the commonwealth fund presidential candidates health care plans: a first look karen davis president,...
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THE COMMONWEALTH
FUND
Presidential Candidates Health Care Plans: A First Look
Karen DavisPresident, The Commonwealth Fund
National Press Foundation November 11, 2007
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THE COMMONWEALTH
FUND
What Are the Problems?What Are the Problems?
Costs of Care
Quality of Care Chasm
Uninsured Rates
Administrative Complexity
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THE COMMONWEALTH
FUND
US Scorecard: US Scorecard: Why Not the Best?Why Not the Best?
Commonwealth Fund Commission National ScorecardCommonwealth Fund Commission National Scorecard
69
71
67
51
71
66
0 100
Long, Healthy &Productive Lives
Quality
Access
Efficiency
Equity
OVERALL SCORE
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 3
• 37+ Indicators• U.S. compared to benchmarks
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THE COMMONWEALTH
FUND
Health Care is Top Domestic Issue for 2008 Presidential Health Care is Top Domestic Issue for 2008 Presidential RaceRace
42
27
1613
117 6 5
0
20
40
60
Iraq Health care Economy Immigration Terrorism Education Gas P rices Taxes
Percent of Americans who think issue is the most important problem for government to address
Source: Kaiser Health Tracking Poll: Election 2008, Issue 3, August 2007
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THE COMMONWEALTH
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Uninsured Top Priority for CongressUninsured Top Priority for CongressAccording to Health Care Opinion LeadersAccording to Health Care Opinion Leaders
64%
64%
66%
70%
75%
76%
80%
80%
81%
88%
Reduce racial/ethnic disparities in care
Reform Medicare payment to reward performance onquality, efficiency
Control the rising cost of prescription drugs
Address shortage of trained health care professionals
Ensure families don't pay excessive out-of-pocketcosts in relation to income
Expand SCHIP to reach all uninsured children
Increase use of IT to improve quality, safety of care
Reform Medicare to ensure its long-run solvency
Enact reforms to moderate rising health care costs
Expand coverage for the uninsured
Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan 2007.
“How important do you think the following health care issuesare for Congress to address in the next five years?”
Top 10 issues: Percent responding “absolutely essential” or “very important”
9
9
8
7
6
5
3
3
2
1
Rank
Note: Based on a list of 17 issues.
Health Insurance Coverage Getting Worse for Adults, Better for Children
Data: Two-year averages 1999–2000, updated with 2007 CPS correction, and 2005–2006 from the Census Bureau’s March 2000, 2001 and 2006, 2007 Current Population Surveys.
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SDMA
RI
CT
VTNH
MD
Percent change between 1999-2000 and 2005-2006 in uninsured adults ages 18-64
Percent change between 1999-2000 and 2005-2006 in uninsured children under 18
Increased 4.1% to 7%
Decreased –2.4 to 0%
Increased 0.1% to 4%
Decreased -7% to -2.5%
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
MD
MEVTNH
MARI
CT
DE
DC
HI
CO
GAMS
OK
NJ
SD
WA
ORID
MT ND
WY
NV
CAUT
AZ NM
KS
NE
MN
MO
WI
TX
IA
ILIN
AR
LA
AL
SCTN
NCKY
FL
VA
OH
MI
WV
PA
NY
AK
ME
DE
DC
HI
CO
GAMS
OK
NJ
SDMA
RI
CT
VTNH
MD
Increased 4.1% to 7%
Decreased –2.4 to 0%
Increased 0.1% to 4%
Decreased -7% to -2.5%
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THE COMMONWEALTH
FUND
Adults With No or Unstable Insurance Are Less Adults With No or Unstable Insurance Are Less Likely to Get Preventive Screening TestsLikely to Get Preventive Screening Tests
82
56
7577
31
5664
18
48
0
20
40
60
80
100
Pap test Colon cancer screening Mammogram
Insured all year Insured now, time uninsured in past year Uninsured now
Percent
Note: Pap test in past year for females ages 19–29, past three years age 30+; colon cancer screening in past five years for adults age 50–64; and mammogram in past two years for females age 50–64.Source: S.R. Collins et al., Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey, The Commonwealth Fund, April 2006.
