  independent health professional student
  association
• Entirely Student Led.
• Over 68,000 members.
• Over a million community service hours each year.
• For 58 years, a progressive voice in American
  medicine.
• Unites the voices of physicians-in-training to
  fight for a healthcare and medical education
  system that reflect OUR values!!

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International perspective
Total Spending on Health Care, 2005
Source OECD Health Data 2007
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International perspective
Health Care Spending per Capita, 2005
Source OECD Health Data 2007
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Health status and outcomes
Life Expectancy at Birth, 2004-5
Source OECD Health Data 2007
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Health status and outcomes
Infant Mortality, 2004-5
Source OECD Health Data 2007
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Outline

• Insurance Coverage in the U.S. Health Care System
• Strategies for Increasing Health Care Access
  Pros and Cons

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Insurance Coverage in the US Health Care System
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Health insurance coverage of non-elderly
population
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Profile of the uninsured

• 47.0 million Americans
• 81 from working families
• 52-59 from low-income families (200 FPL)
• 80 are adults
• 50 are ethnic minorities
• 79 are American citizens

Source Kaiser Commission on Medicaid and the
Uninsured Source US Census Bureau
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Health insurance coverage of non-elderly
population
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Employer-sponsored insurance

• Offered by employers as part of benefits package
• Administered by private insurance companies
  (for-profit and non-profit)
• Employer pays bulk of premium employee pays
  remainder
• Significant erosion of employer-sponsored
  insurance in recent years

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Health insurance coverage of non-elderly
population
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Individual insurance

• Purchased directly by people who do not get
  coverage through their employers
• Non-group (individual) plans
• Premiums based on individual health risk
• High-risk individuals with limited access
• High Deductibles
• Administratively expensive

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Health insurance coverage of non-elderly
population
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Medicare

• Covers elderly (ages 65 and older) and
  non-elderly with disabilities
• Administered by the federal government
  (essentially a single-payer system)
• Financed through
• Federal income taxes
• Payroll taxes
• Out-of-pocket payments by enrollees

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Medicare

• Four parts
• Part A hospital insurance
• Part B supplemental insurance
• Part C managed care
• Part D prescription drugs
• Significant coverage gaps - most enrollees obtain
  supplemental insurance
• Spending growth generally slower than private
  insurance
• Aging population and increased technology
  presents challenges for the future

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Medicaid

• Covers certain low-income individuals not every
  poor person is covered!
• Administered by state governments
• Often out-sourced to non-government
  administrators
• Financed jointly by the state and federal
  governments
• Benefits are fairly comprehensive, but many
  providers wont take care of Medicaid patients

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Minimum Medicaid Eligibility Levels, 2004
Income eligibility levels as a percent of the
Federal Poverty Level
Note The federal poverty level was 10,488 for a
single person and 16,079 for a family of three
in 2006. SOURCE Cohen Ross and Cox, 2004 and
KCMU, Medicaid Resource Book, 2002.
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State Childrens Health Insurance Program (S-CHIP)

• Supplements Medicaid by covering low-income
  children who are ineligible for Medicaid
• Administered and financed similarly to Medicaid
• Similar problems to Medicaid
• Low reimbursement rates ? some providers refuse
  to accept S-CHIP
• Under-enrollment
• Eligibility varies by specific populations and
  states

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Strategies for Increasing Healthcare Access
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Public Program Expansions Medicaid, CHIP,
Medicare
Do nothing market will fix itself
National Health Insurance
Tax credits
Individual Mandates
Employer Mandates
Individual Commodity
Public Good
U.S. system
Health care system adopted by every other
industrialized democracy
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Tax credits

• AMA plan - offer tax credits to people to
  purchase health insurance.
• Tax credits would be
• Inversely related to income
• Contingent upon purchase of health insurance
• Refundable
• Advanceable
• Financed by repeal of tax subsidy

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Tax credits - pros

• Makes health insurance available to more people
• Keeps current system in place
• Tax infrastructure already in place
• May increase choice of insurance plans

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Tax credits - cons

• Not universal
• Builds on individual market (inefficient and
  discriminatory)
• Problems of current system would remain
• Employers tempted to drop coverage
• No cost controls
• No guarantee that competition will help
• Does not take co-pays and deductibles into
  consideration

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Public Program Expansions Medicaid, CHIP,
Medicare
Do nothing market will fix itself
National Health Insurance
Tax credits
Individual Mandates
Employer Mandates
Individual Commodity
Public Good
U.S. system
Health care system adopted by every other
industrialized democracy
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Individual mandates

• Force everyone to have health insurance through
  some mechanism
• Employer-based
• Medicaid
• Individual market
• People would pay a penalty for not having health
  insurance

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Individual mandates - pros

• Achieves close to universal coverage
• Easily understood
• Leaves current system in place
• Appeals to anti-freeriding ethic

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Individual mandates - cons

• High cost of purchasing health insurance
• Disproportionately burdensome to low-income
  individuals
• Builds on inefficient individual market
• No cost controls
• Difficulty and cost of enforcing mandate
• Deductibles, co-pays

