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Historically, most policies have covered: Hospital Physician Some preventive care Some cost-sharing, possibly with catastrophic cap If the goal is to expand coverage to more individuals: Who receives coverage (all, low income, kids, disabled, workers)? Bare-bones policies or comprehensive health insurance? One standard benefit package, standardized packages, or tailored plans? How much cost-sharing (deductibles, coinsurance, maximum per year)?5*Z 75*Z 5Paying for CarelHow is health insurance financed today? Employer-sponsored: Employee/employer contributions/foregone wages, tax exclusion Medicare: Payroll taxes, federal income taxes, enrollee premiums (Part B income-related in 2007), and beneficiary cost-sharing Medicaid: Federal income taxes and state tax revenues, nominal cost-sharing If the goal is to expand coverage to more individuals: How should it be financed? Should premiums be related to a person s income? Should the current tax exclusion for employer coverage be limited? Stretch limited resources by offering less generous benefits? Note: Strategies for increasing efficiency (Health IT, P4P, etc.) to be discussed in January (# 7d (AxH7 \%Incremental vs. Comprehensive Reforms If the goal is to reform the health care system, how do we get there? Comprehensive Focus: Achieve coverage for all Examples: Individual mandates; Single payer systems; Voucher system Incremental Focus: Expand coverage to certain populations, improving insurance markets, promoting quality reforms, etc., but not achieve coverage for all Examples: Subsidies for individually-purchased insurance; Medicare or Medicaid expansions; Employer mandates; Health Savings Accounts (HSAs); Quality incentives (January materials)F d CF<         l           !Combining Incremental ReformsYComprehensive reforms can be built on frameworks that combine multiple incremental strategies (addressing quality, efficiency, cost, as well as access) However, comprehensive reforms have stated principal goal of guaranteeing coverage for all Features must include: Formal structure that ties parts together Public commitment Accountability  [ M W; Incremental Reforms$ n SubsidiescGoal: Reduce number of uninsured by subsidizing purchase of health insurance, often through tax credits Examples of subsidy proposals: Provide tax credits to low and middle-income to buy insurance on individual market Create a tax deduction for purchase of individual insurance Provide tax credits for businesses who offer health insurance to employees RfoMedicare or Medicaid ExpansionsCGoal: Reduce number of uninsured by expanding eligibility for existing government programs (e.g., Medicaid, Medicare) Examples of expansion proposals: Raise income ceiling for Medicaid and SCHIP eligibility Extend public coverage to all uninsured children Offer Medicare to more adults (e.g., age 55-64) without insuranceBtmEmployer MandateshGoal: Increase access to health insurance for workers and their families, by requiring employers to offer health insurance Examples of employer mandate proposals: Require employers to cover percentage of premium; small employers in purchasing pools Impose  free rider surcharges on employers and employeesBy&p Health Savings Accounts]Goal: HSAs and other forms of consumer-directed care have a goal of making health coverage more affordable by encouraging consumers to be more cost-conscious and focus on healthier behaviors Features of HSAs: People set aside their own money, before taxes, to pay for health care Usually combined with high-deductible health insurance Examples of HSA and other consumer-directed care proposals: Tax credits for employer contributions to HSAs Revise tax definition to include deduction for HSAs and allow people to carry up to $500 in unused flexible spending account (FSA) money over from year to year  < : Comprehensive Reforms$ s Individual MandatesGoal: Achieve universal coverage using current system as base Examples of individual mandate proposals: Require individuals to buy insurance, and provide tax credits to do this; those with the lowest income would pay zero