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