"2014 is Now: Why Access for All Matters to Us All" presented by Dr. Len Nichols on September 23, 2013.

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2014 is Now:
Why Access for All Matters to Us All
Len M. Nichols, Ph.D.
George Mason University

2. Why Is Reform so Hard?
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3. Linkages
Values
Health
System
Economy
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4. Family Premium / Median Income
10.8%
20.9%
0
5
10
15
20
25
1996 2011
AHRQ premium, Census Income data
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Author’s calculations, treating average employer contribution as income

5. The Bottom Line of Where We Are
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Allow US to Default ?

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8. Two Roads to Fiscal Balance
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CUTS
RE-ALIGN
INCENTIVES

9. Why Not Cost Containment First?
• It wouldn’t work
¾ of hospitals lose money on Medicare
• It’s not consistent with our values
Leviticus, Matthew, Qu’ran, Book of Mormon
John Wayne movies
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10. What is Reform REALLY About?
• Elevating population health and stewardship
• Signaling that “Business As Usual” is over
• Changing obsolete business models
• Incentive Realignment
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11. Incentive Alignment Is Multi-Dimensional
Wellness &
Cost Sharing
Decision
Support
Payment
Reform
Patient
Employer/PayerClinicians
Community
Community

12. Why IS Reform So Hard?
• Competing World Views (and fact bases)
• Someone’s excess cost is someone else’s income
• We waited so long, required change is not
incremental
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13. A Little History
• Bismarck 1883
• The Roosevelts
• Truman, Dingell Sr.
• Great Society  Nixon
– Medicare + Medicaid, HMO Act, ERISA
• Carter v. Kennedy  Reagan (TEFRA, DRGs)
• GHW Bush  Clinton
– Medicaid Expansion, RBRVS; HIPAA, SCHIP
• W  large FQHC increase, Medicare Drug
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14. Notice Patterns in our History
• Recurrent push toward expanding access
• Mindfulness of cost to society, preservation of
market liberties
• Bipartisan support was norm until 2009
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15. Why was this time so different?
• Timing was tough
• Tactics and Strategy of Opposition
• Kennedy’s illness, Naiveté and key judgment
calls of Obama team
• Forces unleashed by Great Recession, rhetoric
of socialist overreach hard to tame, with us still
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17. Lots of stuff has been called “socialism”
• “The crown jewel of the socialist welfare
state in America is Social Security.”
• “The American Medical Association said
today that it was placing an advertisement in
100 newspapers to make its position clear on
its opposition to Medicare. The
advertisement calls Medicare ‘the beginning
of socialized medicine.'"
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18. From Poolesville, MD 1954
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Little Rock, 1957 Health Reform Town Hall, August 2009

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22. Economic Impacts of Medicaid Expansion
• Initial estimates from Deep Red state
governments were uniformly negative
• Methodologically defensible studies have all
reached positive conclusion
• Still, and maybe forever, Ideology trumps
math, for some
• History of Medicaid adoption was checkered, too
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23. Post-Supreme Court decision on ACA
• Created opportunity to oppose Obamacare in
the name of fiscal prudence for state
• Argument undercut by 3 facts:
– Feds would pay 100% of expansion population
costs for 3 years, 90% thereafter
– VA would save money for 5-6 years, low cost
thereafter compared to economic benefit to state
– Chamber of Commerce of VA came to support
Medicaid expansion
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24. Are We Overtaxed?
-0.04
-0.03
-0.02
-0.01
0
0.01
0.02
0.03
0.04
0 5 10 15 20 25 30 35 40 45
GDP growth, 2008-2011 cumulative
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2008 Overall Tax Rate (Federal plus State)
Japan
USA
AUS
FRA
GER
OECD

25. Health Impacts
• Long history of controversial findings
– People who argue coverage does not help and does
not matter are all insured, I’ve noticed
– Health impacts hard to show for basically healthy
population in the short run
– Natural experiments hard to do, best methods not
applied in late 1960s
• Recent Oregon studies are well done
– Year 1: self-r. health, esp. MH, use+compliance UP
– Year 2: no sig change in BP and CHOL levels, Lowered
depression, increased diag. of diabetes, eliminated
catastrophic OOP health expenses
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26. Health System Impacts
• Hospitals do most of uncompensated care in US
– Expansion will reduce uninsured by 26-61%
– Significantly reducing the uninsured problem makes
delivery and payment reform possible, profitable
• Medicaid expansion will force integration of
behavioral and acute care
• Expansion makes multi-payer initiatives
easier, gives states more of driver’s seat than
Feds
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27. Ask Yourselves These Questions
• What do I want my health system to be like?
• Is that more likely if we repeal or if we
engage, implement and amend?
• How should success be measured?
• What are the consequences of failure?

28. Constitutional Convention
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Internet photo of work by Junius Brutus Stearns, 1856

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30. Where Innovation Is Tradition
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