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THE

COMMONWEALTH
FUND

Presidential Candidates Health


Care Plans: A First Look

Karen Davis
President, The Commonwealth Fund
National Press Foundation
November 11, 2007
kd@cmwf.org
www.commonwealthfund.org
2

What Are the Problems?

Uninsured Rates Costs of Care

Administrative THE

Quality of Care Chasm


COMMONWEALTH
FUND

Complexity
US Scorecard: 3

Why Not the Best?


Commonwealth Fund Commission National Scorecard

Long, Healthy &


69
Productive Lives

Quality 71

Access 67

Efficiency 51

Equity 71
• 37+ Indicators
• U.S. compared to
OVERALL SCORE 66
benchmarks
0 100
THE
COMMONWEALTH
FUND

Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006 3
4
Health Care is Top Domestic Issue for 2008
Presidential Race
Percent of Americans who think issue is the most important problem for
government to address
60

42
40

27

20 16
13
11
7 6 5

0
Iraq Health care Economy Immigration Terrorism Education Gas Prices Taxes

THE
COMMONWEALTH
FUND

Source: Kaiser Health Tracking Poll: Election 2008, Issue 3, August 2007
Uninsured Top Priority for Congress 5

According to Health Care Opinion Leaders


“How important do you think the following health care issues
are for Congress to address in the next five years?”
Top 10 issues: Percent responding “absolutely essential” or “very important”
Rank
Expand coverage for the uninsured 1 88%

Enact reforms to moderate rising health care costs 2 81%

Reform Medicare to ensure its long-run solvency 3 80%

Increase use of IT to improve quality, safety of care 3 80%

Expand SCHIP to reach all uninsured children 5 76%

Ensure families don't pay excessive out-of-pocket


6 75%
costs in relation to income

Address shortage of trained health care professionals 7 70%

Control the rising cost of prescription drugs 8 66%

Reform Medicare payment to reward performance on


9 64%
quality, efficiency

Reduce racial/ethnic disparities in care 9 64% THE


COMMONWEALTH
FUND
Note: Based on a list of 17 issues.

Source: The Commonwealth Fund Health Care Opinion Leaders Survey, Jan 2007.
Health Insurance Coverage Getting Worse
for Adults, Better for Children

Percent change between 1999-2000 and Percent change between 1999-2000 and
2005-2006 in uninsured adults ages 18-64 2005-2006 in uninsured children under 18

NH ME
WA VT NH
WA VT ME
MT ND
MN MT ND
OR MN
WI NY MA
ID SD OR NY MA
MI RI WI
ID SD RI
WY CT MI
PA NJ WY
IA PA CT
NE OH IA NJ
IN DE NE OH
NV IN DE
IL WV MD NV
UT VA IL MD
CO DC UT WV VA
CA KS MO KY CO DC
CA KS MO KY
NC
TN NC
OK TN
AR SC
AZ NM OK AR SC
MS AL GA AZ NM
MS AL GA
TX
LA TX
LA
FL
FL
AK
AK

HI Decreased -7% to -2.5%


HI

Decreased –2.4 to 0%

Increased 0.1% to 4%

Increased 4.1% to 7%

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.
7
Adults With No or Unstable Insurance Are Less
Likely to Get Preventive Screening Tests

Percent
Insured all year Insured now, time uninsured in past year Uninsured now
100
82
77 75
80
64
56 56
60
48

40 31

18
20

0
Pap test Colon cancer screening Mammogram

Note: Pap test in past year for females ages 19–29, past three years age 30+; colon cancer screening in past five THE
years for adults age 50–64; and mammogram in past two years for females age 50–64. COMMONWEALTH
FUND
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.
Adults Without Insurance Are Less Likely 8

to Be Able to Manage Chronic Conditions


Percent of adults ages 19–64 with at least one chronic condition*

Insured all year Insured now, time uninsured in past year Uninsured now

75

58 59

50
35
27
25 18 16

0
Skipped doses or did not fill Visited ER, hospital, or both for chronic
prescription for chronic condition condition
because of cost

THE
*Hypertension, high blood pressure, or stroke; heart attack or heart disease; diabetes; asthma, emphysema, or lung disease.
COMMONWEALTH
FUND
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).
9
Figure 12.

