1. Anjali joins the Single Payer Movement

2. From the Affordable Care Act to Universal Health Care in New York State
Contents
2 – 28 Sample presentation
Supplementary Material
Evolution of Health Insurance in the US
Where Americans Get their Insurance Coverage
The Affordable Care Act/Obamacare
Why does US Health Care Cost So Much
International Health Status Comparisons

3. NY Metro Chapter Physicians for a National Health Program 2016 - 2017
From the Affordable Care Act to Universal Health Care in New York State
Contents of this Powerpoint file:
Slides
1 – 27 Sample presentation
Evolution of Health Insurance in the US
Where Americans Get their Insurance Coverage
The Affordable Care Act/Obamacare
Why does US Health Care Cost So Much
International Health Status Comparisons
NY Metro Chapter
Physicians for a National Health Program

4. This presentation will:
Give an overview of the current health system and why reform is needed
Explain single payer health care
Discuss how the New York Health Act would work
Review the financing proposal for New York Health
Make the case for support single payer health care.

5. Affordable Care Act: the Health Reform Law of the Land
Web-based insurance “exchanges” or “marketplaces” offer private insurance and Medicaid to uninsured individuals and small employers
All citizens and legal immigrants are required to be insured or pay a penalty
Premium subsidies for incomes up to 400% Federal poverty level (FPL)
Cost-sharing subsidies for incomes up to 250% FPL
Medicaid for all below 138% poverty level. In NY, new low-cost Essential Plan between % FPL
Pilot projects testing methods of containing costs 5

6. Millions are Now Covered, Millions More Remain Uninsured
Note: The uninsured include about 5 million undocumented immigrants.
Source: Congressional Budget Office

7. Source: Census Bureau 2016. NYS Dept. of Health 2016

8. Underinsurance is Now the Norm

9. Insurance Premiums Continue RisING
Average Annual Worker and Employer Contributions to Premiums and Total Premiums for Family Coverage,
$5,791
$6,438*
$7,061*
$8,003*
$9,068*
$9,950*
$10,880*
$11,480*
$12,106*
$12,680*
$13,375*
$13,770*
$15,073*
$15,745*
$16,351*
$16,834*
$17,545*
*Estimate is statistically different from estimate for the previous year shown (p < .05).
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

10. Health Insurance Costs vs. Workers’ Earnings
…FAR FASTER THAN WAGES
Health Insurance Costs vs. Workers’ Earnings
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, Bureau of Labor Statistics, Consumer Price Index, U.S. City Average of Annual Inflation (April to April), ; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, (April to April).

11. Workers Face Rising Deductibles
Average Annual Deductible for Workers Enrolled in Single Coverage,
* Estimate is statistically different from estimate for the previous year shown (p<.05).
NOTES: Average general annual deductible is among all covered workers. Workers in plans without a general annual deductible for in-network services are assigned a value of zero.
SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits,

12. Health Care Spending as a Percentage of GDP, 1980–2013
IT DOESN’T HAVE TO BE THIS WAY
Every other country covers all their citizens and spends half what we do.
Percent
Health Care Spending as a Percentage of GDP, 1980–2013
Percent GDP
* 2012.
Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers.
Source: OECD Health Data 2015.

13. What Makes the Difference?
Unlike in the US -- in these countries government has a central role in:
Funding the system
Overseeing and regulating it.
Our own Medicare program for seniors shows the benefits of a government-funded, regulated system:
Reliable financing
Slower cost growth
Transparent coverage decisions.

14. PRIVATE INSURERS’ HIGH OVERHEAD RAISES COSTS, WASTES MONEY

15. Billing and Private Insurance Overhead Consume Nearly 30 cents of Every Dollar
28%

16. and Medicare grows far slower than private insurance
Composite
Medicare

17. conclusions
The Affordable Care Act will not solve the central problems:
-- so many are still uninsured and
underinsured
-- continued rising, unaffordable cost.
We can do better, by giving government a central role in financing and overseeing health care coverage and prices.

18. Covers everyone -- Costs less!
New York Health Act A4738/S4840
Passed in 2015 & 2016
Universal coverage: Everybody in, nobody out!
Comprehensive benefits
No financial barriers to care: no deductibles or co-pays
Funded by progressive State taxes along with existing Federal and State funds
Covers everyone -- Costs less!

