1. Progress and Pathology in US Health Policy
Rick Kronick, Ph.D.
Professor
Department of Family Medicine and Public Health

2. Agenda
Progress
Pathology
Whither the Affordable Care Act?

3. Access Quality Cost triangle

4. PROGRESS

5. Uninsured Rate Among the Nonelderly Population, 1972-2015
Share of population uninsured:
Source: CDC/NCHS, National Health Interview Survey, reported in and

6. Health spending growth has slowed, and was close to being on pace with economic growth from
From 1970 – 1980, the average annual growth in the U.S. economy was 10% per year, compared to health spending growth of 12.0%. Although health spending growth has since moderated, it generally continued to outpace growth of the economy, though by a somewhat smaller margin. The 2010 – 2012 period, however, saw an average annual growth rate in health expenditures that was similar to growth in GDP.
Source: Author’s analysis of National Health Accounts and price data from the Bureau of Labor Statistics

7. Annual change in expenditures per insured person for private insurance, Medicare, and Medicaid,
Source: CMS National Health Accounts, Table 21
Title: Expenditures, Enrollment and Per Enrollee Estimates of Health Insurance: United States, Calendar Years
Source: CMS National Health Accounts, Table 21

8. Adverse Events per 1000 Hospitalizations, 2010 to 2015

9. Improvements in Patient Safety 2010 - 2015
21% reduction in HACs
124,000 lives saved
3.1 million patient harms avoided
$28.2 billion in savings

10. Medicare 30-day hospital readmission rates have declined
Percent of inpatient readmissions within 30 days of an acute hospital stay, among Medicare beneficiaries 65 and older,
Hospital readmission within 30-days of being discharged from a hospital stay is not entirely preventable, but can be reduced for certain diagnoses and services. Improvement in this area is often linked to improved quality of care. Medicare 30-day hospital readmission rates have improved about 8 percent from
Source: Centers for Medicare & Medicaid Services. Geographic Variation Public Use File
For more information see:

11. HHS’ Delivery System Reform Initiative
Goal: Better Care, Smarter Spending, Healthier People
How we get there:
Improve the way providers are paid
Promote value-based payment systems
Bring proven alternative payment models to scale
Improve and innovate care delivery
Encourage integration, coordination of clinical and support services
Improve population health
Promote patient engagement
Share information with providers, consumers, and others to support better decisions; maintain privacy
Create transparency on cost and quality information
Bring electronic health information to the point of care
Source: Burwell SM. Setting Value-Based Payment Goals: HHS Efforts to Improve U.S. Health Care. NEJM 2015 Jan 26; published online first.

12. PATHOLOGY

14. Access Pathologies
Continuation of a fragmented system with tens of millions of people uninsured and many inequities
High deductibles and out of pocket costs, creating access barriers for low-income people

16. Cost Pathologies Still primarily Fee-for-Service, rewarding volume
Primary care still undervalued
High administrative costs
High prices

17. Percentage of US office-based physician visits covered under capitation arrangements

18. Ratio of Average Hourly Earnings for Specialists Relative to Primary Care

19. Costs of Health Care Administration in the United States and Canada, 1999
Abcd

20. Average Standardized Payment Rates Per Inpatient Hospital Stay, By Primary Payer, 1996-2012

21. Quality Pathologies
Underinvestment in public health Imperative to ‘pay for value’ when we have very limited ability to measure it (and underinvestment in developing measures) Lack of care coordination, particularly for patients with chronic care needs Insufficient attention to patient preferences, and insufficient involvement of patients in decision making Insufficient attention to and rewards for safety and process improvement Electronic Health Records not yet interoperable; valuable information often not available to clinicians and patients

22. Whither the ACA? The House passed a bill that would have, if enacted:
Rolled back federal support for Medicaid expansion
Imposed a ’per-capita’ cap on federal Medicaid payments
Converted income-related subsidies into age-related subsidies
Eliminated the ‘individual mandate’
As estimated by the CBO, resulted in an increase in the uninsured of over 20 million, and raised premiums in the individual market
Had virtually no support from organized interest groups representing patients, providers, pharma, or insurers
Two high profile attempts to ‘repeal and replace’ have failed in the Senate, although 29 senators were willing to vote for the first version
President Trump says that he wants the Senate to try again in 2018

23. Implementation Matters!
Even an HHS fully committed to making the Federal Marketplaces work had many troubles
Web site debacle in 2013
Ongoing challenges in areas such as special enrollment periods, risk adjustment, responding to insurer withdrawals, quality measurement, standardization of benefits, transparency, marketing, etc.
An HHS is committed to undermining the ACA, it has many opportunities to do so, including:
Shortening open enrollment (OE) from 12 weeks to 6
Shutting down the web site during OE for maintenance at strategic times
Slashing an already inadequate marketing budget from $100 M to $10 M, and cutting support for navigators by 60%
Creating continuing uncertainty about whether Cost Sharing Reduction subsidies will be paid
Not enforcing the ’individual mandate’
Continually telling people that the ACA is on the verge of collapse, and discouraging enrollment
Likely consequences: lower enrollment; higher premiums; further retrenchment by insurers

24. Summary Progress Pathology
20 million fewer people uninsured
Cost growth closer to GDP growth than any time over the past 50 years
Medicare spending per beneficiary growing especially slowly
Some momentum towards increasing the value of primary care, and attention to population health
Pathology
28 million still uninsured; many other underinsured
High prices for many goods and services; volume still rewarded financially
Insufficient rewards for quality and safety
An uncertain future, with greater likelihood of moving backwards than forwards on access and cost