2. Loss of super majority in the Senate Supreme Court challenge Presidential election

4. Exchanges: Who will run them? Will they open on time? Individual mandate: Will it work? Employer mandate: Will they hang in there? Medicaid expansion: How many states opt out? Lawsuits: contraception, employer mandate, subsidies

5. It became health “insurance” reform What it does not do: Address the problems of cost and access (Price x Units = Costs)

6. What we’re up against

7. State’s reluctance to expand Medicaid Low-tax, low-service political culture: 47 th in tax expenditures per capita Budgetary pressures

8. Uninsured rate of 23.7% cut in half 10% in rural counties; 11% in urban counties; 9.5% in suburban counties If Medicaid is not expanded, uninsured rate would be cut by one-quarter

9. Fact: Law was shaped and largely paid for by the health-care industry Prediction: Health-care lobbyists won’t let the law die

10. Feds to the states States to hospital districts (especially on ACA Insurance companies (and providers) to employers Employers to employees

14. High-deductible health plans Accountable care

16. Overuse of technology Market power High prices

18. Proton therapy: Average $63,511 Radiation therapy: Average $36,808

22. It’s the prices

24. Fewer businesses offer health insurance High poverty: 1 out of 3 counties has at least 20% below the federal poverty line

28. 25% of Texans have unmet medical needs, which leads the nation

29. Health Care Cost Growth Affects Living Standards Family of four with employer coverage—income increased from $76,000-$99,000 (1999-2009) Health care spending costs consumed almost all Premiums $490-$1,115/mo. Out of pockets $135-$235/mo. If health care costs had increased at rate of inflation, family would have had additional $545/mo. (vs. $95) Even $95 was “artificial”—tax collections insufficient to cover increases in Federal health care spending

33. 1 out of 4 are 60 years or older

35. Primary care increase, 21%; overall increase, 36%

36. 16,830 primary care physicians in active practice in 2009 68 per 100,000 pop 81:100 K is national average 118 of 254 counties are full HPSAs 26 counties had no primary care physicians in 2009

37. …until the 82 nd legislature gutted the programs

39. Texas MDs: 202/100K; U.S. 257/100K Shortages in 36 out of 40 medical specialties

40. 45% of med students leave state 38% of THOSE preferred not to Most who leave do not return $168,000 state investment in each is lost

41. Hospitals: 8% Medicaid cut in 2011, 2% in 2009 Hospitals: DSH payments going away, but state refuses to expand Medicaid Hospitals: $19 billion in Medicare cuts over the next 10 years; Baylor takes $900 million hit Physicians: 2% cut in Medicaid in 2011 Physicians: SGR is up again in December 2012

42. $52 billion in federal funding this decade Each $1 generates an additional $2 Will cost Texas hospitals $25 billion Penalties for Texas businesses: $299-$448 million annually Net of $900 million per biennium savings from state-funded programs Expansion = 231,000 new jobs by 2016

46. Number of insured grows 50%, if Perry relents Waits for new patients could be 90 days

47. AHRQ: Texas is dead last among the 50 states

52. The report is “fake and false," and "this federal government... doesn't like Texas to begin with."

53. Uninsured population, and children specifically Number of executions Amount of carbon dioxide emissions Toxic chemicals released into water Population with food insecurity (2 nd ) Population – and children – below FPL (4 th ) Among U.S. metro areas: 4 of the 5 worst poverty rates; 12 out of 20 worst uninsured rates

54. Per capita spending on mental health Percent of adults with a high school diploma Percent of non-elderly women with health insurance Worker’s compensation coverage Percent of women getting prenatal care Percent of poor covered by Medicaid (49 th ) Average credit score (49 th ) Percent with employer health insurance (48 th )

55. 2020: 97% of population growth in Texas will be non-white 5 million more residents 50% of public-school enrollment is Hispanic Hispanics will exceed whites by 2020 and exceed 50% by 2040 Hispanic average age: 26. Whites: 40

56. Nearly half say cost burden is “very serious” 1 out of 3 uninsured; 1 out of 4 forego care Half are on Medicaid or eligible for it Nearly half say care was poorly managed More likely to wait for test results or have access to latest technology Elderly less likely to be on Medicare Undocumented ineligible for public insurance Communication and cultural gaps NPR/Harvard/RWJF, Sick in America, May 2012

59. steve@unitedstatesofhealth.com (817) 605-0931 Speech based on the book Health Care in 2020: Where Uncertain Reform, Bad Habits, Too Few Doctors and Skyrocketing Costs Are Taking Us Back of your business card: “eBook” means you want a free copy of How Health Reform Affects Texas; “Speak” means you would like to talk to me about addressing another group