19. New York Health Act Eligibility Every resident of NYS covered
No barriers due to age, sex, income, wealth, employment, or health status
No regressive insurance premiums
No payments at time of service
No deductibles, no co-pays

20. New York Health Act Comprehensive Benefits Primary & Preventive Care
Inpatient and Outpatient Hospital Care
Prescription Drugs
Dental, Vision, & Hearing Care
Long-term care*
Free choice of provider
* Currently being added to NY Health; adds just 5% to cost

21. New York Health Act Provider Reimbursement
Providers paid in full by New York Health, with no charges to patients
New reimbursement methods will be developed to replace fee-for-service payments
Rates negotiated with provider organizations

22. New York Health Act Financing Progressive graduated payroll tax,
80% employer, 20% employee
Graduated tax on non-wage income for high- income earners
Federal Medicare, Medicaid, CHIP, ACA funds
NY Health pays Medicare Part B & Part D premiums & local share of Medicaid
Bottom line: Tax on $50,000 wages: 6%
Employer-based cost today: 11% of wages

23. Covering Everyone while Saving Money!
2019 $B
Additional Costs
Covering the uninsured and poorly-insured %
Elimination of cost-sharing %
Enhanced Medicare & Medicaid fees %
Savings
Reduced insurance administrative costs %
Reduced physician & hospital admin costs %
Bulk purchasing of drugs & devices %
Reduced fraud %
-24.7%
20.0
11.2
10.8
42.0
Total Costs %
-28.6
-20.7
-16.3
Total Savings
Net Savings %
Source: Economic Analysis of the NY Health Act, Gerald Friedman, April 2015;
Moss-Rodberg analysis of long-term care, September 2016 23

24. Marginal Payroll Tax & Effective Tax as Percent of Income
Marginal tax rate
Source: Economic Analysis of the NY Health Act, Gerald Friedman, April 2015;
Moss-Rodberg analysis of long-term care, September 2016

25. The New York Health Plan is Affordable and Sustainable
Eliminates unnecessary and wasteful administrative costs
Unified purchasing lowers drug and equipment prices
Coordinated investment planning allows savings on facilities & equipment
Most Important: Unified funding allows control and planning of future costs

26. Would you favor replacing the ACA with a federally funded healthcare program providing insurance for all Americans?
Source: Gallup Poll, May 2016

28. New York Health We can do better! Beyond the ACA!
Everybody in, nobody out!
Single payer health care for all New Yorkers!

29. QUESTIONS?

30. THE EVOLUTION OF HEALTH INSURANCE IN THE UNITED STATES

31. BEGINNINGS: PRIVATE EMPLOYMENT-BASED HEALTH INSURANCE
Blue Cross is formed in 1936; Blue Shield in 1946
WW II: Health benefits linked to employment
1952: IRS rules employer contributions are tax deductible for employers and not income for employees
1950s: Commercial life insurance companies begin selling health insurance to employers

32. MEDICARE AND MEDICAID: LIMITED GOVERNMENT HEALTH INSURANCE
Medicare for those over 65 years or long-term disabled
Medicaid for poor adults with dependent children, pregnant women, blind, and some disabled
Rising cost of medical care due in part to
innovations in medical technology and drugs
U.S. remains the only industrialized nation without universal access to health care

33. DOMINANCE OF FOR-PROFIT HEALTH INSURANCE
1990 – 2009
Many non-profit Blue Cross plans convert to for-profit companies
Expansion of for-profit managed care limits access, produces popular backlash and some state limits
Managed care restricts access, but costs keep rising much faster than the general cost of living
State Child Health Insurance Program (CHIP) offers states block grants for coverage beyond Medicaid limits
Many states contract out all or part of Medicaid & CHIP
Medicaid Part D drug benefit offered via private plans

34. EXPANSION OF UNIVERSAL HEALTH INSURANCE WORLDWIDE
Germany
1911 – Switzerland
New Zealand
1945 – Belgium
France
1946 – United Kingdom
1947 – Sweden
1961 – Greece
1961 – Japan
1966 – Canada
1973 – Denmark
1974 – Australia
1978 – Italy
1979 – Portugal
1986 – Spain
1996 – South Africa
2002 – Taiwan
None of these countries rely on private, for-profit insurance companies.