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THE COMMONWEALTH
FUND
Adults Without Insurance Are Less LikelyAdults Without Insurance Are Less Likelyto Be Able to Manage Chronic Conditionsto Be Able to Manage Chronic Conditions
161827
58
35
59
0
25
50
75
Skipped doses or did not fill
prescription for chronic condition
because of cost
Visited ER, hospital, or both for chronic
condition
Insured all year Insured now, time uninsured in past year Uninsured now
Percent of adults ages 19–64 with at least one chronic condition*
*Hypertension, high blood pressure, or stroke; heart attack or heart disease; diabetes; asthma, emphysema, or lung disease. Source: S. R. Collins, K. Davis, M. M. Doty, J. L. Kriss, A. L. Holmgren, Gaps in Health Insurance: An All-American Problem, Findings from the Commonwealth Fund Biennial Health Insurance Survey (New York: The Commonwealth Fund, Apr. 2006).
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THE COMMONWEALTH
FUND
Figure 12.
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THE COMMONWEALTH
FUND
International Comparison of Spending on Health, International Comparison of Spending on Health, 1980–20051980–2005
0
1000
2000
3000
4000
5000
6000
7000
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Source: OECD Health Data 2007.
0
2
4
6
8
10
12
14
16
1980
1982
1984
1986
1988
1990
1992
1994
1996
1998
2000
2002
2004
United StatesGermanyCanadaFranceAustraliaUnited Kingdom
Average spending on healthper capita ($US PPP)
Total expenditures on healthas percent of GDP
10
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THE COMMONWEALTH
FUND
Cumulative Annual Changes in National Health Cumulative Annual Changes in National Health Expenditures Growth, 2000-2007Expenditures Growth, 2000-2007
0
25
50
75
100
125
2000 2001 2002 2003 2004 2005 2006* 2007*
Net cost of private health insurance adminstration
Family private health insurance premiums
Personal health care
Workers earnings
Note: Data on premium increases reflect the cost of health insurance premiums for a family of four/ The average premium increase is weighted by covered workers. *2006 and 2007 private insurance administration and personal health care spending growth rates are projections.SOURCE: A. Catlin, “National health Spending in 2005: The Slowdown Continues,” Health Affairs, January/February 2007, 143-153; J. A. Poisal, et al. “Health Spending Projections Through 2016: Modest Changes Obscure Part D’s Impact,” Health Affairs, February 2007, w242-w253; 2000-2007 Kaiser Employer Benefits Survey
109%
65%
91%
24%
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THE COMMONWEALTH
FUND
Percentage of National Health ExpendituresPercentage of National Health ExpendituresSpent on Health Administration and Insurance, 2003Spent on Health Administration and Insurance, 2003
Net costs of health administration and health insuranceas percent of national health expenditures
1.9 2.1 2.12.6
3.34.0 4.1 4.2
4.8
5.6
7.3
0
2
4
6
8
France
Finlan
d
Japan
Canada
United K
ingdom
Netherla
nds
Austria
Austral
ia
Switzerla
nd
German
y
United S
tate
sa b c *
a2002 b1999 c2001*Includes claims administration, underwriting, marketing, profits, and other administrative costs;based on premiums minus claims expenses for private insurance.Data: OECD Health Data 2005.Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.
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THE COMMONWEALTH
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Why Does the Current Health Insurance System Why Does the Current Health Insurance System Fail to Promote High Performance?Fail to Promote High Performance?
• Access to care is unequal• Poor access to care is linked to poor
quality• Care delivery is inefficient• Fragmented health insurance system
makes it difficult to control costs• Financing of care for uninsured and
underinsured families is inefficient• Positive incentives in benefit design and
insurance markets are lacking
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THE COMMONWEALTH
FUND
Roadmap to Health Insurance for All: Roadmap to Health Insurance for All: Principles for ReformPrinciples for Reform
• Builds an essential foundation for quality and efficiency as well as access
• Benefits cover essential services with financial protection
• Premiums/deductibles/out of pocket costs affordable
• Coverage is automatic, stable, seamless• Choice of health plans or care systems• Broad health risk pools; competition based on
performance not risk or cost shift• Simple to administer: lowers overhead costs
providers/payers• Minimizes dislocation• Financing adequate/fair/shared across
stakeholders
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THE COMMONWEALTH
FUND
What are the Options for Health Insurance Reform?What are the Options for Health Insurance Reform?
