CONFRONTING THE FUTUREMarch 18-21, 2018

CCAR

129THANNUALCONVENTIONOFTHECENTRALCONFERENCEOFAMERICANRABBIS

The Progress of US Health Reform: The Affordable Care Act and Beyond

Prof.JohnEMcDonoughHarvardT.H.ChanSchoolofPublicHealthMarch20,2018

Session Outline

• The Big Picture of the U.S. Healthcare System • Some Essential Basics about the ACA • Where Are We Right Now? • Reform Options from Here…

• This Afternoon • Community Health and Collective Impact

1. The Big Picture of the U.S. Healthcare System

JAMA – This Past Week •  Papanicolas I, Woskie L, Jha, A. “Health Spending in the United

States and Other High-Income Countries.” JAMA. 2018;319(10):1024-1039.

• Cross-national comparison of US, UK, Canada, Germany, Australia, Japan, Sweden, France, Netherlands, Switzerland, and Denmark

•  “the data suggest that the main driving factors (of high US healthcare spending) were likely related to prices, including prices of physician and hospital services, pharmaceuticals, and diagnostic tests … administrative costs appears much higher in the United States … efforts targeting utilization alone are unlikely to reduce the gap in spending between the United States and other high-income countries, and a more concerted effort to reduce prices and administrative costs is likely needed.”

Health Care Spending • Gross Domestic Product (GDP): US 3rd highest at $52,100

• Poverty Rate: US #1 at 24% vs. 18% mean • US has lowest % of population >age 65

• US @ 14.5% vs. 18.2% mean • Health Spending:

• US is #1 at $9403 vs. $5419 mean • US health spending was 17.8% GDP in 2016; • From Australia at 9.6 to Switzerland at 12.4.

Social Determinants of Health/Population Health • Smoking: 2nd best @ 11.4% >15 smoke daily; mean 16.6%

• Alcohol: 4th best @ 8.8 vs. 9.1 mean • Obesity: Worst for obese or overweight adults @ 70.1%; mean 55.6%; range 23.8-63.4

• Life Expectancy in Years: Worst at 78.8 years: range 80.7-83.9 years; mean 81.7 years

• Infant Mortality: Worst – 5.8/1,000 live births; 3.6 mean • Highest Neonatal mortality: 4.0 vs. 2.6 • Highest maternal mortality: 26.4 per 100K vs. 8.4 mean

• 2nd worst low birthweight – 8.1% vs. 6.6% mean

Health Insurance/Admin Costs/Pharma • Health Insurance:

•  US at 90% insured, lowest rate. Mean is 99%. All other 10 have automatic/compulsory enrollment and 99/100% covered.

•  Administrative & Governance Costs: •  Highest at 8%, vs. 1-5% in all other countries, and 3% mean

•  Pharma: •  Per capita cost at $1443 vs. range of 466 (NLD) to 939 (CSE) – 749 mean. •  For 3 of 4 common meds (Crestor, Lantus, Advair, Humira), US price more

than double the next highest price •  Innovation – US and CSE had highest # of new chemical entities at 111 and

26. US is 57% of total production of new chemical entities – 194 total •  US highest level of private spending on drugs @ 36%, vs. mean of 8%

(CA@30)

Services and Usage •  It’s Mostly Not About Overuse

•  Hospital Beds: 2.8 per 1,000 vs. 4.8 mean •  Discharges: 125 per 1,000: 84 in Canada vs. 255 in Germany, 150 mean •  Nearly all utilization measures near or below average •  Mental and Behavioral Health discharges: 679 per 100K, vs. 736 mean •  Length of Stay – below mean: normal delivery 2 vs. 2.8; AMI – 5.4 vs. 6.1

• With Some Important Exceptions •  MRI units in US 2nd: 38 per 1 million; vs. 22 mean •  CT Scan units in US 3rd: 41 per 1 million vs. 36.5 mean; •  High avoidable hospitalization for diabetes: 191 per 100K vs. 125.6 mean •  High avoidable hospitalization for asthma: 89.7 per 100K vs. 42.4 mean

• US quality and access measures vary •  Lowest public satisfaction with health system: 19% say it works

well

Health Care Workforce • Not Too Many Physicians or Nurses

•  Physicians: 2.6 per 1,000 or 8th, vs. 3.3 mean; •  Share of physicians in primary care: 43%, 8th, right at mean of 43% •  Nurses: 11.1 per 1,000 vs. 11.8 mean

• Salaries are the highest: •  Physician generalists at #1: $218,173; range of $86,607 (SW)-

$154,126 (GR); “nearly double the mean remuneration” •  Physician specialists #1: $316,000 vs. $98,452 (SW) to $202,291

(AUS) •  Nurses #1: $74,160 vs. 42,492 (FR) to $65,082 (NE) •  HC Wages as Ratio to Mean National Wage: US #1: specialists

5.3-3.7; generalists 3.6-2.7; nurses 1.23 to 1.1

Summary of Indicators • Highestspendingonhealthcarebyfar• Worstpopulationhealth/socialdeterminantsofhealthmeasuresbyfar

•  Obesity•  LifeExpectancy•  InfantMortality

• Notexcessivesupplyoruseofmedicalservices•  Lowestrateofhealthinsurancecoverage• Highestadministrative/systemoverheadcosts• Highestprices/salariesformostlyeverything,especiallypharmaceuticals

#1:DriveforNearUniversalCoverage

#2: Cost: Health Spending per Capita, 2011 Adjusted for Cost of Living

* 2010. Source: Commonwealth Fund and OECD Health Data 2013.

