1. War, Its Aftermath & U.S. Health Policy: Policies and Prospects Jeanne M. Lambrew, PhD Associate Professor LBJ School of Public Affairs, University of Texas Senior Fellow, Center for American Progress June 9, 2008 AcademyHealth Annual Research Meeting

2. 2 OUTLINE Overview of Health Reform Plans Will Health Reform Meet the Needs of Active Military, Reservists, Guardsmen, and Veterans? Will the Health Needs of these Individuals Drive Reform?

3. OVERVIEW OF PLANS General Health Policies Obama Nat’l Health Insurance Exchange –Choice of private plans –Public plan option –Benefits like Federal plans –Guaranteed access Sliding-scale assistance Pay or play All children covered McCain Shift from employer to individual market –Eliminates tax exclusion –De-regulation through cross-state shopping Flat tax credit –$2,500 for individuals –$5,000 for families High-risk pools 3

4. Health Policies for Veterans Obama Reverse 2003 limit on access to benefits Expand benefits: Including prosthetics, spinal cord injury, aging, and women's health Fully fund VA Medical Care: Including the establishment of a VA Planning Division to avoid future budget shortfalls Streamline claims systems Improve mental health treatment: Including the recruitment of more health professionals, improved screening, and expanded access Improve care for traumatic brain injury: Obama will establish standards of care for Traumatic Brain Injury, the signature injury of the Iraq war Expand Vet Centers: Providing more counseling for vets and their families McCain Expand eligibility for health care benefits for reservists and their families Ensure adequate Veterans' Health Care funding: Including higher pay to recruit and retain VA physicians and dentists Support choice of accessing health care outside of the VA system Expand access to affordable health care for military retirees: Allowing retirees to remain eligible military health programs when eligible for Medicare; providing tax breaks for health insurance premiums Opposed user fees for military retirees for using military medical facilities Streamline claims system Allow disabled vets to enroll in Federal Employees Health Benefits Program 4

5. FIT OF HEALTH REFORM Overview of Needs Access to Care Nature of Covered Benefits Access to Coverage Continuity of Coverage Affordability of Coverage 5

6. Access to Care Special Challenges: –VA, Military Treatment Facilities not always accessible –Shortage of certain types of providers Obama: –Strengthens VA system –Invests in health care workforce McCain: –Strengthens VA system –Allows alternative to VA 6

7. Nature of Covered Benefits Special Challenges: –Mental health needs –Rehab, therapies –Chronic conditions and disabilities Obama: –Supports enhanced VA benefits –Supports minimum benefits in new pool McCain: –Increases VA funding that could support enhanced benefits –Proposes high-risk pool and Medicaid supplemental coverage for extra benefits for vulnerable populations 7

8. Access to Coverage Special Challenges: –Veterans predisposed to health problems –Reservists/guard and families at risk of losing employer-based coverage Obama: –Guarantees access to private and public plans McCain: –Creates high-risk pool for people denied private insurance 8

9. Continuity of Coverage Special Challenges: –Combat-related health problems may persist –Families often experience combat-related health problems as well (e.g., mental illness) –Implicit promise of health care for life Obama: –Covers all children –Purchasing pool offers the option of keeping coverage despite work and family transitions McCain: –Aims to enhance the individual insurance market through deregulation and tax policy –Extends health coverage for military retirees 9

10. Affordability of Coverage Special Challenges: –Work transitions could limit access to employer- sponsored health benefits and ability to afford it –Premiums could be high for vets with pre-existing conditions that do not qualify for VA benefits Obama: –Preserve choice of employer coverage through “pay or play” –Offers sliding-scale premium assistance and rating protections McCain: –Promotes insurance independent of work and expects competition to make premiums affordable –Offers flat tax credit for private insurance 10

11. WILL WAR AFFECT HEALTH REFORM World War II United States: 1945: President Truman special message to Congress –Cited health gaps as limitation to military readiness; 30 percent rejected from service –“…each year we lose many more persons from preventable and premature deaths than we lost in battle or from war injuries during the entire war.” Great Britain: 1948: National Health Service created as part of post-war reconstruction 11

12. Korean and Vietnam War Expansion of VA System Creation of CHAMPUS Overshadowed by creation of Medicare and Medicaid 12

13. Current Climate Heighted media attention –Injuries, disabilities, PTSD –Gaps in military, VA, and insurance –Blogs, internet coverage Different concern about military readiness –“If the Democrats win the election this year, and are able to enact a health care plan that extends adequate coverage to all Americans, the loser could be the Army.” NYT, May 30, 2008 13

14. Opportunity Literal leadership –Increasing number of veterans in Congress –Military leadership may step up focus on health Circumstances –Withdrawal of troops may create pressure for domestic investment, in vets and in domestic “nation building” Symbolism –New definition of citizenship, obligations, and opportunities 14