premium Mandate that everyone have health insurance or pay modest penalties Create incentives for uninsured to buy into proposed  Medicare Plus program, but later impose individual mandate if high number of uninsured persons remains f> *` ;(at  Single PayerGoal: Achieve universal coverage and reduce administrative costs Examples of single payer model proposals: Physicians for a National Health Insurance Program: Comprehensive benefits (medical, dental, LTC, Rx, mental health) Medicare, Medicaid, private health insurance restricted or eliminated For-profit hospitals phased out; hospitals given set budget for year Doctors salaried or paid on fee-for-service basis by federal government Global budget that grows each year with GDP Copayments, deductibles low or zero; financed through variety of taxes State-designed comprehensive insurance CA, NY, MA...BZ Z*Z4ZZ5Z?(45{Voucher SystemGoal: Achieve universal coverage for basic services Example of voucher system (Emanuel & Fuchs proposal): Guaranteed enrollment and renewal of risk-adjusted voucher Choice of plans offering basic services Additional services available for higher premium with after-tax dollars Financing through value added tax (VAT) Employer-sponsored health insurance, Medicaid, Medicare eliminatedZ5 634" Combining Incremental Reforms $ Oregon Business Council Package of incremental strategies: Changes to control cost growth ! system savings ! increased coverage No formal integration of public and private initiatives Employers strategies: HSAs, increase cost-sharing, etc. to make consumers more cost-conscious Quality incentives (P4P, health IT to be discussed in January) Increase information on quality, costs, etc. (To be discussed in January) Government s role: Streamline regulation for Medicare and Medicaid Support for health IT development and standards Malpractice and insurance market reforms Public health initiatives and consumer education&ZZZZZZ! L  )Massachusetts Health Care Trust (S. 755) ,Integrated package leading to comprehensive reform: Single payer: eliminates private insurance coverage for basic benefits Coverage for all Massachusetts residents Legislative timetable Government s role: Oversee delivery of health care services to Massachusetts s residents Collect and disburse funds Negotiate methods and rates of compensation with health care providers and facilities, and approve capital expenditures in excess of $500,000 Support for health IT development and standards Support development and implementation of health quality standards Support development of innovative approaches to health promotion, health education, and research r4ZZ ZZZ4/       0` 33` Sf3f` 33g` f` www3PP` ZXdbmo` \ғ3y`Ӣ` 3f3ff` 3f3FKf` hk]wwwfܹ` ff>>\`Y{ff` R>&- {p_/̴>?" dd@ ? " Pd@ @`d n?" dd@   @@``PR    @ ` ` p>>   (  d   C .Abackground"  6&     T Click to edit Master title style! !  0x)  "   FClick to edit Master text styles Second level Third level Fourth level!    GH  0޽h ? 3380___PPT10.` "[ Default Design( 0 8(     NYckk z%  c v* K%%KKpp  N\Cckk  ?% c x* K%%KKppd  c $ ?XK  c4  NTckk  ) c RClick to edit Master text styles Second level Third level Fourth level Fifth level!     S  T(_ckk z  c v* K%%KKpp  Tckk  ? c x* K%%KKppH  0.k ? 3380___PPT10.DX  ,(  , , 0P] z%  ] X*  , 0]  ?% ] Z*  , 6D] z  ] X*  , 6]  ? ] Z* H , 0.k ? 3380___PPT10.{O#  0   &P (   ~   s * `p   H   0޽h ? f___PPT10i.%@Wa+D=' = @B +   0 @\0(  \x \ c $l    x \ c $@m 0   H \ 0޽h ? 33___PPT10i. n1+D=' = @B +  0 80(  8x 8 c $c  c x 8 c $\c c H 8 0޽h ? 33___PPT10i. n1+D=' = @B +  0 @0(  @x @ c $$tc  c x @ c $tcp c H @ 0޽h ? 33___PPT10i. n1+D=' = @B +0  0 `$0(  $x $ c $ic  c x $ c $jc c H $ 0޽h ? 3380___PPT10.g0  0 0(  x  c $c  c x  c $c@ c H  0޽h ? 3380___PPT10.g#   0   &`d(  d~ d s *(c`p  c H d 0޽h ? f___PPT10i.%@Wa+D=' = @B +}  0 $(  r  S  c  c r  S |c c H  0޽h ? 33___PPT10i.ޱ+D=' = @B +}  0  $(  r  S c  c r  S `c c H  0޽h ? 33___PPT10i...+D=' = @B +}  0 $(  r  S c  c r  S c c H  0޽h ? 33___PPT10i.$I+D=' = @B +}  0 0$(  r  S Hc  c r  S  c c H  0޽h ? 33___PPT10i.+D=' = @B +#   0   &l(  l~ l s *,c`p  c H l 0޽h ? f___PPT10i.%@Wa+D=' = @B +}  0 `$(  r  S ,c  c r  S xc c H  0޽h ? 