Greg Poulsen, vice president of strategy for Intermountain Healthcare, gave the Salt Lake Chamber Capitol Club an inside look at the federal healthcare bill and the effect it will have on reform efforts in Utah.

1. March 2010 Reform Update
Greg Poulsen

2. Niels Bohr
2

3. A Remarkable Series of Events Allowed the
Senate Win on Christmas Eve.
- Democrats gained a shocking (even to them)
9 Senate seats in the 2008 election
- Ted Steven’s loss in a very conservative state
- Al Franken’s very tight win

4. Senator Edward Kennedy
February 22, 1932 – August 25, 2009
Special Election, January 19, 2010
4

5. News Flash: January 10, 2010
“Democrat Martha Coakley,
buoyed by her durable statewide
popularity, enjoys a solid, 15-
percentage-point lead over
Republican rival Scott Brown as
the race for US Senate enters
the homestretch, according to a
new Boston Globe poll of likely
voters.”
5

6. News Flash: January 15, 2010
“…in the last two days the
bottom has fallen out of her poll
numbers.”
6

7. News Flash: January 19, 2010
Mr. Brown Goes to Washington
7

8. Are We Almost There Yet?
July 28: Healthcare Endgame on Capital Hill (AP)
August 21: Healthcare Endgame Near But Uncertain
(Reuters)
October 14: Senate, Administration Begin
Healthcare Endgame (NBC)
October 27: Health Care Endgame is in Sight
(Politico)
November 23: Healthcare Endgame is Here (NPR)
January 10: Senate and House in Healthcare
Endgame (Reuters)
March 10: Obama Pushes for Healthcare endgame
(AP)
March 13: Health Care Endgame Begins (WSJ)
March 21: This time we were not kidding

9. The Process – Where Are We Now?
- House passed the Senate bill 219 – 212 (Mar 21)
- House “Corrections” package passed 220 – 211
- “Deem and Pass” was not utilized
- Bill now goes to the President for signature – The
Senate bill will become law (at least temporarily)
- The Senate will take up the Corrections bill
- Republicans will certainly challenge anything that is
not directly budget related since it uses
“reconciliation”
- If even a single word is changed in the Senate, then
the bill must go back to the House
- Idaho, South Carolina and Virginia have enacted
legislation pushing court challenges on the legality of
federal mandates. 34 other states are considering
similar legislation

10. The Bills

11. The Bills – With Reconciliation

12. What’s In The Bill: Insurance
• Individual mandate
• Employer responsibility
• “Guaranteed Issue”
• Insurance exchange
• Premium and cost-sharing subsidies
• Expand Medicaid/CHIP
• Payment reform

13. Trend in the Number of Uninsured Nonelderly,
2012–2019:Current Trend the Reconciliation Bill
Millions
80 Current Trend
Reconcilliation
60 53 53 54
50 51 51 51 51 51 52
50 51 50 50
40
32
26
22 22
20 22 22
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Note: The uninsured includes unauthorized immigrants. With unauthorized immigrants
excluded from the calculation, nearly 94% and 96% of legal nonelderly residents are
projected to have insurance under the Senate and House proposals, respectively.
Data: Estimates by The Congressional Budget Office.

14. Family Premiums Under Reconciliation Bill
After Premium Subsidies (National Average)
$12,000
$10,000
$8,000 $8,644
$6,000 $6,483
$4,000
$2,778
$2,000 $1,505
$0
$0
100% 133% 150% 200% 250% 300% 350% 400%
($22,050) ($29,327) ($33,075) ($44,100) ($55,125) ($66,150) ($77,175) ($88,200)
Income for a Family of Four
% FPL (Annual Income)
* For a family of four in a medium-cost area in 2009 (age 40). Premium estimates are based on: Senate Silver Plan, actuarial value = 0.70; House Basic Plan, actuarial value =
0.70. Actuarial value is the average percent of medical costs covered by a health plan.
** Senate bill exempts individuals with premium contributions in excess of 8 percent of income from requirement to buy insurance.
Note: FPL refers to Federal Poverty Level. Under the Senate bill, people are eligible for Medicaid up to 133% FPL; under the House bill, people are eligible for Medicaid up to
150% FPL. CBO estimated an average family premium of $14,400 in 2016 for the Senate Finance bill, approximately $10,000 in 2009.
Source: Commonwealth Fund analysis of proposals. Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator – Premium Assistance for
Coverage in Exchanges/Gateways, http://healthreform.kff.org/Subsidycalculator.aspx.

