This is the healthcare marketplace specialization, healthcare marketplace

overview course, and this is Module 3.3.3, Current U.S. Health Reform.

My name is Stephen Parente.

So what has been proposed to address the uninsured problem?

We talked about the scale a bit and where things have gone before and

the goal of getting there.

There are really several major buckets of initiatives that you can think about here.

One is pay or play.

This is generally aimed at employers, to pay or

play, that is either they pay by, excuse me, play by having

people get their insurance provided by work or they pay essentially a cost.

This was initiated in 1992, it failed.

There were other points incidents, before it was attempted as well.

One of the issues is whether or not states can get out of this or

not, in terms of the provisions that's there.

Both Hilary Clinton and

President Obama's proposal in 2008 had elements of pay or play.

And then, Mitch Rodney's proposal in 2006, not the comedy

Rodney, had their proposals there as well.

But it is not part in very limited form, part of our current law.

There's employer mandate, but

there are many other pieces of the affordable care act as well.

National health insurance, the idea of everybody being covered,

people sort of travel around the world, as I do from time to time, people will say,

you're in health care, why couldn't you fix this thing?

Well, here's the problem.

It's not as if people didn't try.

There were actually congressional votes in 1918, 1935,

1948, 1965, 1974, 1994.

And they've always been dead on arrival.

Why?

It's hard to say what's going to change it.

Basically after two World Wars, depressions,

if that can provide a catalyst, it's not clear what would do it now.

But generally the flavor for the U.S.

is to try to do things more through the private sector.

And so, instead what we have is a variety of incremental coverage solutions.

We've got coverage for the elderly and the disabled through Medicare 1966.

For folks that were poor through the states, 1967,

end stage renal disease 1974 and then poor kids and their moms in 1997.

So there's a track record of success, but potentially there's incremental and

could cost more in the long run.

So we do have a brand new law that has come out there.

The Affordable Care Act, otherwise known as ACA.

And one of the key pieces is the concept of marketplaces and or exchanges.

They're called in the law of stages that later were revised by the administration,

by the Obama administration called market places.

And so, there's lots of different elements of what's there.

There are health insurance standards in terms of minimum requirements.

There are funding that comes from the federal government, the structure that's

organized by the federal government and the states, eligibility is determined

based on what's in the statute, and generally you have to be, basically,

133% of the federal poverty line to be able to get the Medicaid coverage.

And then, above that, there are exchange options that are available to you,

there's also the outside market meaning getting coverage from

the individual insurance market that's not part of the exchanges and

the section 125 which relates to the Medicaid market as well.

So then we looked at other pieces that were part of the ACA,

again fully implemented in 2014, passed in 2010.

And so, one of the things that comes from that is the CMS Innovation Center,

CMS Center for Medicare and Medicaid services.

We have lots of pilots and demonstrations.

We have the idea of having a Medicaid Global Payment Demonstration where

Medicaid providers are going to get one lump sum to take care of hospitalization,

everything that happens inside that hospitalization and

even the days that go along with that.

There's the notion of actually having this concept of a medical home.

For the Medicaid population where a group practice would be assigned a set of

patients much like managed care to manage them in a much more holistic and

comprehensive manner.

There's the idea of having bundled payments also for the Medicaid program

that would be put into place, the idea of value based purchasing, of insurance.

I mean, there has to be some quality metrics to know what you're

actually buying before you actually put the dollars in.

There were changes for Medicare, for the elderly as well,

to essentially reduce hospital admissions by giving hospitals

penalties if they actually had readmissions that are reported.

And then, finally, this notion of bundled payment.

Basically, the idea is like bundled cable services that we're going to pay for

a variety of different services not just one piece at the time for

a set of major conditions.

So when we think about what the impact of national health reform will be,

lots of estimates vary.

When the law was passed for the Affordable Care Act in 2010, there was

the congressional budget office, otherwise known as CBO, that made their estimates.

They said that the plan would cost $940 billion.

They said I would save $130 billion.

I actually did my own estimates, later published in the journal,

showing that that estimate was probably too low,

that the cost could be 1.6 trillion, and if that was the case,

we were actually going to be spending more money than increasing the deficit.

Now, again, just going by CBO's numbers, where does that money get spent?

Really, the two major areas is this part here,

which is the Medicaid expansion for everyone in the states.

Now, that actually later got countermanded in part by the Supreme Court.

We'll talk about that in a second.

And then, through health insurance exchanges, essentially premium subsidies.

And there's other exchange premium credits that come into the design as well.

Plus their risk that are reimbursed in this space.

Nothing really happened prior to 2014, then in 2014.

Where does all the money come from to essentially pay for health reform?

The largest chunk actually comes from this part here which is to reduce

physician fees for Medicare doctors, which doesn't really have

anything to do with folks under the age of 65, people were concerned that they were

going to be taking money from 1 population to pay for care for care for another.

But that was what was in the law and that would do it.

The problem was it hasn't been fully implemented,

we'll focus on that for a second.

Medicare Advantage is an HMO plan designed for

seniors that want to readjust their rates but that would yield additional savings.

The other one was to have additional savings from Medicare and

readjusting those savings as well.

There was a thought that by reinsurance and risk adjustment you would get

additional dollars coming back from the insurers to pay for risk adjustment.

So you add all these up there were pretty substantial costs,

there's even an additional hospital tax that was going to be applied as well.

When you put the two pieces together, the money coming in,

the money coming out, estimate.

This is again what gives you by 2019, $122 billion in net savings where initially

you sort of spend more money than you come with the deposit but

then you start spending more money again.

So that's the trend, the problem is that there are several pieces that may not

actually happen, so for example, there's a market

basket update that has physicians and

Medicaid which are not paid very much money in hospitals as well,

get the same rate as Medicare temporarily, that temporary aspect could go away.

If it does go away it's going to be a lot of extra cash that has to go out.

Also, this idea of the Medicare Physician Fee Fix,

which has finally been thrown away, it hasn't been in operation for a while.

Those dollars, as well, would not necessarily be there.

There was an additional excise tax.

This is the tax for medical devices and then

well also what's known as the Cadillac tax of the pieces that's now been suspended.

So now the tax isn't there.

And actually in the Class Act which was designed for long term care insurance,

that has also been eliminated as well.

So really, all these components that we're to pay for

Affordable Care Act almost all of them had been removed.

And actually when you've put those pieces together and extend it over a period of

time, it's a much bigger impact than you would otherwise expect.

It leads to essentially additional deficit impact

of $540 billion or even longer because of 2029.

So train wrecks like this could happen to DC.

This is a bit of an illustration.

This is a little bit of a train buff myself.

This is Union Station in Washington DC, the nation's capital.

This is actually an older picture where an electric locomotive,

also known as the GG1, actually a beautiful art deco design, but

actually in operation for way longer a time than they were probably expected on

the Pennsylvania Railroad and later in Amtrak.

Was running, in this particular instance its brakes were blown and

it plowed right into the station.

Amazingly, no one was really hurt by, but it actually,

there's a subbasement to this area here, and it collapsed.

Folks that visit DC today, this would be your food court and

the shopping court above when you come in.

The renovation in DC, if you've ever been there, that station is just stunning.

It's one of the first major urban renovations in the 80s and 90s.

It sort of set the pace for the rest of the country, and well worth a visit.

This concludes our module on health reform today.

3.3.3 Current U.S. Health Reform

Healthcare Marketplace

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