33___PPT10i.r#+D=' = @B +}  0 p$(  r  S _]  ] r  S Pc] ] H  0޽h ? 33___PPT10i.F+D=' = @B +  0 0(  x  c $<]  ] x  c $] ] H  0޽h ? 33___PPT10i.F+D=' = @B +#  0   & (  ~  s *]`p  ] H  0޽h ? f___PPT10i.%@Wa+D=' = @B +   0 t0(  tx t c $0!]  ] x t c $!] ] H t 0޽h ? 33___PPT10i.F+D=' = @B +   0 0(  x  c $1]  ] x  c $l2]@ ] H  0޽h ? 33___PPT10i.F+D=' = @B +0  0 0@(  ^  S XK     c $D] )   6Incremental Reform: Employer mandates: Goal: increase access to health insurance for workers and their families, by requiring employers to offer health insurance. (The Clinton Health Plan included employer mandates) Examples of employer mandate proposals include: Requiring employers to cover a percentage of premium; include small employers in purchasing pools. Could create high risk pools and provide limited coverage to  uninsurables by pooling risk (for example, employees in small employers). There are such plans currently: state programs cover about 180,000 people nationally; there is significant cost-sharing required for beneficiaries; and benefits are capped. States usually pay for high-risk pools from  sin taxes , but high-risk pools usually operate at a loss. Impose a  free rider surcharge on employers and employees who either do not offer or do not join an available plan. wH  0.k ? 3380___PPT10.E l  0 p(|(  (^ ( S XK   ] ( c $, )  ] r^Incremental versus Comprehensive Reforms. If the goal is to reform the health care system, how do we get there? Comprehensive: focus might be on achieving coverage for all. Examples would include individual mandates, single payer systems, and a voucher system. Incremental: focus might be on expanding coverage to certain populations, improving insurance markets, promoting quality reforms; but, not achieving coverage for all. Examples would be: subsidies for individually-purchased insurance, Medicare or Medicaid expansions, employer mandates, HSAs, and quality incentives. Staff used the general framework in Fuchs and Emanuel s article in November/December issue of Health Affairs. Incremental changes would address particular aspects of health care costs, quality, or access (would not necessarily be small changes). Comprehensive could include universal coverage or other changes and could also incorporate multiple incremental reforms.H ( 0.k ? 3380___PPT10.vf 0 RJH(  HX H C XK   cJ H S Lvc )  c Presentation on Policy Proposals regarding health care coverage, costs and financing, by Craig Caplan, Policy Analyst, to the Citizens Health Care Working Group, December 15, 2005, in Washington, D.C.6__H H 0.k ? 3380___PPT10. `@  0   LP (  LX L C XK   ] L S  )  ] RBenefit design and coverage: What does health insurance coverage look like today? Historically, most policies have covered: Hospital Physician Some preventive care Some cost-sharing, possibly with catastrophic cap If the goal is to expand coverage to more individuals: Who receives coverage (all, low income, kids, disabled, workers)? Bare-bones policies or comprehensive health insurance? One standard benefit package, standardized packages, or tailored plans? How much cost-sharing (deductibles, coinsurance, maximum per year)? Health reform proposals incorporate benefit design features from prevalent programs employer-sponsored often the model. For example, when Medicare was created, the intention was to provide the same kind of coverage as in Blue Cross/Blue Shield. The Federal Employee Health Benefit Plan was comparable to what was available in the group market in the area. (Medicaid is different, as is VA they are more comprehensive and means-tested mostly in VA).R*[7R*[5     H L 0.k ? 3380___PPT10.(`u5 0  T(  TX T C XK    T S (ʕ )   <Health insurance is financed in different ways today: Employer-sponsored insurance: premiums, employer contributions/lower wages, favorable tax treatment, group rates (discounted). Medicare: Part A (Hospital Insurance): primarily payroll taxes, Tax on social security benefits for high income; Part B, D: general revenues, premiums. Medicaid: Federal and state taxes; more enrollee cost-sharing for Rx under legislative proposals. Individual market: Premiums/also underwriting some states have high-risk pools, reinsurance. If the goal is to expand coverage to more individuals, how should it be financed; should premiums be related to a person s income; should the ucrrent tax exclusion for employer coverage be limited; should we stretch limited resources by offering less generous benefits?