THE COMMONWEALTH

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Health Care Reform in the 2008 Health Care Reform in the 2008 Presidential ElectionPresidential Election

Sara R. Collins, Ph.D. Sara R. Collins, Ph.D. Assistant Vice PresidentAssistant Vice President

The Commonwealth FundThe Commonwealth FundAlliance For Health Reform Briefing Alliance For Health Reform Briefing

March 14, 2008March 14, 2008

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Why Does the Current Health Insurance System Why Does the Current Health Insurance System Fail to Promote High Performance?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

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Five Key Strategies Five Key Strategies for High Performancefor High Performance

1. Extending affordable health insurance to all

2. Aligning financial incentives to enhance value and achieve savings

3. Organizing the health care system around the patient to ensure that care is accessible and coordinated

4. Meeting and raising benchmarks for high-quality, efficient care

5. Ensuring accountable national leadership and public/private collaboration

Source: Commission on a High Performance Health System, A High Performance Health System for the United States: An Ambitious Agenda for the Next President, The Commonwealth Fund, November 2007

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Roadmap to Health Insurance for All: Principles for Reform

• Provides equitable and comprehensive insurance for all

• 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

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Health Insurance Reform and the Presidential Candidates: Two Distinct Approaches

• Expanded coverage through individual insurance market with tax incentives, changes to employer benefit tax exemption, and deregulation of state markets (McCain)

• Universal coverage through mixed private–public group insurance, reorganized and regulated private group insurance markets, with shared responsibility for financing from government, employers, individuals (Clinton, Obama)

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Features of Candidates’ Approaches to Health Care ReformClinton Obama McCain

Individual Mandate Yes Children only No

EmployerShared Responsibility

Large firms offer or contribute

X% of payroll

Offer or contribute X%of payroll No

Medicaid/ SCHIP Expansion Yes Yes No

Private Insurance Markets

New group Health Choices Menu through FEHBP with private &

public plan options

New group National Health Insurance

Exchange with private & public plan options

Purchase private individual

insurance in any state

Subsidies for Low to Moderate Income

Tax creditfor premium

>X% of income

Sliding scale premium subsidies

Tax credit $2,500 for individuals,

$5,000 for families

Quality and Efficiency Measures

HIT, Transparency, P4P, Prevention,

Comparative effectiveness, Chronic disease management,

Disparities, Malpractice reform

HIT, Transparency, P4P, Prevention,

Comparative effectiveness, Chronic disease management,

Disparities, Malpractice reform

HIT, Transparency, P4P, Prevention, Chronic disease

management, Malpractice reform

Source: S. R. Collins and J. L. Kriss, Envisioning the Future: The 2008 Presidential Candidates' Health Reform Proposals, The Commonwealth Fund, January 2008.

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Where Leading Candidates Stand on Health Care Reform FeaturesClinton Obama McCain

Most Candidates From Both Parties Agree

Expand coverage Yes Yes Yes

Health IT Yes Yes Yes

Transparency Yes Yes Yes

Malpractice reform Yes Yes Yes

Prevention Yes Yes Yes

Some Candidates Agree Yes

Pay for performance Yes Yes Yes

Comparative effectiveness Yes Yes Yes

Candidates Differ

Universal coverage Yes Yes No

Individual mandate Yes Children only No

Employer pay or play Yes Yes No

Changes to employer benefit tax exemption Yes No Yes

Regulation of insurance markets Yes Yes No

Financing Source Yes Yes No

Source: S. R. Collins and J. L. Kriss, Envisioning the Future: The 2008 Presidential Candidates' Health Reform Proposals, The Commonwealth Fund, January 2008.

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Support for the Proposal That Employers ShouldEither Provide Health Insurance to Their Employees orContribute to a Fund That Would Help Cover Workers

Without Health Insurance

8188

7379

0

25

50

75

100

Total Democrat Republican Independent

Percent of adults who say that employers should eitherprovide health insurance or contribute to a fund

Source: S. R. Collins and J. L. Kriss, The Public's Views on Health Care Reform in the 2008 Presidential Election, The Commonwealth Fund, January 2008. Analysis of the Commonwealth Fund Biennial Health Insurance Survey (2007).

