Moderator:Marcia Nielsen, PhD, MPHVice Chancellor for Public Policy and PlanningAssociate Professor in Health Policy and ManagementUniversity of Kansas Medical Center

Federal health reform: Answering the “Five Ws”

Panelists• Andy Allison, PhD▫ Executive Director, Kansas Health Policy Authority

• Sandy Praeger▫ Commissioner, Kansas Insurance Department

• Jen Brull, MD▫ President, Kansas Academy of Family Physicians and

private practice physician

• Sharon Homan, PhD▫ Vice president for Public Health, Kansas Health Institute

• Susan Sherry▫ Community Catalyst, Boston, MA

Who can you believe?

Federal health reform: Answering the Five Ws

Starting with, “Why?”

Note: $US PPP = purchasing power parity.Source: Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

Average spending on healthper capita ($US PPP)

0

2

4

6

8

10

12

14

16

1980 1984 1988 1992 1996 2000 2004

United StatesGermanyCanadaNetherlandsNew ZealandAustraliaUnited Kingdom

Total expenditures on healthas percent of GDP

$7,290

$2,454

16%

8%

We spend too much as a nation

As families: Average Family Premium as a Percentage of

Median Family Income, 1999–2020

11 1213

1416

17 18 18 18 18 19 19 19 20 20 21 21 22 22 23 24

18

0

5

10

15

20

25

1999

2000

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

2014

2015

2016

2017

2018

2019

2020

Data: Commonwealth Fund calculations based on Kaiser/HRET, 1999-2008; 2008 MEPS-IC; U.S. Census Bureau, Current Population Survey; Congressional Budget Office.

Projected

Percent

In the private and public sectors: Health Care Expenditure per Capita

by Source of Funding, 2007*

3,3074,005

2,618 2,726 2,844 2,7582,124 2,446

2,056

3,092

449 589 510 360

441

890

720

1,350 580 246 470528

571542

2,716

38

8820479 343

0

1,000

2,000

3,000

4,000

5,000

6,000

7,000

8,000

US NOR SWITZ CAN FR GER SWE AUS* UK ITA

Out-of-pocket spending

Private spending Public spending

* 2006Source: OECD Health Data 2009 (June 2009).

Dollars

*Adjusted for Differences in Cost of Living

We get too little value in outcomes

81.1 80.782.282.382.382.482.983.083.083.784.084.284.4

78.2 77.1 75.477.278.077.278.278.978.479.078.479.277.5

0

10

20

30

40

50

60

70

80

90

FR SWITZ* ITA* AUS CAN* SWE NOR* GER* NETH OECDMedian

NZ UK** US*

Female Male

* 2006** 2005Source: OECD Health Data 2009 (June 2009).

Years Mortality rate at birth, 2007

7681

88 84 89 8999 97

8897

109 106116 115 113

130 134128

115

65 71 71 74 74 77 80 82 82 84 84 90 93 96 101 103 103 104 110

0

50

100

150

Fran

ceJa

pan

Austra

liaSpa

in

Italy

Canad

aNor

wayNeth

erlan

dsSwed

enGre

ece

Austri

aGer

many

Finlan

dNew

Zeala

ndDen

mark

United

King

dom

Irelan

dPor

tuga

lUnit

ed S

tates

1997/98 2002/03Deaths per 100,000 population*

Source: 2008 Commonwealth Fund * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections.See report Appendix B for list of all conditions considered amenable to health care in the analysis.Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008).

In access to health care:Mortality Amenable to Health Care

9

Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity).Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

AUS CAN GER NETH NZ UK US

OVERALL RANKING (2010) 3 6 4 1 5 2 7

Quality Care 4 7 5 2 1 3 6

Effective Care 2 7 6 3 5 1 4

Safe Care 6 5 3 1 4 2 7

Coordinated Care 4 5 7 2 1 3 6

Patient-Centered Care 2 5 3 6 1 7 4

Access 6.5 5 3 1 4 2 6.5

Cost-Related Problem 6 3.5 3.5 2 5 1 7

Timeliness of Care 6 7 2 1 3 4 5

Efficiency 2 6 5 3 4 1 7

Equity 4 5 3 1 6 2 7

Long, Healthy, Productive Lives 1 2 3 4 5 6 7

Health Expenditures/Capita, 2007 $3,357 $3,895 $3,588 $3,837* $2,454 $2,992 $7,290

Country Rankings

1.00–2.33

2.34–4.66

4.67–7.00

Compared to other countries:Overall Ranking of Health Care Systems

53.4

36.9 37.9

30.0 31.034.7

40.638.4

44.849.6

0

10

20

30

40

50

60

1963 1968 1974 1980 1987 1990 1995 2000 2005 2010

Millions uninsured

Note: Figures for 1963-1974 are U.S. residents without hospital insurance.Data: National Health Interview Survey, Current Population Survey, The Lewin Group.

We don’t spend wisely

Total Number of Uninsured, 1963–2010

Or timely: Ability to See Doctor When Sick or Need Care

36

26

42 43

6054

48

26

0

20

40

60

80

AUSCAN FR

GERNETH NZ UK US

18

34

1826

38

14

23

0

20

40

60

80

AUSCAN FR

GERNETH NZ UK US

Same-day appointment 6+ days wait or never ableto get appointment

Data collection: Harris Interactive, Inc.Source: 2008 Commonwealth Fund International Health Policy Survey of Sicker Adults.

Base: Adults with any chronic conditionPercent

We see health care as a business

We do NOT see health care as a system

What constitutes a system?…Interstate Highway SYSTEM: A Primer

• Named after Dwight Eisenhowser, who championed its formation in 1956

• Largest and most expensive public works program (investment!) in history

• Idea came from German autobahn• Standards are a necessity▫ Speed limits▫ Horizontal, vertical, and tunnel clearance▫ Bridge strength

• Kansas first state to start paving

What “system” pieces are we missing?

• Logical connection between components of system▫ No central governing agency BUT no true marketplace▫ Some reject health care as a public good, but ERs must

treat all patients who come through their doors▫ Lack of interoperability in health information technology

– and in coordination, clinical practice guidelines, etc

• Responsible stewardship of resources• Our overuse, misuse, and underuse cost too much money

and lead to poor outcomes

• Uniquely American innovation▫ Attempts at national system deemed “socialist” instead of

using the best practices from other nations

Where? Reform to be implemented by states Benefits Challenges

• Majority of costs are borne by the federal government

• Reduction in the # of uninsured

• Allowed to design and oversee insurance Exchanges based on their own needs

• Assistance with high risk pools for uninsurable adults

• Enroll newly eligible beneficiaries in Medicaid despite significant budget cuts and limited administrative resources (2014)

• Coordinate Medicaid enrollment with Exchanges

• Implement other Medicaid specific changes

• Maintain current Medicaid and CHIP eligibility through 2019

• Implement new waste, fraud and abuse provisions

• Consider demonstration projects for tort reform

28

When? Timeline for federal reform

Panelist discussion

Sample questions for panelists• First of all, does this presentation leave out important

aspects of the “why, when, where” of federal health reform?

• Second, from your perspective, how would you each answer the other “W” questions? i.e. “who” and “what” are the most important aspects of health reform?

• Third, from your perspective, what got left out of federal health reform?

• Fourth, what is your organization doing to get ready for federal health reform?

• Fifth, what would you like the folks in the audience, Sunflower grantees and the general public, to know or do in the next sixth months to help advance health reform?