Principles for Reform
Tax Incentives and Individual Insurance
Markets
Mixed Private-Public Group Insurance with Shared Responsibility
for Financing Public Insurance
Covers Everyone 0 + +Minimum Standard Benefit Floor – + +Premium/Deductible/Out-of-Pocket CostsAffordable Relative to Income
– + +
Easy, Seamless Enrollment 0 + ++Choice + + +Pool Health Care Risks Broadly – + ++Minimize Dislocation, Ability to Keep Current Coverage + ++ –
Administratively Simple – + ++Work to Improve Health Care Quality and Efficiency 0 + +
0 = Minimal or no change from current system; – = Worse than current system; + = Better than current system; ++ = Much better than current systemSource: S.R. Collins, et al., A Roadmap to Health Insurance for All: Principles for Reform, Commission on a High Performance Health System, The Commonwealth Fund, October 2007.
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THE COMMONWEALTH
FUND
Medicare for All, Private Insurance Exchanges, Tax Incentive Medicare for All, Private Insurance Exchanges, Tax Incentive Proposals Cause Major Shifts in Coverage, 2007Proposals Cause Major Shifts in Coverage, 2007
Current LawHealthy Americans Act
(Wyden)
Total population = 295.1 million
Uninsured47.8
(16%)
PrivateNon-Employer
9.5(3%)
Employer 153.7(52%)
Medicaid/SCHIP37.5
(13%)
Medicare31.9
(11%)
CHAMPUS3.4
(1%)
DualEligible
8.0(3%)
Uninsured2.5
(1%)
HAACoverage
248.8(84%)
Medicare31.9
(11%)
CHAMPUS3.9
(1%)
DualEligible
8.0(3%)
Note: Average monthly coverage. Primary payer is determined on basis of current prevailing coordination of benefits practices.Source: The Lewin Group for The Commonwealth Fund.
EmployerRetiree
3.3(1%)
Uninsured38.8
(13%)
PrivateNon-Employer
29.3(10%)
Employer145.2(49%)
Medicaid/SCHIP38.5
(13%)
Medicare39.9
(14%)
CHAMPUS3.4
(1%)
President Bush’sProposal
Medicare31.9
(11%)
Employer5.0
(2%)
AmeriCare246.8(83%)
CHAMPUS3.4
(1%)
Dual Eligible8.0
(3%)
AmeriCare (Stark)
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THE COMMONWEALTH
FUND
Some Reform Proposals Reduce Total Health System Spending,Some Reform Proposals Reduce Total Health System Spending,But Federal Government Outlays Require Feasible Financing But Federal Government Outlays Require Feasible Financing
(Change in Health Spending by Stakeholder Group, (Change in Health Spending by Stakeholder Group, Billions of Dollars, 2007)Billions of Dollars, 2007)
President Bush’s
Proposal
Healthy Americans Act2
(Wyden)
AmeriCare(Stark)
Total Uninsured Covered, Millions
9.0 45.3 47.8
Federal Government $70.4 $24.3 $154.5
State and Local Government
($0.3) ($10.2) ($57.4)
Private Employers ($50.8) $60.2 ($15.2)
Households ($31.0) ($78.8) ($142.6)
Net Health System Cost in 2007 (in billions)
($11.7) ($4.5) ($60.7)
Total Uninsured Not Covered1, Millions
38.8 2.5 0
1Out of an estimated total uninsured in 2007 of 47.8 million.2Estimates reflect a mandatory cash-out of benefits on the part of employers that currently offer coverage.Source: S. R. Collins, K. Davis, and J. L. Kriss, An Analysis of Leading Congressional Health Care Bills, 2005-2007: Part I Insurance Coverage, The Commonwealth Fund, March 2007
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THE COMMONWEALTH
FUND
Creating Consensus: Creating Consensus: Minimal Disruption in Current Coverage, 2004Minimal Disruption in Current Coverage, 2004
Medicaid/CHIP10%
Employer58%
Non-group4%
CURRENT INDIVIDUAL MANDATE
CHAMPUS/Others
1%
Uninsured15%
Medicare12%
Non-group1%
CHAMPUS/Others
1%
Uninsured1%
Medicaid/CHIP/FHIP
15%
Medicare14%
Employer59%
Congressional Health Plan
9%
Source: K. Davis and C. Schoen, “Creating Consensus on Coverage Choices,” Health Affairs (Web Exclusive April 23, 2003). Lewin Group estimates using the Health Benefits Simulation Model.
