1. National Health Care Reform 2009 Daniel B. McLaughlin

2. A New Healthy America

3. The heavy hand of Government

4. Health Care Town Halls

6. The Best Health Care System in the World

9. Total National Health Expenditures (NHE), 2009–2020 Current Projection and Alternative Scenarios NHE in trillions Cumulative reduction in NHE through 2020: $3 trillion Note: GDP = Gross Domestic Product. Data: Estimates by The Lewin Group for The Commonwealth Fund. Source: Commonwealth Fund Commission on a High Performance Health System, The Path to a High Performance U.S. Health System: A 2020 Vision and the Policies to Pave the Way (New York: The Commonwealth Fund, Feb. 2009).

10. Editorial, Minneapolis Star Tribune , March 31, 2002

11. An Estimated 116 Million Adults Were Uninsured, Underinsured, Reported a Medical Bill Problem, and/or Did Not Access Needed Health Care Because of Cost, 2007 Medical bill/debt problem 17.7 million 10% Cost-related access problem 25.9 million 15% Source: S. R. Collins, J. L. Kriss, M. M. Doty, and S. D. Rustgi, Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families—Findings from the Commonwealth Fund Biennial Health Insurance Surveys, 2001–2007 (New York: The Commonwealth Fund, Aug. 2008). Adequate coverage and no bill or access problem 61.4 million 35% Uninsured anytime during the year or underinsured 17.6 million 10% Medical bill/debt and cost-related access problem 54.4 million 31% 177 million adults, ages 19–64

12. The Uninsured Source: NY Times 8-23-2009 Category Description Number (millions) Working Poor Income < $44,000 per year – family of 4 30 Better Off Income < $88,000 per year – family of 4 4.7 Young Adults Age 16 – 19, 50% from families with income < $16,000 13 Already Eligible Eligible for Medicaid, CHIP but don’t know or enrollment issues 11 Underinsured High deductibles, restrictions 25 Non Citizens Receive care in ERs 9.7 (6 estimated to be illegal)

13. Market Share of Two Largest Health Plans, by State, 2006 Note: Market shares are for the combined HMO+PPO product market. For MS and PA, shading represents shares of top three insurers in 2002–2003. Source: American Medical Association, Competition in Health Insurance: A Comprehensive Study of U.S. Markets, 2008 Update ; J. Robinson, “Consolidation and the Transformation of Competition in Health Insurance,” Health Affairs , Nov./Dec. 2004 23(6):11–24; D. McCarthy et al., The North Dakota Experience: Achieving High-Performance Health Care Through Rural Innovation and Cooperation (New York: The Commonwealth Fund, May 2008). AK HI 70% – 79% Less than 50% 50% – 69% 80% – 100% WA OR ID MT ND WY NV CA UT AZ NM KS NE MN MO WI TX IA IL IN AR LA AL SC TN NC KY FL VA OH MI WV PA NY MD ME VT NH MA RI CT DE DC CO GA MS OK NJ SD

14. Health Care Costs Concentrated in Sick Few— Sickest 10 Percent Account for 64 Percent of Expenses 1% 5% 10% 49% 64% 24% Source: The Commonwealth Fund. Data from S. H. Zuvekas and J. W. Cohen, “Prescription Drugs and the Changing Concentration of Health Care Expenditures,” Health Affairs , Jan./Feb. 2007 26(1):249–57. 50% 97% $36,280 $12,046 $6,992 $715 Distribution of health expenditures for the U.S. population, by magnitude of expenditure, 2003 Expenditure threshold (2003 dollars)

15. Figure 19. Variation in Per Capita Medicare Spending by Hospital Referral Region, 2000 Source: The Commonwealth Fund, from Eliot Fisher, presentation at Academy Health Annual Research Meeting, June 2006.

16. Questions - Comments

18. Federal Reform 2009 Reduce cost growth, Improve access, and Improve quality and safety In a way that is acceptable to the American Public

19. The legislative process House Energy & Commerce House Ways & Means House Education & Labor Senate HELP Senate Finance Full Senate Full House Conference Committee Old & New Agencies

20. House Energy and Commerce Committee Final Mark up SEC. 411. ELECTION TO SATISFY HEALTH COVERAGE PARTICIPATION REQUIREMENTS EXCISE TAX WITH RESPECT TO FAILURE TO MEET HEALTH COVERAGE PARTICIPATION REQUIREMENTS.— ‘‘ (1) IN GENERAL.—In the case of any employer who fails (during any period with respect to which the election under subsection (a) is in effect) to satisfy the health coverage participation requirements with respect to any employee to whom such election applies, there is hereby imposed on each such failure with respect to each such employee a tax of $100 for each day in the period beginning on the date such failure first occurs and ending on the date such failure is corrected.”

21. Health Care – A Systems View Professional - Patient

22. Health System – Core Professional - Patient Illness Burden Consumer Behavior Knowledge Tools – Dx & Rx

23. Health System – Tools Professional - Patient Illness Burden Consumer Behavior Knowledge Tools – Dx & Rx Facilities Medical Technology Health Care Workers Information Technology

29. Questions - Comments

30. Health System – Consumer Professional - Patient Illness Burden Consumer Behavior Tools – Dx & Rx Past Experience – Personal, networks Information Market/Clinical Financial resources & goals Knowledge

34. Health System – Education & Research Professional - Patient Illness Burden Consumer Behavior Knowledge Tools – Dx & Rx Primary Education Continuing Education Research

37. Questions - Comments

38. Health System – Financing Professional - Patient Illness Burden Consumer Behavior Knowledge Tools – Dx & Rx Financing Sources & Structure Individuals Employers Government Financial resources & goals

39. Employers Remain Primary Sponsor of Coverage Distribution of 307 Million People by Primary Source of Coverage Employer Direct 164m 53% Uninsured 49m 16% Medicare 39m 13% Medicaid 42m 14% Medicare 41m 13% Individual Direct 14m 5% Employer Direct 55m 18% Total Employer 164m (53%) Total Individual 14m (5%) Source: The Lewin Group, The Path to a High Performance U.S. Health System: Technical Documentation (Washington, D.C.: The Lewin Group, 2009).

42. The Exchange

44. Financing Strategy Medicare Advantage –Health Plans Drug Discounts Hospital Inflation (-1.5%), Re- admits, DSH Income Taxes - > $500,000 ? Taxes – Cadillac Health plans ? Subsidies for individuals and small business Medicaid eligibility buy down MD fees – repeal SGR Fix 50% of donut hole $ One Trillion 4% of total NHE

45. Bending the cost curve Competition between Health Plans New payment systems Bundled payments Increased payment for primary care/prevention P4P and penalties for hospital readmissions Payment to ACOs Geographic Adjustment (?) Comparative effectiveness research MedPac on steroids - IMAC Less Likely Tort Reform (Pilots?) Consumer Directed Health Care Direct insurance rate regulation

47. Questions - Comments

48. Reform’s Impact on Stakeholders

53. Questions - Comments

54. “ Americans always do what is right, but only after trying everything else.” Winston Churchill

55. The Best Health Care System in the World

57. Thank You May the road rise up to meet you. May the wind be always at your back. May the sun shine warm upon your face; the rains fall soft upon your fields and until we meet again, may God hold you in the palm of His hand. Dan McLaughlin [email_address] 651-962-4143