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Strategies for Increasing Healthcare Access. Flávio Casoy (adapted from Kao-Ping Chua and Vanessa Calderón) Jack Rutledge Fellow American Medical Student Association. It takes more than medical school to make a physician!.

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Strategies for Increasing Healthcare Access

Flávio Casoy(adapted from Kao-Ping Chua and Vanessa Calderón)Jack Rutledge FellowAmerican Medical Student Association



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  • AMSA - the nation’s OLDEST and LARGEST independent health professional student association

  • Entirely Student Led.

  • Over 68,000 members.

  • Over a million community service hours each year.

  • For 58 years, a progressive voice in American medicine.

  • Unites the voices of physicians-in-training to fight for a healthcare and medical education system that reflect OUR values!!


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International perspective

Total Spending on Health Care, 2005

Source: OECD Health Data 2007


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International perspective

Health Care Spending per Capita, 2005

Source: OECD Health Data 2007


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Health status and outcomes

Life Expectancy at Birth, 2004-5

Source: OECD Health Data 2007


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Health status and outcomes

Infant Mortality, 2004-5

Source: OECD Health Data 2007


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Outline

  • Insurance Coverage in the U.S. Health Care System

  • Strategies for Increasing Health Care Access: Pros and Cons




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Profile of the uninsured

  • 47.0 million Americans

  • 81% from working families

  • 52-59% from low-income families (200% FPL)

  • 80% are adults

  • 50% are ethnic minorities

  • 79% are American citizens

Source: Kaiser Commission on Medicaid and the Uninsured

Source: US Census Bureau



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Employer-sponsored insurance

  • Offered by employers as part of benefits package

  • Administered by private insurance companies (for-profit and non-profit)

  • Employer pays bulk of premium; employee pays remainder

  • Significant erosion of employer-sponsored insurance in recent years



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Individual insurance

  • Purchased directly by people who do not get coverage through their employers

  • Non-group (individual) plans

    • Premiums based on individual health risk

    • High-risk individuals with limited access

  • High Deductibles

  • Administratively expensive



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Medicare

  • Covers elderly (ages 65 and older) and non-elderly with disabilities

  • Administered by the federal government (essentially a single-payer system)

  • Financed through:

    • Federal income taxes

    • Payroll taxes

    • Out-of-pocket payments by enrollees


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Medicare

  • Four parts:

    • Part A – hospital insurance

    • Part B – supplemental insurance

    • Part C – managed care

    • Part D – prescription drugs

  • Significant coverage gaps - most enrollees obtain supplemental insurance

  • Spending growth generally slower than private insurance

  • Aging population and increased technology presents challenges for the future


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Medicaid

  • Covers certain low-income individuals; not every poor person is covered!

  • Administered by state governments

  • Often out-sourced to non-government administrators

  • Financed jointly by the state and federal governments

  • Benefits are fairly comprehensive, but many providers won’t take care of Medicaid patients


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Minimum Medicaid Eligibility Levels, 2004

Income eligibility levels as a percent of the Federal Poverty Level:

Note: The federal poverty level was $10,488 for a single person and $16,079 for a family of three in 2006.

SOURCE: Cohen Ross and Cox, 2004 and KCMU, Medicaid Resource Book, 2002.


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State Children’s Health Insurance Program (S-CHIP)

  • Supplements Medicaid by covering low-income children who are ineligible for Medicaid

  • Administered and financed similarly to Medicaid

  • Similar problems to Medicaid:

    • Low reimbursement rates → some providers refuse to accept S-CHIP

    • Under-enrollment

    • Eligibility varies by specific populations and states



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Public Program Expansions: Medicaid, CHIP, Medicare

Do nothing; market will fix itself

National Health Insurance*

Tax credits

Individual Mandates

Employer Mandates

Individual Commodity

Public Good

U.S. system

*Health care system adopted by every other industrialized democracy


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Tax credits

  • AMA plan - offer tax credits to people to purchase health insurance.

  • Tax credits would be:

    • Inversely related to income

    • Contingent upon purchase of health insurance

    • Refundable

    • Advanceable

  • Financed by repeal of tax subsidy


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Tax credits - pros

  • Makes health insurance available to more people

  • Keeps current system in place

  • Tax infrastructure already in place

  • May increase choice of insurance plans


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Tax credits - cons

  • Not universal

  • Builds on individual market (inefficient and discriminatory)

  • Problems of current system would remain

  • Employers tempted to drop coverage

  • No cost controls

  • No guarantee that competition will help

  • Does not take co-pays and deductibles into consideration


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Public Program Expansions: Medicaid, CHIP, Medicare

Do nothing; market will fix itself

National Health Insurance*

Tax credits

Individual Mandates

Employer Mandates

Individual Commodity

Public Good

U.S. system

*Health care system adopted by every other industrialized democracy


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Individual mandates

  • Force everyone to have health insurance through some mechanism:

    • Employer-based

    • Medicaid

    • Individual market

  • People would pay a penalty for not having health insurance


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Individual mandates - pros

  • Achieves close to universal coverage

  • Easily understood

  • Leaves current system in place

  • Appeals to “anti-freeriding” ethic


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Individual mandates - cons

  • High cost of purchasing health insurance

  • Disproportionately burdensome to low-income individuals

  • Builds on inefficient individual market

  • No cost controls

  • Difficulty and cost of enforcing mandate

  • Deductibles, co-pays


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Individual mandates - cons

  • Massachusetts – Individual Mandate

    • Single, male, 26 year-old, earning 301% FPL - $2,631 per month, in Framingham, MA