(6yH T 0.k ? 3380___PPT10.)~l 0 P`%(  `^ ` S XK    ` c $d  )   Questions to be discussed: What do we mean when we are talking about coverage? How do we pay for services? How to achieve these ends? Examples from organizations, policy researchers, bills in Congress and states(mPH ` 0.k ? 3380___PPT10.(`u58 0 phH(  h^ h S XK    h c $  )   >* Incremental Reforms H h 0.k ? 3380___PPT10. `# 0 p3(  p^ p S XK    p c $ )   )Comprehensive ReformsH p 0.k ? 3380___PPT10. `6  0 F(  X  C XK     S   )   HAnother example is the Massachusetts Health Care Trust (S. 755) Consists of Integrated package leading to comprehensive reform: Single payer: eliminates private insurance coverage for basic benefits Coverage for all Massachusetts residents Legislative timetable Government s role: Oversee delivery of health care services to Massachusetts s residents Collect and disburse funds Negotiate methods and rates of compensation with health care providers and facilities, and approve capital expenditures in excess of $500,000 Support for health IT development and standards Support development and implementation of health quality standards Support development of innovative approaches to health promotion, health education, and research jL4H  0.k ? 3380___PPT10.b  0 r(  X  C XK     S   )   tCombining Incremental and Comprehensive Reform: Most proposals combine different features combining both incremental and comprehensive proposals. An example is the Oregon Business Council which combines incremental strategies (focused on cost-control strategies now before coverage for all can be achieved) Package of incremental strategies: Changes to control cost growth ! system savings ! increased coverage No formal integration of public and private initiatives Employers strategies: HSAs, increase cost-sharing, etc. to make consumers more cost-conscious Quality incentives Increase information on quality, costs, etc. Government s role: Streamline regulation for Medicare and Medicaid Support for health IT development and standards Malpractice and insurance market reforms Public health initiatives and consumer education Y3! LH  0.k ? 3380___PPT10.p0! 0 @(  d  c $XK     s *hp] )   *Combining incremental reforms: Comprehensive reforms can be built on frameworks that combine multiple incremental strategies (addressing quality, efficiency, cost, as well as access). However, comprehensive reforms have stated principal goal of guaranteeing coverage for all. Features comprehensive reforms must include: -- Formal structure that ties parts together -- Public commitment -- Accountability x"VW-AH  0.k ? 3380___PPT10.vf`" 0 0p(  ^  S XK     c $  )   fRCombine incremental reforms; Comprehensive reform with incremental reform featuresH  0.k ? 3380___PPT10. ` 0 P#(  X  C XK     S l] )   %Incremental Reforms: Susidies The goal of subsidies would be to reduce the number of uninsured by subsidizing the purchase of health insurance, often through tax credits. Examples of subsidy proposals include: Provide tax credits to low and middle-income to buy insurance on individual market. Create a tax deduction for purchase of individual insurance. Provide tax credits for businesses who offer health insurance to employees. 8H  0.k ? 3380___PPT10.* 0 `*(  X  C XK   ]  S ] )  ] ,Incremental Reforms: Medicare or Medicaid Expansions To reduce the number of uninsured, existing government programs like Medicaid and Medicare could be expanded. Examples of expansion proposals include: Raise income ceiling for Medicaid and SCHIP eligibility (in other words, cover people with higher incomes). Extend public coverage to all uninsured children (beyond those added by SCHIP). Offer Medicare to more adults (for example, those age 55-64) without insurance. 8  H  0.k ? 3380___PPT10.