THE
COMMONWEALTH
FUND
10
International Comparison of Spending on
Health, 1980–2005
Average spending on health Total expenditures on health
per capita ($US PPP) as percent of GDP
7000
United States
Germany 16
Canada
6000 France
14
Australia
United Kingdom
5000 12

4000 10

8
3000

2000 United States


4 Germany
Canada
1000 France
2 Australia
United Kingdom
0 0

80 82 84 86 88 90 92 94 96 98 00 02 04 9 80 9 82 984 986 988 990 992 994 996 998 000 002 004
19 19 19 19 19 19 19 19 19 19 20 20 20 1 1 1 1 1 1 1 1 1 1 2 2 2 THE
COMMONWEALTH
FUND

Source: OECD Health Data 2007. 10


Cumulative Annual Changes in National
11

Health Expenditures Growth, 2000-2007


125
Net cost of private health insurance adminstration
109%
Family private health insurance premiums
100
Personal health care
91%
Workers earnings
75
65%

50

25 24%

2000 2001 2002 2003 2004 2005 2006* 2007*


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
THE
projections. COMMONWEALTH
SOURCE: A. Catlin, “National health Spending in 2005: The Slowdown Continues,” Health Affairs, January/February 2007, 143-153; J. FUND

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
Percentage of National Health Expenditures 12

Spent on Health Administration and Insurance, 2003


Net costs of health administration and health insurance
as percent of national health expenditures

8 7.3

6 5.6
4.8
4.0 4.1 4.2
4 3.3
2.6
1.9 2.1 2.1
2

0
a b c
*
ce nd pan a da om ds tri
a
al ia nd an
y
tes
n la n d n s r la a
Fr
a
Fi
n Ja Ca ng rl a Au ust e r
erm St
K i he A itz G te
d
d et Sw i
ite N Un
Un
a
2002 b1999 c2001
*Includes claims administration, underwriting, marketing, profits, and other administrative costs; THE
based on premiums minus claims expenses for private insurance. COMMONWEALTH
FUND
Data: OECD Health Data 2005.
Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2006.
13
Why Does the Current Health Insurance
System 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
THE
COMMONWEALTH
FUND
14

Roadmap to Health Insurance for All:


Principles 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
THE
COMMONWEALTH
FUND
15
What are the Options for Health Insurance Reform?
Mixed Private-Public
Tax Incentives and Group Insurance with
Individual Insurance Shared Responsibility
Principles for Reform Markets for Financing Public Insurance

Covers Everyone 0 + +
Minimum Standard Benefit Floor – + +
Premium/Deductible/
Out-of-Pocket Costs – + +
Affordable 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; THE
++ = Much better than current system COMMONWEALTH
FUND
Source: 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.
16
Medicare for All, Private Insurance Exchanges, Tax Incentive
Proposals Cause Major Shifts in Coverage, 2007
Current Law
Uninsured
47.8 Employer
Healthy Americans Act
(16%) 153.7 Dual Medicare
Uninsured
2.5
(Wyden)
(52%) Eligible 31.9 (1%)
Medicaid/ 8.0 (11%)
SCHIP (3%) HAA
37.5 Coverage
(13%) CHAMPUS 248.8
3.9 (84%)
Dual (1%)
Eligible
8.0
(3%) AmeriCare President Bush’s
Medicare (Stark) Proposal
31.9 Dual Eligible
(11%) Medicare 8.0 Uninsured
CHAMPUS CHAMPUS 31.9 (3%) 38.8
Employer
3.4 3.4 (11%) (13%)
145.2
(1%) (1%) (49%)
Employer Employer
Private Retiree 5.0
Non-Employer 3.3 (2%) Medicaid/
9.5 (1%) SCHIP
(3%) 38.5
(13%)

Medicare
39.9
(14%)
AmeriCare
246.8
(83%) CHAMPUS
3.4
Private
(1%)
Non-Employer
Total population = 295.1 million 29.3
(10%)
THE
COMMONWEALTH
FUND
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.
17
Some Reform Proposals Reduce Total Health System Spending,
But Federal Government Outlays Require Feasible Financing
(Change in Health Spending by Stakeholder Group,
Billions of Dollars, 2007)
President Healthy
AmeriCare
Bush’s Americans Act2
(Stark)
Proposal (Wyden)
Total Uninsured Covered,
9.0 45.3 47.8
Millions

Federal Government $70.4 $24.3 $154.5

State and Local


($0.3) ($10.2) ($57.4)
Government

Private Employers ($50.8) $60.2 ($15.2)

Households ($31.0) ($78.8) ($142.6)

Net Health System Cost in


($11.7) ($4.5) ($60.7)
2007 (in billions)
Total Uninsured Not
38.8 2.5 0
Covered1, Millions

1
Out of an estimated total uninsured in 2007 of 47.8 million. THE
COMMONWEALTH
2
Estimates reflect a mandatory cash-out of benefits on the part of employers that currently offer coverage. FUND

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
18
Creating Consensus:
Minimal Disruption in Current Coverage, 2004