% GDP

Per Capita Health Care Spending among OECD Nations

0

2

4

6

8

10

12

14

16

18

1980 1983 1986 1989 1992 1995 1998 2001 2004 2007 2010 2013

US (17.1%) FR (11.6%) SWE (11.5%) GER (11.2%) NETH (11.1%) SWIZ (11.1%) DEN (11.1%) NZ (11.0%) CAN (10.7%) JAP (10.2%) NOR (9.4%) AUS (9.4%)* UK (8.8%)

Notes: GDP refers to gross domestic product. Dutch and Swiss data are for current spending only, and exclude spending on capital formation of health care providers. Source: OECD Health Data 2015.

Health Care Spending as Share of GDP, 1980–2013 Health Care Spending as % of Gross Domestic

Product

* 2012.

The Value Issue

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US spends way more and has lower life expectancy than many other OECD countries

Health & Social Service Spending Combined

Source: EH Bradley et al. Health and social services expenditures: associations with health outcomes. BMJ Qual Saf; 2011;20:826-831.

ImbalanceBetweenMedicalandNon-MedicalSocialSpending

E.C.Schneider,D.O.Sarnak,D.Squires,A.Shah,andM.M.Doty,Mirror,Mirror:HowtheU.S.HealthCareSystemComparesInternationallyataTimeofRadicalChange,TheCommonwealthFund,July2017.

AUS CAN FRA GER NETH NZ NOR SWE SWIZ UK US

OVERALL RANKING 2 9 10 8 3 4 4 6 6 1 11

Care Process 2 6 9 8 4 3 10 11 7 1 5

Access 4 10 9 2 1 7 5 6 8 3 11

Administrative Efficiency 1 6 11 6 9 2 4 5 8 3 10

Equity 7 9 10 6 2 8 5 3 4 1 11

Health Care Outcomes 1 9 5 8 6 7 3 2 4 10 11

Exhibit 2

2017 Health Care System Performance Rankings

Source: Commonwealth Fund analysis.

CommonwealthFundInternationalComparisons

2. Some Essential Basics about the ACA

The Affordable Care Act by Title

# Title Name Detail 1 Quality, Affordable Health Care for All Americans

Private Insurance Reform and coverage expansion

2 Role of Public Programs Medicaid expansion/CHIP

3 Improving the Quality and Efficiency of Health Care Medicare/delivery system reform

4 Prevention of Chronic Disease and Improving Public Health

Prevention/wellness/public health

5 Health Care Workforce Workforce

6 Transparency and Program Integrity Fraud, sunshine, comparative effectiveness research

7 Improving Access to Innovative Medical Therapies Biosimilars

8 Community Living Assistance Services & Supports CLASS (repealed)

9 Revenue Measures New taxes and fees

10 Reauthorization of Indian Health Care Improvement Act plus Health Care Education & Reconciliation Act

Manager’s Amendment plus HCERA

The Affordable Care Act (ACA) by Title

3. Where Are We Right Now?

On Health Insurance Coverage • RepealandReplace–#1legislative2017goalforDCRepublicans–isdeadfor2018and,morethanlikely,foralongtimetocome

• Republicans’NewIdentityCrisis–Whatarewefor?•  SabotageandUnderminetheACAateverychance

•  AssociationHealthPlans•  Extensionofshortterminsuranceplansfrom3to12months•  WorkrequirementsasconditionforMedicaideligibility

•  Fixasmuchaspossiblebecauseit’snowinourhands•  Reinsurancetolowerpremiums•  Outreachandenrollmentfunding

•  MalignNeglect

• Democrats’StruggleCompetitionforNewIdeas

4. Reform Options from Here…

Democrats’ Reform Options from here… • Single Payer – Medicare for All

• 60 Senate Democratic votes or bust – literally • Medicare for More

• e.g.: Center for American Progress’ “Medicare Extra” • Solo Targets:

• Drug Pricing • Transparency/surprise billings etc. • Protections from high cost sharing (i.e.: deductibles) • Medicaid Expansion in 19 non-participating states

• State/Local/Neighborhood Opportunities

ACA Delivery System Reforms Are Holding

Pre-ACA System ACA System Fee for service Fee for Value

Pay for performance Pay for Outcomes

Underlying system ethos based on licensure, accreditation, and professional responsibility

Accountable Care and The Institute for Health Care Improvement’s (IHI) “Triple Aim”: •  Improve the patient experience

of care •  Lower per capita costs •  Improve population health

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ACA on the Verge of a Nervous Breakdown

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Afternoon Session:

OpportunitiesforCommunityHealthImprovement

FSG: Collective Impact • CommonAgenda/SharedVision• ShareMeasurementwithshortlistofindicators• MutuallyReinforcingActivities

• Diversestakeholdersacrosssectors• Differentiated&mutuallyreinforcingactionplan

• ContinuousCommunication• BackboneSupport

• Ongoingsupportforindependent,funded,dedicatedstaff

Additions to Five Collective Impact Pillars • Priority placed on equity •  Include community members in the collective • Recruit and co-create with cross-sector partners • Use data to continuously learn, adapt, improve • Cultivate leaders with unique system leadership skills • Focus on program and system strategies • Focus on program and system strategies • Build a culture that fosters relationships, trust, and respect

across participants • Customize for local context