35. Progress(?) of US Reform Proposals
1948 – National Health Ins
1971- Employer mandate
1965 -Medicare
1994 -Individual mandate*
2009 -Public option**
* “each eligible individual must enroll in an applicable health plan for the individual and must pay any premium required with respect to such enrollment.” (S.1775)
** “you can choose to enroll in the new public plan” 35

36. Where Americans Now Get Their Coverage
See Notes (Use View/Notes Page)

37. Most Americans Get Their Coverage from the Private Sector…
(49.0 million)
(54.1 million)
(169.0 million)
(14.1 million)
Most Americans get their insurance from their employer or from individual/personal purchase.
A little more than a quarter get their coverage from Medicare, which covers the elderly and disabled, and Medicaid, which covers the poor.
In 2013, just before the ACA went into effect, there were 42 million uninsured. This was 13.6% of the population, about 1 out of every 7 residents.
“Uninsured” means they were uninsured for an entire year; when the Census Bureau conducted its survey in March of 2014, they answered “No” to the question “Were you insured at any time during the previous 12 months?” Many more, of course, perhaps twice as many, were uninsured at some time during those twelve months.
(42.0 million)
(34.5 million)
Source: Health Insurance Coverage in the United States: 2013,
Census Bureau, 2014 37

38. Most of the Money Comes from the Public Sector before the Affordable Care Act
Private Insurance
34%
Federal Government
(existing Medicare, Medicaid, other)
34%
(Federal tax subsidy)
While a little more than a quarter of the population is covered by government insurance programs, principally Medicare and Medicaid, nearly half of the money comes from those two programs. Why is that? It is because those two programs cover the sickest part of the population, the elderly and the poor. Private insurance covers the working population, the healthiest part of the population.
The government spends an additional 6% of the total in subsidizing employer-based insurance, which is treated as a business expense for businesses and therefore deductible from their profits.
In addition, governments at all levels pay for health insurance for their employees. IN total, government pays for more than 60% of all health care in this country.
Out of pocket
12%
State and Local Government
(existing Medicaid, other)
13%
Other private funds
(charity, etc.) 7%
Source: Health Affairs, Feb. 2010; data for 2009 38

39. ( Medicare, Medicaid, ACA subsidy, other) State and Local Government
Even More Money Comes from the Public Sector with the Affordable Care Act
Private Insurance
29%
Federal Government
( Medicare, Medicaid, ACA subsidy, other)
40%
(Federal tax subsidy)
Out of pocket
12%
After the ACA went into effect, government spent additional funds in the expansion of Medicaid and in subsidizing the purchase of private insurance on the ACA “marketplaces”.
Other private funds
(charity, etc.) 7%
State and Local Government
(Medicaid, other)
12%
Source: CBO and Lewin projections

40. In the US, we pay for national health insurance (which most other countries have, but we don’t get it!

41. Compared to Other Countries, Our Public System Covers Fewer, and Private Insurance Dominates
In nearly every other country, the total population is covered by a program in which the government either funds or oversees and regulations the provision of care.
In this country, just a little more than a quarter of the population is covered by Medicare, Medicaid, and smaller programs such as the Veterans Health Administration.
United States
Source: F. Colombo and N. Tapay, Private Health Insurance in OECD Countries, OECD 2004

42. Shrinking Private Insurance

44. Employer-sponsored insurance vs Medicaid

45. Growth in Medicaid Enrollment
Medicaid enrollment has also been rising dramatically in New York State
Growth in Medicaid Enrollment

46. The Number of Uninsured has fallen, but more than 25 million Americans remain without insurance
Affordable Care Act

47. Health Care Costs Place a Heavy Burden on Many Americans

48. Out-of-Pocket Health Care Spending per Capita, 2007 Adjusted for Differences in Cost of Living
Dollars
* 2006
Source: OECD Health Data 2009 (June 2009).

49. Physician Burden of Health Care Administration
Medscape Physician Compensation Report 2015

50. HEALTH CARE IS A CAUSE OF PERSONAL BANKRUPTCIES
62% of personal bankruptcies are due to medical expenses and over 75% had health insurance at the outset of their bankrupting illness.* * Himmelstein, et.al. Am J Med, August, 2009