CURRENT INDIVIDUAL MANDATE


CHAMPUS/ Uninsured
Uninsured Others 1%
CHAMPUS/ 15% Employer 1%
Others 58% Medicaid/
1% CHIP/FHIP
Employer
15%
Medicaid/ 59%
CHIP
Medicare
10%
14%

Non-group
Medicare
1%
12%
Congressional
Health Plan
Non-group
9%
4%

THE
COMMONWEALTH
FUND
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.
Creating Consensus: Choice between Private
19

Insurance and Public Program Coverage


New Coverage for Currently Uninsured

11m 13m 14m 1m

Congressional
Employer Group CHIP/FHIP Medicare
Health Plan
Coverage TOTAL = 43 m TOTAL = 38 m
TOTAL = 24 m
TOTAL = 165 m

3m 11m 3m 1m

Improved Coverage for Underinsured


THE
COMMONWEALTH
FUND
Source: K. Davis and C. Schoen, “Creating Consensus on Coverage Choices,” Health Affairs (Web Exclusive
April 23, 2003).
20

Health 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

THE
COMMONWEALTH
FUND
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Features of Candidates’ Approaches to Health Care Reform
Senator Senator Senator Mayor Senator Governor
Clinton Edwards Obama Giuliani McCain Romney
Individual
Mandate X X Children only No No No

Employer TK% of payroll,


small
Shared businesses
Responsibility exempt 6% of payroll TK% of payroll No No No
Tax credit
Subsidies for Health $2,500 for
Tax credit for Refundable tax Sliding scale insurance individuals,
Low-income premium >TK% credit on sliding premium credit for low- $5,000 for Premium
Uninsured of income scale subsidies income families subsidies

Medicaid/ Parents/ children


up to 250% FPL;
SCHIP childless adults
expansion X up to 100% FPL X No No No
Private Health
Choices Menu
through FEHBP National Health
& public Regional health Insurance Purchase Purchase
insurance plan markets with Exchange with private private
option modeled private & public private & public insurance in insurance in any Emphasis on
Risk pooling after Medicare plan options plan options any state state private markets
HIT, HIT, HIT,
Transparency, Transparency, Transparency,
P4P, Prevention, P4P, Prevention, P4P, Prevention,
Comparative Comparative Comparative HIT,
effectiveness, effectiveness, effectiveness, Transparency,
Chronic disease Chronic disease Chronic disease HIT, P4P, Prevention,
Quality and management, management, management, Transparency, Chronic disease HIT,
Disparities, Disparities, Disparities, Prevention, management, Transparency,
Efficiency Malpractice Malpractice Malpractice Malpractice Malpractice
THE
Malpractice
COMMONWEALTH
Measures reform reform reform reform reform reformFUND
22
Candidates’ Agreement on Health Care Reform Features
Senator Senator Senator Mayor Senator Governor
Clinton Edwards Obama Giuliani McCain 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 THE
COMMONWEALTH
insurance markets X X X No No NoFUND
Judging the 2008 Presidential 23
Candidates’ Health Plans
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 4 3 3 4 6 4
GDP
Consumer informed choices 7 6 7 4 6 4
Provider QI tools, best practices 8 7 7 3 5 3
Providers compete on 6 6 6 5 6 4
quality/price
No adverse effect on coverage or 7 8 7 5 6 4
patients
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 6 5 5 9 9 8
employers
TOTAL 86 83 81 65 82 64
THE
COMMONWEALTH
FUND
Note: Scale is 1-10; 10 is the best
Source: Marilyn Werber Serafini, "Judging the 2008 Health Plans," National Journal, October 26, 2007
24
Health 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
THE
COMMONWEALTH
FUND
25

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

THE
COMMONWEALTH
FUND
26
Visit the Fund’s website at
www.commonwealthfund.org

THE
COMMONWEALTH
FUND
27

Thank You!
Stephen C. Schoenbaum, Sara Collins,
M.D., Executive Vice
President and Executive Assistant Vice
Director, Commission on a President,
High Performance Health src@cmwf.org
System, scs@cmwf.org

Cathy Schoen, Senior


Vice President for Katherine Shea,
Research and Research
Evaluation Associate
cs@cmwf.org
ks@cmwf.org

THE
COMMONWEALTH
FUND
28

Appendix: Presidential Candidate Plans

THE
COMMONWEALTH
FUND
29
Senator 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 THE
COMMONWEALTH
FUND
30
Senator 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
THE
– Employer 6% of payroll contribution COMMONWEALTH
FUND
31
Senator 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)
THE
COMMONWEALTH
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– Employer contribution
32
Mayor 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
THE
COMMONWEALTH
FUND
33
Senator 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 THE
COMMONWEALTH
FUND
34
Governor 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 THE
COMMONWEALTH
FUND

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