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THE COMMONWEALTH
FUND
New Coverage for Currently Uninsured
Congressional Health Plan
TOTAL = 24 m
MedicareTOTAL = 38 m
11m 13m
CHIP/FHIPTOTAL = 43 m
Employer Group Coverage
TOTAL = 165 m
14m 1m
Improved Coverage for Underinsured
3m 1m3m 11m
Source: K. Davis and C. Schoen, “Creating Consensus on Coverage Choices,” Health Affairs (Web Exclusive April 23, 2003).
Creating Consensus: Choice between Private Creating Consensus: Choice between Private Insurance and Public Program CoverageInsurance and Public Program Coverage
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THE COMMONWEALTH
FUND
Health Reform and the Presidential CandidatesHealth Reform and the Presidential Candidates
• Leading Democrats:
– Mixed private-public insurance
– Shared financial responsibility (government, employers, households), individual mandate
– FEHBP or Medicare national insurance connector
– IT, prevention, chronic care management, comparative effectiveness, pay for performance, transparency
– Finance with system reforms and repeal/expiration of high-income tax breaks
• Leading Republicans:
– Tax incentives for purchase of individual insurance
– Make employer health insurance contributions taxable income to employee
– Buy insurance from any state
– Greater state flexibility to reallocate Medicaid/SCHIP dollars
– Tort reform, transparency, IT
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THE COMMONWEALTH
FUND
Features of Candidates’ Approaches to Health Care ReformFeatures of Candidates’ Approaches to Health Care Reform
Senator Clinton
Senator Edwards
Senator Obama
Mayor Giuliani
Senator McCain
Governor Romney
Individual Mandate X X Children only No No No
Employer Shared Responsibility
TK% of payroll, small
businesses exempt 6% of payroll TK% of payroll No No No
Subsidies for Low-income Uninsured
Tax credit for premium >TK%
of income
Refundable tax credit on sliding
scale
Sliding scale premium subsidies
Health insurance
credit for low-income
Tax credit $2,500 for
individuals, $5,000 for families
Premium subsidies
Medicaid/ SCHIP expansion X
Parents/ children up to 250% FPL; childless adults up to 100% FPL X No No No
Risk pooling
Private Health Choices Menu
through FEHBP & public
insurance plan option modeled after Medicare
Regional health markets with
private & public plan options
National Health Insurance
Exchange with private & public
plan options
Purchase private
insurance in any state
Purchase private
insurance in any state
Emphasis on private markets
Quality and Efficiency Measures
HIT, Transparency,
P4P, Prevention, Comparative effectiveness,
Chronic disease management, Disparities, Malpractice
reform
HIT, Transparency,
P4P, Prevention, Comparative effectiveness,
Chronic disease management, Disparities, Malpractice
reform
HIT, Transparency,
P4P, Prevention, Comparative
effectiveness, Chronic disease
management, Disparities, Malpractice
reform
HIT, Transparency,
Prevention, Malpractice
reform
HIT, Transparency,
P4P, Prevention, Chronic disease
management, Malpractice
reform
HIT, Transparency,
Malpractice reform
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THE COMMONWEALTH
FUND
Candidates’ Agreement on Health Care Reform FeaturesCandidates’ Agreement on Health Care Reform FeaturesSenator Clinton
Senator Edwards
Senator Obama
Mayor Giuliani
Senator McCain
Governor Romney
Candidates From Both Parties Agree
Expanding coverage X X X X X X
Health IT X X X X X X
Transparency X X X X X X
Malpractice reform X X X X X X
Some Candidates Agree
Pay for performance X X X No X No
Prevention X X X X X No
Candidates Differ
Universal coverage X X X No No No
Individual mandate X X All children No No No
Employer pay or play X X X No No No
Changes to employer benefit tax exemption X No No X No Unclear
Regulation of insurance markets X X X No No No
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THE COMMONWEALTH
FUND
Judging the 2008 Presidential Judging the 2008 Presidential Candidates’ Health PlansCandidates’ Health Plans
Note: Scale is 1-10; 10 is the bestSource: Marilyn Werber Serafini, "Judging the 2008 Health Plans," National Journal, October 26, 2007
Clinton Edwards Obama Giuliani McCain Romney
Universal Coverage 9 9 7 4 6 4
Use existing dollars 4 4 4 6 6 6
Government gets value for money 6 6 6 4 6 4
Spending constant percent of GDP
4 3 3 4 6 4
Consumer informed choices 7 6 7 4 6 4
Provider QI tools, best practices 8 7 7 3 5 3
Providers compete on quality/price
6 6 6 5 6 4
No adverse effect on coverage or patients
7 8 7 5 6 4
Coverage affordable for sickest 8 9 8 3 5 3
