national health reform and the 2008 presidential election (jennifer tolbert)

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K A I S E R C O M M I S S I O N O N

Medicaid and the Uninsured

Figure 0

National Health Reform and the 2008Presidential Election

Jennifer TolbertPrincipal Policy Analyst,

Kaiser Commission on Medicaid and the Uninsured

for

National Press FoundationNovember 12, 2007

Washington, DC





Figure 1

Number of Nonelderly Uninsured Americans,2004 - 2006

37.0

8.48.7

9.4

34.6 35.6

2004 2005 2006

ChildrenAdults

Uninsured in Millions

SOURCE: KCMU/Urban Institute analysis of March CPS for each year.

43.0 44.446.5





Figure 2

$2$

$

$ 2

$ 2

$$$

2 2 2 2

p er ri u i

W rker ri u i

Average A ua Pre iu s sf r vered W rkers 2 a d 2

Note: Family coverage is defined as health coverage for a family of four. Datarepresents average for all types of plans.SOURCE: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 2007.

$2

$

$

$ 2

Si g e verage Fa i verage





Figure 3

umulative hanges in Health Insurance Premiums,Overall Inflation, and or ers¶ Earnings, 2000-2006

0%

%

2 %

3%

%

3%

%

3%

0%

%0%

2%%

20%

%%

0%% %

%

0%

20%

0%

60%

0%

00%

2000 200 2002 2003 200 200 2006

Health Insurance Premiums Overall Inflation or ers' Earnings

Note: Data on premium increases reflect the cost of health insurance premiums for afamily of four.SOURCE: Employer Health Benefits, 2006 Annual Survey , Kaiser Family Foundationand Health Research & Educational Trust, September 2006.





Figure 4

ho are the Uninsured?

4

4

4

4

Total = 46 5 million uninsured

SOURCE: KCMU/Urban Institute analysis of March 2007 CPS.

Other Adults

Parents

hildren

Parents

Other Adults

hildren

hildren

Parents

Other Adults

< 00 FPL

00- FPL

00 FPL+





Figure 5

Source: K aiser Health Tracking Poll: Election 2008

Percent naming HEALTH ARE as one of the to two issues they¶d most li e to hear residential candidates tal about, by olitical arty self-identification:

Trend: Interest in Health are Rising

ar- Jun- Aug- Oct-

Democrats

Inde endents

Re ublicans





Figure 7

hat Plan oes the Public ant?

A new health lan that would rovideinsurance for nearly all of the

uninsured and would involve asubstantial increase in s ending

A new health lan that is more limitedand would cover only some uninsured

grou s, but would involve less s ending

A health lan that would eethings basically as they are

Pro osals from 008 andidates:

SOURCE: Kaiser Health Tracking Poll: Election 2008, Volume 3, October 2007.





Figure 8

Presidential andidates iffer in A roachto Health are Reform

� Democrats generally favor:± universal coverage

± strengthening the private employer-based system

± building on existing public programs

± purchasing pools and insurance market reforms± mandates on employers and individuals

± financing by rolling back tax breaks for wealthiest Americans

� Republicans generally favor:

± tax incentives for the purchase of insurance

± expanding the individual insurance market

± consumer-directed plans such as HSAs

± deregulation of the insurance market

± limiting the role of public programs





Figure 9

«But There Are Areas of Agreement

� Im ortance of health information technology toim rove system efficiency and quality

� Need for rice trans arency

� Need to im rove affordability of health insurance

� Need for some assistance for low-income to affordcoverage





Figure 10

Hillarylinton

BaracObama

ohnEdwards

RudyGiuliani

MittRomney

ohnMc ain

Plan Announced: 9/17/07 5/29/07 2/18/07 7/31/07 8/24/07 10/11/07

Individual MandatesFor

hildrenOnly

Em loyer Mandates

Public ProgramEx ansion

New InsurancePooling Mechanism

Premium Subsidies

Insurance Mar etRegulation More More More Less Less Less

hange TaxTreatment of Insurance

a s for > 250,000

Encourage

onsumer- irectedare





Figure 11

ohn Edwards

� Individual mandate

� Require em loyers to offer or contribute to coverage

� Ex and Medicaid and S HIP to all families under 250 FPL and adults

under 100 FPL

� reate non rofit regional urchasing ools with rivate lans andublic lan based on Medicare

� Refundable sliding-scale tax credits for urchasing coverage throughools

� Regulations on insurers to revent denials of coverage

� Estimated cost between 90-120 billion, funded by ending tax cuts for those with annual incomes over 200,000





Figure 12

Hillary linton

� Individual mandate

� Require large employers to offer or contribute; tax credits for smallemployers that offer coverage