51. THE AFFORDABLE CARE ACT (ACA) or OBAMACARE

52. Health Reform: The President’s Fateful Choice
In creating a reform plan, the President could
have chosen to
– build on the public sector, especially Medicare, or
– expand the private sector.
He chose to base his program on private insurance:
– leave the basic structure unchanged
– attempt to achieve the goals of health reform –
universal coverage and cost control – through
regulation.
By 2009, the government was already paying for more than half of all health care delivered in this country (through Medicare, Medicaid, and the tax deduction for employer-based insurance). It was therefore logical that expanding coverage by expanding public coverage, especially the successful and popular Medicare program, was a logical option. However, for political reasons – because of the likelihood of heavy industry lobbying and Congressional opposition, Obama chose the private route instead. 52

53. The Great Dealmaker The Obama Administration made a series of deals to pass the ACA:
The insurance industry: Everyone required to
buy their product -- and no public option
The drug industry: No negotiation on prices
The AMA: No cut in physician fees
Hospitals: No cut in reimbursements, only
slower growth in public payments
Employers: Continued control of health benefits yet still
voluntary and subject to possible “Cadillac tax”
Nervous members of the public: “You can keep
what you have” – even though it wasn’t really true
These “deals” with the various “stakeholders” in health care were made by the Congressional committees considering the legislation, with the assistance and collaboration of the Obama Administration. This entire process is described in Steven Brill’s revealing book America's Bitter Pill: Money, Politics, Back-Room Deals, and the Fight to Fix Our Broken Healthcare System.

54. The New Reform Plan: Affordable Care Act or Obamacare
Provides insurance coverage for some of the uninsured
Leaves millions uninsured
Leaves millions more underinsured, with unaffordable deductibles and copays
Does almost nothing about the rising cost of health care! 54

55. Costs Will Keep On Rising
National Health Expenditures (trillions)
6.6% annual growth
$4.7
$4.67
$4.5
6.4% annual growth
6.0% annual growth
National Health Expenditures as Percent of GDP
The projections for the cost of health care indicated that costs would continue to grow, even after the reform bill was passed. In fact, there was a brief slowdown in , as a consequence of the financial crisis of 2008, but the rise in cost has resumed as expected.
Notes: * Modified current projection estimates national health spending when corrected to reflect underutilization of services by previously uninsured.
Source: D. M. Cutler, K. Davis, and K. Stremikis, Why Health Reform Will Bend the Cost Curve, Center for American Progress and The Commonwealth Fund, December Estimated Financial Effects of PPACA as Amended, Richard Foster, CMS Actuary, April 2010

56. The Problems Facing the Program
Private insurance remains
-- too expensive for many people to buy and/or use
-- complex and deficient in many ways, including
very narrow networks
-- profitable for the insurers when they can avoid
sick people and limit what they have to pay for.
The reform program tries to solve these problems through
-- creating online “marketplaces” to simplify
purchasing insurance
-- providing subsidies for individuals and small employers
-- trying to tame the insurance companies through
public exposure and regulation

57. Overall Consequences of ACA
Continued reliance on private insurance
Employment-based insurance largely unchanged
The health care “market’ will continue to determine the cost of health care coverage and the level of copays and deductibles
Experimental pilot programs will try to reduce costs
Result: The ACA has made little difference in the lives of most people, since its coverage expansions only affect small employersm and because it didn’t change the way we pay for health care.

58. The ACA is being implemented over ten years:
Insurance companies required to cover dependent children up to age 26
No annual or lifetime limits on coverage
Gradually close the Medicare drug benefit “donut hole”, finally closed in 2020
Annual government review of insurance rate increases but no federal power to deny or limit increases.
Experimental programs within Medicare aimed at reducing costs (e.g. Primary Care Medical Home, Accountable Care Organizations, bundled payments, new “MACRA value-based payment” program)

59. The Insurance Mandate, Subsidies, and Medicaid
Citizens and legal immigrants required to be insured with penalties up to 2.5% of income
Insurers required to accept everyone, regardless of pre- existing conditions
State-based online insurance “marketplaces” set up for individuals and small employers
Subsidies up to 400% Federal poverty level, so that premium for individuals is less than 9.5% of income
“Hardship waiver” if premium is greater than 8% of income; individual can remain uninsured!
Medicaid for all below 138% poverty level in those states that accepted the expansion

60. What Happened to the Public Option? The Original “robust” Plan:
Open enrollment
Medicare-like, backed by the Federal Government
119 million members
The Congressional Plan:
Restricted enrollment (only the uninsured)
Self-sustaining, follow same rules as private insurers
Reimbursements based on private, not Medicare rates
Perhaps 6 million members
The 800-pound gorilla turned into a mouse – and then it was gone!
When studies showed that over 100 million people would choose the public option, Congressional support collapsed. 60

61. WHY ARE US COSTS SO HIGH?

62. The U.S. has lagged near the bottom of the Bloomberg Health-Care Efficiency Index since it was created in 2012.

63. Health Care Spending as a Percentage of GDP, 1980–2013
Every other country covers all their citizens and spends half what we do.
Percent
Health Care Spending as a Percentage of GDP, 1980–2013
* 2012.
Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers.
Source: OECD Health Data 2015.