    • Premium: $150/month

    • Drugs: $30/generics, 50% for brand names

    • Co-pay $25 per doctor visit, $100 per ED

    • Procedure, Study, or Hosp stay: $2000 Deductible + 20% co-insurance

    • $5000 max out of pocket (not counting drugs or visits to doctors or EDs)


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Public Program Expansions: Medicaid, CHIP, Medicare

Do nothing; market will fix itself

National Health Insurance*

Tax credits

Individual Mandates

Employer Mandates

Individual Commodity

Public Good

U.S. system

*Health care system adopted by every other industrialized democracy


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Employer mandates

  • Variation #1: Employers forced to provide health benefits to employees

  • Variation #2: Play-or-pay – employers provide health benefits that meets certain standards or submit to payroll tax to fund public coverage for employees


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Employer mandates

  • Low-wage employers temporarily subsidized

  • Expansion of Medicaid for unemployed or others who don’t get health insurance through their employer


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Employer mandates - pros

  • Achieves close to universal coverage

  • Builds on current system

  • Levels the playing field for employers

  • People like getting health insurance from their employer (mostly)

  • Most of new cost is hidden from employees


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Employer mandates - cons

  • Opposition from many businesses

  • Disproportionately burdensome for small businesses

  • Implicit tax on employees (lower wages)

  • Potential layoffs of low-wage jobs

  • Inhibits creation of new jobs

  • No cost controls

  • Disadvantages of employer-based system (non-portability, economic strain on businesses)


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Public Program Expansions: Medicaid, CHIP, Medicare

Do nothing; market will fix itself

National Health Insurance*

Tax credits

Individual Mandates

Employer Mandates

Individual Commodity

Public Good

U.S. system

*Health care system adopted by every other industrialized democracy


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Public program expansion

  • Expand eligibility of Medicaid, S-CHIP, and other public programs to more people

  • Examples:

    • Expansion by income – cover everyone under 200% of poverty level

    • Expansion by demographic – cover childless adults


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Public program expansion - pros

  • May lead to universal coverage eventually (pincer strategy)

  • Infrastructure largely in place already

  • Leaves current system in place

  • Potential political support to expand access to some groups (esp. children)


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Public program expansion - cons

  • Not necessarily universal coverage

  • Anti-welfare sentiment

  • Lack of a political voice of potential beneficiaries

  • Access problems with Medicaid/S-CHIP

  • May be seen as unjust

  • May “take the wind out of the sails” of more comprehensive reforms


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Public Program Expansions: Medicaid, CHIP, Medicare

Do nothing; market will fix itself

National Health Insurance*

Tax credits

Individual Mandates

Employer Mandates

Individual Commodity

Public Good

U.S. system

*Health care system adopted by every other industrialized democracy


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National health insurance

  • NHI = having a health insurance plan that is available to everyone

  • Does not specify financing (single payer vs. multi payer)

  • Does not specify whether DELIVERY of health care is public or private


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Countries with NHI

…(South Africa)

Industrialized countries without NHI?

only one …


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Example of NHI: Single payer

  • Government becomes main reimburser of health care providers

  • Universal coverage for defined services

  • Automatic enrollment

  • Private insurance for “supplemental” benefits

  • Financed by taxes, offset by less premiums

  • Delivery remains mostly private


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Single payer - pros

  • Universal coverage

  • Greatly reduced administrative costs

  • Coverage is portable (not tied to employment)

  • Free choice of doctors and hospitals

  • Very little uncompensated care

  • Greater potential to control costs

  • More rational and efficient allocation of resources and technology


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Single payer - cons

  • No choice in insurance plans

  • Potential for underfunding by hostile government or recession

  • Potential for mismanagement

  • Politically more difficult

    • Special interests

    • Transition period

    • Resistance to taxes


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Public Program Expansions: Medicaid, CHIP, Medicare

Do nothing; market will fix itself

National Health Insurance*

Tax credits

Individual Mandates

Employer Mandates

Individual Commodity

Public Good

U.S. system

*Health care system adopted by every other industrialized democracy


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Conclusion: How do you evaluate a solution?

  • Every solution has disadvantages, no matter what. Based on your values, you can select which disadvantages are outweighed by the advantages.

  • If you value a profit-driven industry that sees healthcare as a commodity, tax credits may be appealing.

  • If you value universality and comprehensiveness, NHI may be appealing.


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What does AMSA support?

  • For the last 15 or so years, AMSA has supported a public, single, national health insurance system to ensure that everyone has access to affordable, quality heatlhcare.

  • Actively fight for sCHIP, Medicare, Medicaid, Community Health Centers, Title VII, and much more….


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More Ways To Get Involved:

  • JOIN MEDICAL STUDENTS JUST LIKE YOU – JOIN AMSA!

    www.amsa.org

  • Attend Your Regional Conference:

    • 1,2,3: Nov 9th – Nov 11th ~ Portland, ME


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Opportunities

  • Universal Healthcare Leadership Institute

    • September 29-October 1, 2007 (Apps closed)

  • SeaCouver

    • Feb 6-10, 2008 (Application Due on Nov 18)

  • Venezuelan Health Systems Study Tour

    • April 7-13, 2008

  • Jack Rutledge Internship

    • All the time


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Flávio Casoy

American Medical Student Association

Jack Rutledge Fellow for Universal Health Care and

Eliminating Health Disparities

[email protected]

(703) 620-6600 ext. 256


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