Patients seek value for money 5 4 5 6 7 5
Patients have access to providers 8 8 8 7 8 8
Employers help pay for coverage 8 8 8 5 6 7
No financial hardship on employers
6 5 5 9 9 8
TOTAL 86 83 81 65 82 64
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THE COMMONWEALTH
FUND
Health Reform and the Presidential CampaignHealth Reform and the Presidential Campaign
• Health policy a top domestic issue • Universal coverage is central to high performance
health system– Needs to be combined with initiation of effective
health system reforms
• Organize the health care system around the patient to ensure accessible and coordinated care
• Align financial incentives: payment reform and effective strategies for enhancing value and achieving savings
• Pursue and raise benchmark levels of high quality, efficient care and enhance capacity to innovate and improve including IT capacity
• Ensure national leadership and public/private collaboration
25
THE COMMONWEALTH
FUND
Why Not the Best?Why Not the Best?
• Current directions absent policy change – Costs expected to go to 20% of GDP– More uninsured, affecting middle class families as
well as low-income– More underinsured, bill problems, medical debt
• Aiming higher: Why not the best?– U.S. has the resources and expertise– Benchmarks for a high performance health system
are achievable– Achieving consensus requires that everyone
participate and be willing to come together for the greater good
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THE COMMONWEALTH
FUND
Visit the Fund’s website atVisit the Fund’s website atwww.commonwealthfund.orgwww.commonwealthfund.org
27
THE COMMONWEALTH
FUND
Thank You!Thank You!
Stephen C. Schoenbaum, M.D., Executive Vice President and Executive Director, Commission on a High Performance Health System, [email protected]
Katherine Shea, Research Associate
Cathy Schoen, Senior Vice President for Research and Evaluation [email protected]
Sara Collins, Assistant Vice President, [email protected]
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THE COMMONWEALTH
FUND
Appendix: Presidential Candidate PlansAppendix: Presidential Candidate Plans
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THE COMMONWEALTH
FUND
Senator Clinton’s Health PlanSenator Clinton’s Health Plan• Universal health coverage with mixed private-public coverage, individual mandate• National insurance connector building on FEHBP, Medicare-like product option; keep
current coverage if prefer• Sliding scale premium assistance; expand Medicaid/SCHIP• Shared financial responsibility; tax breaks for small business under 25 employees• Require all health plans to cover prevention; coordinate public spending on
prevention; create National Prevention Initiative• End insurance discrimination to help reduce administrative costs• Quality and Efficiency Reforms
– Chronic care coordination models– Create “paperless” health information technology system– Create independent “Best Practices” Institute– Implement Smart Purchasing Initiatives to constrain excess expenditures on
prescription drugs and managed care– Pay providers for coordinated care, bonuses for maintenance of physician
specialty certification• Revenue
– $110 billion annual federal budget cost financed by system reforms and expiration of income-tax cuts for highest income
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THE COMMONWEALTH
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Senator Edwards’ Health PlanSenator Edwards’ Health Plan• Individual mandate once insurance is affordable • Shared responsibility
– Employers provide coverage to workers or pay 6% of wages into pool• Medicaid/SCHIP expansions
– Parents and children up to 250% of poverty– Childless adults up to 100% of poverty
• Sliding scale premium subsidies (refundable tax credits)• Regional Markets – insurance pools of competing private plans and a public plan like
Medicare• Quality and Efficiency Reforms
– Insurance market; guaranteed issue and community rating– Coverage of preventive care and chronic care with minimal cost-sharing– Pay for results – reward quality and efficiency; reward primary care– Transparency – public reporting; IT– Patient safety; FDA device and drug safety– Quality benchmarks– Evidence-based medicine; health services research
• Revenues– $90 to $120 billion a year federal budget cost from eliminating waste in health
system and repealing Bush tax breaks for those over $200,000– Enforcement of capital gains tax– Employer 6% of payroll contribution
31
THE COMMONWEALTH
FUND
Senator Obama’s Health PlanSenator Obama’s Health Plan