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Individual mandates - cons

• Massachusetts Individual Mandate
• Single, male, 26 year-old, earning 301 FPL -
  2,631 per month, in Framingham, MA
• Premium 150/month
• Drugs 30/generics, 50 for brand names
• Co-pay 25 per doctor visit, 100 per ED
• Procedure, Study, or Hosp stay 2000 Deductible
  20 co-insurance
• 5000 max out of pocket (not counting drugs or
  visits to doctors or EDs)

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Public Program Expansions Medicaid, CHIP,
Medicare
Do nothing market will fix itself
National Health Insurance
Tax credits
Individual Mandates
Employer Mandates
Individual Commodity
Public Good
U.S. system
Health care system adopted by every other
industrialized democracy
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Employer mandates

• Variation 1 Employers forced to provide health
  benefits to employees
• Variation 2 Play-or-pay employers provide
  health benefits that meets certain standards or
  submit to payroll tax to fund public coverage for
  employees

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Employer mandates

• Low-wage employers temporarily subsidized
• Expansion of Medicaid for unemployed or others
  who dont get health insurance through their
  employer

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Employer mandates - pros

• Achieves close to universal coverage
• Builds on current system
• Levels the playing field for employers
• People like getting health insurance from their
  employer (mostly)
• Most of new cost is hidden from employees

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Employer mandates - cons

• Opposition from many businesses
• Disproportionately burdensome for small
  businesses
• Implicit tax on employees (lower wages)
• Potential layoffs of low-wage jobs
• Inhibits creation of new jobs
• No cost controls
• Disadvantages of employer-based system
  (non-portability, economic strain on businesses)

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Public Program Expansions Medicaid, CHIP,
Medicare
Do nothing market will fix itself
National Health Insurance
Tax credits
Individual Mandates
Employer Mandates
Individual Commodity
Public Good
U.S. system
Health care system adopted by every other
industrialized democracy
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Public program expansion

• Expand eligibility of Medicaid, S-CHIP, and other
  public programs to more people
• Examples
• Expansion by income cover everyone under 200
  of poverty level
• Expansion by demographic cover childless adults

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Public program expansion - pros

• May lead to universal coverage eventually (pincer
  strategy)
• Infrastructure largely in place already
• Leaves current system in place
• Potential political support to expand access to
  some groups (esp. children)

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Public program expansion - cons

• Not necessarily universal coverage
• Anti-welfare sentiment
• Lack of a political voice of potential
  beneficiaries
• Access problems with Medicaid/S-CHIP
• May be seen as unjust
• May take the wind out of the sails of more
  comprehensive reforms

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Public Program Expansions Medicaid, CHIP,
Medicare
Do nothing market will fix itself
National Health Insurance
Tax credits
Individual Mandates
Employer Mandates
Individual Commodity
Public Good
U.S. system
Health care system adopted by every other
industrialized democracy
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National health insurance

• NHI having a health insurance plan that is
  available to everyone
• Does not specify financing (single payer vs.
  multi payer)
• Does not specify whether DELIVERY of health care
  is public or private

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Countries with NHI
(South Africa)
Industrialized countries without NHI? only one
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Example of NHI Single payer

• Government becomes main reimburser of health care
  providers
• Universal coverage for defined services
• Automatic enrollment
• Private insurance for supplemental benefits
• Financed by taxes, offset by less premiums
• Delivery remains mostly private

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Single payer - pros

• Universal coverage
• Greatly reduced administrative costs
• Coverage is portable (not tied to employment)
• Free choice of doctors and hospitals
• Very little uncompensated care
• Greater potential to control costs
• More rational and efficient allocation of
  resources and technology

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Single payer - cons

• No choice in insurance plans
• Potential for underfunding by hostile government
  or recession
• Potential for mismanagement
• Politically more difficult
• Special interests
• Transition period
• Resistance to taxes

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Public Program Expansions Medicaid, CHIP,
Medicare
Do nothing market will fix itself
National Health Insurance
Tax credits
Individual Mandates
Employer Mandates
Individual Commodity
Public Good
U.S. system
Health care system adopted by every other
industrialized democracy
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Conclusion How do you evaluate a solution?

• Every solution has disadvantages, no matter what.
  Based on your values, you can select which
  disadvantages are outweighed by the advantages.
• If you value a profit-driven industry that sees
  healthcare as a commodity, tax credits may be
  appealing.
• If you value universality and comprehensiveness,
  NHI may be appealing.

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What does AMSA support?

• For the last 15 or so years, AMSA has supported a
  public, single, national health insurance system
  to ensure that everyone has access to affordable,
  quality heatlhcare.
• Actively fight for sCHIP, Medicare, Medicaid,
  Community Health Centers, Title VII, and much
  more.

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More Ways To Get Involved

• JOIN MEDICAL STUDENTS JUST LIKE YOU JOIN AMSA!
• www.amsa.org
• Attend Your Regional Conference
• 1,2,3 Nov 9th Nov 11th Portland, ME

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Opportunities

• Universal Healthcare Leadership Institute
• September 29-October 1, 2007 (Apps closed)
• SeaCouver
• Feb 6-10, 2008 (Application Due on Nov 18)
• Venezuelan Health Systems Study Tour
• April 7-13, 2008
• Jack Rutledge Internship
• All the time

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• Flávio Casoy
• American Medical Student Association
• Jack Rutledge Fellow for Universal Health Care
  and
• Eliminating Health Disparities
• jrf_at_amsa.org
• [phone] ext. 256