� Expand Medicaid and SCHIP

� Expansion of group insurance options through Health Choices Menu(FEHBP buy-in with public plan option based on Medicare)

� Premium subsidies through refundable tax credits, with limit onpremiums as a percent of income

� Regulations on insurers to prevent insurance discrimination

� Reinsurance for catastrophic retiree health costs

� Estimated cost is $110 billion per year, funded by health systemsavings and limiting the tax exclusion for ESI and ending tax cuts for

those with incomes over $250,000





Figure 13

Barac Obama

� Require children to have health coverage

� Require employers to offer or contribute a percentage of payroll to

coverage� Expand Medicaid and SCHIP

� Create a national health insurance exchange with private plans and apublic plan with benefits similar to those in FEHBP

� Provide income-related subsidies for low-income families

� Regulations on insurers to prevent denials of coverage

� Estimated cost is $50-65 billion, funded by ending tax cuts for thosewith incomes over $250,000 and savings to health system





Figure 14

Bill Richardson ennis Kucinich

� National, non-profit single payer system

� Private coverage allowed for

benefits not included in national plan

� Regionally allocated global budgetsfor services, administration, andcapital

� Funded through increased taxesand transferring existing publicspending on health care

� Automatic enrollment

� No premiums

� Phased-in individual mandate

� Require employers to offer or contribute to coverage

� Expand Medicaid and SCHIP

� Allow all to buy-in to FEHBP andthose age 55-64 to Medicare

� Sliding-scale, refundable federal

tax credits for coverage

� Increased insurance regulation

� Estimated cost is $104-110 billion,funded by savings elsewhere inproposal





Figure 15

Rudy Giuliani

� Provide tax deduction of $15,000 for purchase of coverage throughindividual market (echoes Bush proposal)

� Deregulate insurance market to encourage lower-priced policies; allowpurchase of insurance across state lines

� Simplify HSA regulations

� Provide refundable tax credits to help the low-income purchaseinsurance

� Provide states with block grants to reduce costs, expand coverage, andaddress adverse selection issues





Figure 16

Mitt Romney

� Reform tax code to permit full deductibility of premiums and costsharing for those with at least catastrophic coverage

� Eliminate the minimum deductible requirement for HSAs

� Encourage states to deregulate insurance market to provide lower-priced policies

� Use state and federal DSH funds to provide subsidies for lower-

income families to purchase private coverage

� Medicaid block grants with increased state flexibility

� Plan will be financed by redirecting existing federal subsidies for uncompensated care



K A I S E R C O M M I S S I O N O NMedicaid and the Uninsured

Figure 17

ohn Mc ain

� Remove tax advantage for employer-sponsored insurance

� Provide tax credit ($2,500 individual/$5,000 family) to everyone for purchase of private insurance

� Require states participating in Medicaid to develop additionalpremium subsidies for high-cost and low-income individuals

� Encourage multi-year insurance products

� Allow purchase of insurance across state lines, national health

insurance plans (not state-regulated), and association health plans� Encourage state flexibility under Medicaid

� Overall emphasis on controlling costs through improved diseasemanagement, coordinated care, health information technology, andmedical malpractice tort reform




Figure 18

Fred Thom son

� No formal plan announced

� Key statement from speech: ³Ithink it is best if you, yourself decide what is best for you andyour family, with insurance thatdoesn¶t have to depend on your employment ± coverage thatyou can take with you if youchange jobs; insurance that you

may purchase from anywherein the nation for the best value.This would be market drivenand would make healthinsurance affordable for moreAmericans.

Mi e Huc abee

� Provide a health insurance taxdeduction for individuals and families

� Provide a health insurance tax creditfor low-income taxpayers

� Expand HSAs so they are available toeveryone, including those without ahigh deductible plan

� Allow states to experiment with

market-based approaches tocoverage

� Emphasize prevention and diseasemanagement; reduce premiums for those who lead healthy lifestyles




Figure 19

Assessing Ex ansion Pro osals

� Does the proposal seek to achieve universal coverage?

� Will coverage under the proposal be comprehensive?

� How will the proposal affect businesses?

� How will the proposal affect individuals?

� How will the proposal be financed?

� How will the proposal affect cost and quality of health care?

� What is the role for states in the proposal?

� What is the role for the federal government?




Figure 20

The Future of Health are Reform

� Problems plaguing health care system will not go away

± Growing uninsured (47 million)

± Declining rates of employer-sponsored coverage

± Rising health care costs

� States will continue to advance proposals

± Trend-setting states will lead the way

± Comprehensive reform not possible in all states

� SCHIP debate has highlighted ideological divide over healthcare reform and will influence state action

� Health care reform ranks near the top of presidentialcampaign issues

national health reform and the 2008 presidential election (jennifer tolbert)

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