• Shared responsibility - Employers provide coverage to workers or contribute a percentage of payroll toward the costs of the national plan
• Medicaid/SCHIP expansion; Sliding scale premium subsidies• Public health insurance plan – based on FEHBP – available to small businesses,
individuals who don’t have access to group coverage• National Health Insurance Exchange to provide access to private coverage• Mandate that all children have coverage; Young adults expansion – allow young
people up to age 25 to continue coverage through their parents’ plans• Reinsurance for employer health plans• Quality and Efficiency Reforms
– Disease management programs; implement medical homes– Require cost and quality reporting, including medical errors and disparities in
care, from participating providers; Require health plans to report percent of premiums that goes to patient care
– Support efforts to align reimbursement with quality of care– Increase investment in comparative effectiveness reviews and research– Invest $10 billion per year over 5 years for U.S.-wide adoption of standards-
based health IT systems– Increase competition in insurance and drug markets– Promote disease prevention
• Revenues– $50 to $65 billion annual federal budget costs funded through expiration of high
income tax breaks ($200,000 and above)– Employer contribution
32
THE COMMONWEALTH
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Mayor Giuliani’s Health PlanMayor Giuliani’s Health Plan
• Tax incentives to buy health coverage – income-tax exclusion of up to $15,000 for families and $7,500 for individuals to buy private insurance and contribute to expanded health savings accounts
• Buy insurance out-of-state• Block grants to states instead of Medicaid matching funds• Tort reform – reasonable caps on non-economic damages,
alternative dispute resolution• Transparency of prices, provider qualifications, outcomes• Pay Medicare doctors and hospitals more for better-quality
care• Public/private partnerships for IT standards• State Medicaid payments tied to success in promoting
preventive care, tracking obesity in children• Reduce red tape in approval of medical devices
33
THE COMMONWEALTH
FUND
Senator McCain’s Health PlanSenator McCain’s Health Plan
• Keep employer tax incentives, but offer individuals tax incentives to buy insurance -- $2,500 refundable tax credit for individuals, $5,000 for families; if premium less, balance for health savings accounts
• Buy health insurance out-of-state• Association health plans• Medicare/Medicaid pay providers for good
outcomes, coordinating care, preventive services• Transparency about outcomes, quality of care,
costs, and prices• Innovative delivery forms, e.g. retail clinics• Tort reform; protect doctors following clinical
guidelines and patient-safety protocols• National standards for electronic health
information systems and data collection
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THE COMMONWEALTH
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Governor Romney’s Health PlanGovernor Romney’s Health Plan• Recommends “extending health insurance to all Americans, not through a
government program or new taxes, but through market reforms”• Would expand and deregulate the private health insurance market
– Foster competitive health insurance markets in each state to bring down the cost of private health insurance
– Reform tax code to make it cheaper for individuals to purchase private insurance, provide a deduction for the cost of health insurance and catastrophic medical expenses
• Premium assistance to help people purchase private health insurance plans– Redirect state and federal spending from “free care” payments to provide sliding
scale premium assistance• Insist that middle income individuals either purchase health insurance or pay for their
own health care (reform state health insurance regulations to make health insurance more affordable)
• Encourage more Health Savings Accounts and co-insurance products• Enhance the portability of private health insurance• Slow the rate of inflation in health care spending by:
– Instituting tax reforms to promote smart spending on health care– Creating incentives for states to reform their health insurance markets– Implementing medical liability reform (caps on non-economic and punitive
damage awards)• Federalist approach:
– Facilitate and encourage reforms, don’t mandate them– States able to create reforms to match their unique needs– States as laboratories of innovation
• Encourage innovation in Medicaid by providing block grants to states• Enhance the use of information technology• Establish cost and quality transparency