+    0 p(  X  C XK   ]  S Н] )  ] Incremental Reform: Health savings accounts and other types of consumer-directed care. The goal of HSAs and other forms of consumer-directed care is to make health coverage more affordable by encouraging consumers to be more cost-conscious and focus on healthier behaviors. Features of HSAs: people set aside their own money, before taxes, to pay for health care; and HSAs are usually combined with high-deductible health insurance. Examples of how to promote HSAs and other consumer-directed care proposals: provide tax credits for employer contributions to HSAs; and revise tax definition to include deduction for HSAs and allow people to carry up to $500 in unused flexible spending account (FSA) money over from year to year. (WH  0.k ? 3380___PPT10.+@F8  0 H(  X  C XK   ]  S l] )  ] JComprehensive Reform: Individual mandates. Goal: Achieve universal coverage using current system as base Examples of individual mandate proposals: Require individuals to buy insurance, and provide tax credits to do this; those with the lowest income would pay zero premium Mandate that everyone have health insurance or pay modest penalties Create incentives for uninsured to buy into proposed  Medicare Plus program, but later impose individual mandate if high number of uninsured persons remainsJ`+:(`H  0.k ? 3380___PPT10.+B{  0 *"(  X  C XK   ]"  S l] )  ]  Comprehensive Reform: Single payer system. Goal: Achieve universal coverage and reduce administrative costs Examples of single payer model proposals: Physicians for a National Health Insurance Program: Comprehensive benefits (medical, dental, LTC, Rx, mental health) Medicare, Medicaid, private health insurance restricted or eliminated For-profit hospitals phased out; hospitals given set budget for year Doctors salaried or paid on fee-for-service basis by federal government Global budget that grows each year with GDP Copayments, deductibles low or zero; financed through variety of taxes State-designed comprehensive insurance CA, NY, MA...r45+>(45  rH  0.k ? 3380___PPT10.+`g  0 {s (  X  C XK   ]s  S ] )  ] Comprehensive Reform: Voucher system. Goal: Achieve universal coverage for basic services Example of voucher system (Emanuel & Fuchs proposal): Guaranteed enrollment and renewal of risk-adjusted voucher Choice of plans offering basic services Additional services available for higher premium with after-tax dollars Financing through value added tax (VAT) Employer-sponsored health insurance, Medicaid, Medicare eliminatedJ&24H  0.k ? 3380___PPT10.+0r Am@jegls Nqs{ XvH6PTt^nPRY[ pVb#o{}$b`xl1Oh+'0T `hx  Slide 1E007654Whyde539Microsoft Office PowerPoint@8@$a@3?GSg  )'    """)))UUUMMMBBB999|PP3f333f3333f3ffffff3f̙3ff333f333333333f33333333f33f3ff3f3f3f3333f33̙33333f333333f3333f3ffffff3f33ff3f3f3f3fff3ffffffffff3ffff̙fff3fffff3fff333f3f3ff3ff33f̙̙3̙ff̙̙̙3f̙3f333f3333f3ffffff3f̙3f3f3f333f3333f3ffffff3f̙3f3ffffffffff!___www4'A x(xKʦ """)))UUUMMMBBB999|PP3f3333f333ff3fffff3f3f̙f3333f3333333333f3333333f3f33ff3f3f3f3333f3333333f3̙33333f333ff3ffffff3f33f3ff3f3f3ffff3fffffffff3fffffff3f̙ffff3ff333f3ff33fff33f3ff̙3f3f3333f333ff3fffff̙̙3̙f̙̙̙3f̙3f3f3333f333ff3fffff3f3f̙3ffffffffff!___www˜ü¼üüüüüüüüüüüüüü¼üüüüüüüüüüüüüüü™¼¼¼™¼¼ݼݼüݻݻݻݻ¼¼ݼIP(P(P(P(P(P(PIÙtLK$LKLtmDKDnݼ⼒mÙÙüÙÙtmlstnrrKIqIqIICCCCCmEKPJPIPJPIPJPIPJPÙytKKLLtLtݒnDKDnmnJüýüýüýüttݻtJmtttݵݼݼݵݵݼݵݼKmJCD=C=JE(PIP(P(P(PIP(PIÙyKoKsKtLtsnDDKDDCDnÙÙÙütuLtn"tRtLݮݼݒKsݻݻDCDCJPIPJPIPJPIPJPIPÙttooKKLLttDnntKDC"üüüüüüÙuoݙnKRutu$KsݼݒgCmDmCDfIP(PIP(PIP(PIPItKoKtKoEoKttDKnnnnDCnüüüüüüÙPsttttDttutxrKEKݵD=D=CgPJPJPJPIPPPJPJPÙttLuttottt޵nnKtnnC"süýüýüýCCuutnLooDRutCmݼݼݼݵݼKmmfmgmCgf(P(P(P(P(P(P(PItttKoKsKKnntKmDnnsCmCJÙÙÙmCDnnn+Ltt#uLJJs!CݼݼݼݼݼݼݼnݵݵgCD=DfgPIPJPIPJPIPJPIPtttotnKttttKm޼mJtnnnnDmüüüüüümBBCCKuLmtuuDJI!mmݻݮCKCf>gmIP(PIP(PIP(PIPILtttttEtttnmݼ޼JDnDnnsDCCüüüüüüÙ!H!IBHJtt"CtttCH!HCݵݼݵݵݼrnn#E$#fIPJPIPJPJPJPIPJPtttnKtnCCݼKC"tKsnnmüýüýüýmHBBHBCttotuunC!k!mݵݼݼݼݼݻݵIPJLEmKKLDCDmB(PIP(P(P(PIP(PI¼tDCCmC"D"CfÙÙÙmB!B!ott#DKCC!IIIrKE#J#KEKIIBIPIPJPIPJPIPJPIPÙsB?@ABCDEFGHIJKLMNOPQRSTUVWXYZ[\]^_`abcdefghijklmnopqrstuvwxyz{|}~      !"#$%&'()*+,-/0123456789:;<=>?@ABCDEFGHIJKLMNOPQRSTUVWXZ[\]^_`bcdefghmRoot EntrydO)Pictures)qCurrent UseraSummaryInformation(.TPowerPoint Document(DocumentSummaryInformation8Y