15. Penalties for Noncompliance with the Individual
Mandate Reconciliation Bill
$4,000
Penalty per Person
$3,000 $3,000
2016 Rule
$2,000 $1,750
$1,250
$900
$1,000 $750
2014 Rule = $95
$0
$20,000-$30,000 $40,000-$50,000 $50,000-$75,000 $75,000-$100,000 $100,000-$200,000
Income
Note: The penalty under the Reconcilliation bill is implemented at $95 in 2014 and increases to $325 in 2015 and the greater of $695 or up to 2.5% of income, capped at the
average national bronze plan premium, in 2016.
Source: Commonwealth Fund analysis of the proposals; Urban-Brookings Tax Policy Center, “Average Modified Gross Income and Average Modified Adjusted Gross Income
Across Cash Income Levels, 2009”, Oct 15, 2009 available at http://www.taxpolicycenter.org/numbers/displayatab.cfm?Docid=2486&DocTypeID=1.

16. Penalties for Noncompliance with the Employer
Mandate Under Reconciliation Bill
$2,500
$2,000
Penalty per Employee
$2000 penalty
$1,500
$1,000
$500
$0
10 12 18 25 50 100 500 1000
Number of Employees
Note: House bill penalty is based on aggregate payroll. It is illustrated here using 2008 median earnings to estimate firm size. A firm with an aggregate payroll of $500,000 will have an average of 12 workers and a firm with an aggregate payroll of $750,000 will have
an average of
18 workers. The payroll tax is implemented on a sliding scale from 2%–8% for payrolls between $500,000 and $750,000. The Senate bill penalty requires any employer with more than 50 full-time employees that does not offer coverage and has at least one full-time
employee receiving the premium assistance tax credit to make a payment of $750 per full-time employee. An employer with more than 50 employees that offers coverage that is deemed unaffordable or does not meet the minimum benefit standard and has at least
one full-time employee receiving the premium assistance tax credit must pay the lesser of $3,000 for each of those employees receiving the credit or $750 for each of their full-time employees total. Firms are exempt if they have: a payroll less than $500,000
(House), or fewer than 50 workers (Senate).
Data: Median earnings among workers working 50–52 weeks annually was $41,030 (Table P–43, Historical Income Data, Current Population Survey).
Source: Commonwealth Fund analysis of the proposals.

17. Trend in the Number of Uninsured Nonelderly,
2012–2019:Current Trend the Reconciliation Bill
Billions
200 Net Cost of Coverage
180
Revenues
160
140
120
100
80
60
40
20
0
-20 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Source: CBO Report, March 18, 2010

20. What’s In The Bill: Delivery
• Enhance primary care payment by 10%
• Create “Comparative Effectiveness Institute”
• Develop approaches to enhanced quality
evaluation and reporting
• Payment reform pilots
• Medical Home
• Bundled Payment
• Accountable Care Organization

21. Alain Enthoven, PhD
“The United States does not have decades to wait
for health system reform; in 2009 about $1.15
trillion of the federal budget was spent on health
care. And health care expenditures are growing
2.7% per year faster than non-health care gross
domestic product. Congressional reform bills do
practically nothing to slow health expenditures.”

22. National Health Expenditures per Capita,
1980–2007
Data: OECD Health Data 2009 (June 2009).

23. National Health Expenditures per Capita,
1980–2007
Data: OECD Health Data 2009 (June 2009).

24. State Rankings:Health Status vs. Health Cost
Worst
MA NY AK
CT ME
DE
RI
VT
WV
PA
ND
NJ
MN
OH
WI
Health Cost Rank
NB
MD
FL
KY
TN
MO
NH
KS
IA
SD
IN
IL
WY
NC
AL
SC
WA
MT
MI MS
LA
HI
OK
OR
AR
VA
CO
CA
TX
GA
NV
NM
ID
AZ
UT
Best
Best Worst
Source:
Health Status Rank
http://www.americashealthrankings.org/measure/2009/overall.aspx and
http://www.statehealthfacts.org/comparemaptable.jsp?ind=596&cat=5

26. Mortality Amenable to Healthcare
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009

27. Ethnic Disparity: Mortality Amenable to
Healthcare
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009

28. Infant Mortality per 1,000 Births
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009

29. Ethnic Disparity: Infant Mortality
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009

30. 30 Day Overall Hospital Readmission
Rates
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009

31. Number of First-Place Finishes (38 Total)
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009

32. Much of the reform of health care as
opposed to health coverage remains to be
defined, and is anticipated to be tested with
demonstration projects.
Some of those projects will attempt to
determine if the kind of care provided here
can be replicated, while others will attempt
to create new types of approaches and
incentives

33. COULD WE BE PUNISHED FOR DOING WHAT’S RIGHT?
Potentially Avoidable Use of Hospitals
SOURCE: Aiming Higher, State Scorecard on
Health System Performance, The
Commonwealth Fund, October, 2009