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Support for a Health Reform ProposalSupport for a Health Reform ProposalThat Requires That Everyone Have Health Insurance,That Requires That Everyone Have Health Insurance,

with Government Helping Those Who Cannot Afford It with Government Helping Those Who Cannot Afford It

4050

2538

28

30

27

30

0

25

50

75

100

Total Democrat Republican Independent

Somewhat favor

Strongly favor

Percent of adults who strongly/somewhat favor a requirementthat everyone have health insurance

80

52

6868

Source: S. R. Collins and J. L. Kriss, The Public's Views on Health Care Reform in the 2008 Presidential Election, The Commonwealth Fund, January 2008. Analysis of the Commonwealth Fund Biennial Health Insurance Survey (2007).

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Who Do You Think Should Pay for Health Insurancefor All Americans?

66 67 66 70

15 209

148 5

11610 66 3

0

25

50

75

100

Total Democrat Republican Independent

Mostly individuals

Mostly employers

Mostly the government

Shared by individuals, employers, and the government

Percent of adults who say health insurance costs should be paid for by:

Note: Bars do not total to 100% because survey respondents who refused to answer or answered “don’t know” are not shown.Source: S. R. Collins and J. L. Kriss, The Public's Views on Health Care Reform in the 2008 Presidential Election, The Commonwealth Fund, January 2008. Analysis of the Commonwealth Fund Biennial Health Insurance Survey (2007).

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Fifteen Options that Achieve SavingsFifteen Options that Achieve SavingsCumulative 10-Year SavingsCumulative 10-Year Savings

Producing and Using Better Information• Promoting Health Information Technology -$88 billion• Center for Medical Effectiveness and Health Care Decision-Making -$368 billion• Patient Shared Decision-Making -$9 billion

Promoting Health and Disease Prevention• Public Health: Reducing Tobacco Use -$191 billion• Public Health: Reducing Obesity -$283 billion• Positive Incentives for Health -$19 billion

Aligning Incentives with Quality and Efficiency• Hospital Pay-for-Performance -$34 billion• Episode-of-Care Payment -$229 billion• Strengthening Primary Care and Care Coordination -$194 billion• Limit Federal Tax Exemptions for Premium Contributions -$131 billion

Correcting Price Signals in the Health Care Market• Reset Benchmark Rates for Medicare Advantage Plans -$50 billion• Competitive Bidding -$104 billion• Negotiated Prescription Drug Prices -$43 billion• All-Payer Provider Payment Methods and Rates -$122 billion• Limit Payment Updates in High-Cost Areas -$158 billion

Source: Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending, Commonwealth Fund, December 2008.

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Savings Can Offset Federal Costs of Insurance For All: Savings Can Offset Federal Costs of Insurance For All: Federal Spending Under Two ScenariosFederal Spending Under Two Scenarios

$82

$122

$205

$10$13$31

$0

$50

$100

$150

$200

$250

2008 2012 2017

Federal spending under insurance alone

Net federal with insurance plus savings options*

Dollars in billions

* Selected options include improved information, payment reform, and public health.Data: Lewin Group estimates of combination options compared with projected federal spending under current policy..Source: Bending the Curve: Options for Achieving Savings and Improving Value in U.S. Health Spending , Commonwealth Fund, December 2008.

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ReferencesS. R. Collins and J. L. Kriss, Envisioning the Future: The 2008 Presidential Candidates' Health Reform Proposals, The Commonwealth Fund, January 2008.

S. R. Collins and J. L. Kriss, The Public's Views on Health Care Reform in the 2008 Presidential Election, The Commonwealth Fund, January 2008.

K. K. Shea, S. R. Collins, and K. Davis, Health Care Opinion Leaders' Views on the Presidential Candidates' Health Reform Plans, The Commonwealth Fund, January 2008.

The Commonwealth Fund Commission on a High Performance Health System, A High Performance Health System for the United States: An Ambitious Agenda for the Next President, November 2007.

S. R. Collins, C. Schoen, K. Davis, A. K. Gauthier, and S. C. Schoenbaum, A Roadmap to Health Insurance for All: Principles for Reform, The Commonwealth Fund, October 2007.

www.commonwealthfund.orgwww.commonwealthfund.org