64. Canada Introduced Single Payer. We did not.  A Fork in the Road
19%
17%
15%
13%
11% 9% 7% 5%
USA
Canadian Single Payer Fully Implemented
Health costs % of GDP
Canada
1960
1970
1980
1990
2000
2014
Source: Statistics Canada, Canadian Institute for Health Info, and NCHS/Commerce Dept.

65. Why Does the US Spend So Much More than Anyone Else?
Mainstream economists answer:
Too many doctors – but we see doctors less often than in many other countries
Insurance (“moral hazard”) – many countries have no cost sharing and spend less than we do
Unions – other countries are far more unionized then we are
Technology – other advanced countries use the same technology as we do
Prices – our prices are much higher, but why are they higher?

66. Annual Number of Physician Visits per Capita66
We Don’t See The Doctor as Often
Annual Number of Physician Visits per Capita
* 2008
** 2007
Source: OECD Health Data 2011 (June 2011). 66

68. Why Does the US Spend So Much More than Anyone Else?
Single payer advocates answer:
Reliance on unregulated private insurance
However, this can account for only about 15% of the excess cost (Remember: Private insurance pays for only half of all health care; Medicare and Medicaid pay for the other half)
What explains the rest?

70. Billing and Insurance Overhead Consume Nearly 30 cents of Every Dollar
28%

71. So Why Does the US Spend So Much More than Anyone Else?
The fundamental answer: – We allow providers of medical care to set their own prices. No other country does this! – We emphasize expensive specialty care. Other countries prioritize primary care and social services. – In every other country, the government regulates and negotiates physician fees, hospital spending, and drug prices. Health care pricing is not left to the private market.

72. The Market Doesn’t Work in Health Care!
The provision of health care is not a market phenomenon:
- Patients lack information, must rely on providers to guide them, and cannot exercise “consumer” power to balance provider power
- The course of illness, necessary treatments, and ultimate costs are unpredictable
- The patient is often incapacitated
Result: Health care only works with stable prices and in the public interest when there is government oversight and regulation.

73. The classic paper demonstrating that the health care “market” cannot work.

74. Government Action Works in the United States, Too!
Our own experience with the Federally- run Medicare program shows the beneficial effects of a government- funded and regulated system:
Reliable, predictable financing
Slower cost growth
Transparent decisionmaking
Voters can hold decision makers accountable.

75. Here’s the United States, with our Own Medicare Program growing far slower than private insurance
Composite
Medicare

76. The Problem, and the Answer
The Affordable Care Act will not solve the central problem of our health care system: continually rising, unaffordable cost.
We can do better, through a system where government has a central role in funding and oversight.

77. INTERNATIONAL HEALTH STATUS COMPARISONS

78. Hospital Discharges per 1,000 Population
We Don’t Use Hospitals As Much… 78
Hospital Discharges per 1,000 Population
* 2008
Source: OECD Health Data 2011 (June 2011).

79. Average Length of Hospital Stay for Acute Myocardial Infarction79
...And We Don’t Stay as Long
Days
Average Length of Hospital Stay for Acute Myocardial Infarction
* 2008
Source: OECD Health Data 2011 (June 2011).

80. Annual Number of Physician Visits per Capita80
We Don’t See The Doctor as Often
Annual Number of Physician Visits per Capita
* 2008
** 2007
Source: OECD Health Data 2011 (June 2011). 80

81. We Aren’t As Healthy as Others: Mortality Amenable to Health Care
Deaths per 100,000 population*
* Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Analysis of World Health Organization mortality files and CDC mortality data for U.S,
Source: Adapted from E. Nolte and M. McKee, “Variations in Amenable Mortality—Trends in 16 High-Income Nations,” Health Policy, published online Sept. 12, 2011.

82. US Life Expectancy is Less than That of Many Other Countries
United States
Source: OECD 2005

83. …and its Infant Mortality is Higher