two health reform challenges: passage and implementation walter zelman chair, department of health...
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Two Health Reform Challenges: Passage and Implementation
Walter Zelman
Chair, Department of Health Science
California State University, Los Angeles
University of Michigan (Go Blue)
September 24, 2010
Some Systemic Challenges: by the numbers, 2009-10
213 years 60 $1.4 million a day Several trillion dollars 400% of FPL 9% and rising 28 in 2011
The answers
213; years since the constitutional establishment limited (sometimes stalemated) government.
60: votes in the Senate $1.4 M: amount spent by health related interests lobbying,
January-June, 2009; per day Several trillion: Obama spending to date 400% income level that now needs subsidies 9% and rising; unemployment and failing economy 28 in 2011: rough projection of number of Republican
governors in office as states implement reform
Reform Challenges and/or Paradoxes:Why is this So Hard?
Health reform as legislative redistricting:
Reform elements are complex and interrelated. It is impossible to keep it simple or small. the simple becomes the complex and attracts concerns
Can’t have reform without cost control: but can’t get reform with cost control
Reform needs to reduce costs; but easiest way to get success is to increase spending
Challenges and Paradoxes
Reducing costs means changing the delivery system: that, many think, is the most difficult cost control and marketplace challenge
Comprehensive reform takes time: but legislative and political calendars and/or attention spans may not allow that time
Reform may need to happen in the middle, but the middle lacks energy
Challenges and Paradoxes
Public wants change in system, but less in personal circumstances: The incumbency phenomena
Public wants reform, but is wary of cost Reformers should have a Plan B, but putting
it on the table will make passing Plan A much harder: thus, comprehensive reform may be all or nothing
Challenges and Paradoxes
Problems with message:
--Hard to sell cost and coverage reforms at the same time; or, how does saving money cost $1 trillion?
--Stability and change: the system needs a shake-up, but you can keep what you like
Challenges and Paradoxes: 2010
2010 Messaging Can advocate, but not implement, cost
control; public fears too great. Reluctance to make reform about the
uninsured
Left with: insurance reforms: is this worth $1 trillion?
Why not health security for all?
WalterZelman Presentations
Why Reform was so hard
The Economy: deserves a slide of its own
Reform (spending) much harder in difficult economic times
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The Timing of Health Reform
Public concerns Regarding health care Costs and/or access
High Moderate Low
State of TheEconomy
Improving, Healthy
1993-941964-65
Incremental, targeted reform at best
Slowing growth, Recession
2009-10 Reform unlikely
Premium Increases v. Inflation: 1988-2009
-2
0
2
4
6
8
10
12
14
16
18
20
1988 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008
Inflation
Premiums
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Premiums and Poverty Levels: the Rising Costs of Reform
2000 2009 Percent Increase
250% of PovertyFamily of Four
44,007 55,125 25
AverageFamily Premium
5,844 13,375 129
Premium as % of 250% of Poverty
13.2 24
Clout of the Interests: 2000 v 2008
2000: Total spent by health sector: 237m--15% of total federal lobbying
--Most spent by any sector
2008: Total by heath sector: 484 m -- 14% of total federal lobbying
--Most spent by any sector
Source: Center for Responsive Politics
Lobbying Expenditures, in Millions 2009
Pharma BC/BS/AHIP AHA AMA AFL/SEIU0
5
10
15
20
25
30
Source: Center for Responsive Politics
Top Lobbying Industries: 2008
1. Pharmaceuticals
3. Insurance: includes some health, mostly other
4. Business Associations
10. Hospitals and Nursing Homes
14. Health Professionals
20. Health Services/HMOs
Source: Center for Responsive Politics
Percent who say they would support a universal health insurance system even if it…
Let’s Not Forget… Public Debates Matter
35%
33%
28%
18%
Limited their choice of doctors
Meant some treatments currently covered would no longer be covered
Meant there were waiting lines for non-emergency treatments
Meant they would pay either higher premiums or more taxes
Source: ABC News/Kaiser Family Foundation/USA Today Health in America Survey (conducted September 7-12, 2006)
Percent who support a universal health insurance system, in which everyone
is covered by a program like Medicare that is gov’t-run
and financed by taxpayers
56% 40%
Percent who support the current system, in which most people are covered through private employers, but some people have no insurance
Key (Apparent) Strategies for Passage
Promise cost control: but offer few specifics Don’t emphasize the uninsured: may be
necessary to protect against political attack Keep program costs down: means many
remain uninsured; alienate the base? Keep major interests out of the opposition
camp: conflicts with keeping costs down Getting support of key interests means
higher costsWalterZelman Presentations
Reform Passes: But Exposure is Substantial
Messaging problem leaves reform goals unclear
Those with good insurance may not see the value
Necessary absence of visible cost control leaves reform with visible costs, less visible benefit
Size and complexity leaves reform open to traditional big government challenges
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Exposure (cont)
States left with major implementation requirements; state leadership may not support reform
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Implementation challenges
State implementation Early benefits, but not lower costs: premiums
likely to continue rising Public Opinion Politics and political opposition
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Some Implementation Challenges: State Exchanges
Must be in place by 2014: some issues– Who governs– Strong purchaser v price-taker– Leveling the playing field– Small group and individual market pools– Purchasing/selling in and out of the exchange
WalterZelman Presentations
Public Opinion, August, 2010
Fav/oppose Ref Country better off/worse, no diff
05
101520253035404550
Kaiser Family Foundation Walter Zelman Presentations
Reform Danger Signs: Governors
2010 Gubernatorial Incumbents
26 Democrats
13 Republicans
1 Independent (Florida)
2010 Elections: 37 Gubernatorial elections
19 Democratic held seats
17 Republican held seats
1 Independent
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2010 Gubernatorial Forecast: 37 Races Cook Political Report: Sept 18, 2010
Solid D Likely D Lean D Toss-up Lean R LikelyR Solid R0
2
4
6
8
10
12
14
16
18
WalterZelman Presentations
Reasonable Projection: Governors, 2011
Republican: 28
Democrat: 22
(Based on all seats leaning/likely D or R going to that party and split of toss-up races)
WalterZelman Presentations