community catalyst national reform 2009
DESCRIPTION
The opportunity for national health care reform in 2009 - the role of the statesTRANSCRIPT
July 2008
The Opportunity for National Health Reform in 2009
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State Efforts Have Driven Reform Forward
Expanded coverage for children & adults
Reformed insurance markets
Improved quality and cost effectiveness
Reforms in Massachusetts, Maine, Vermont & Illinois, etc. are shaping the national landscape
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Characteristics of Successful Reform
Efforts have been incremental
Passage of reform has required:• Organized consumer activism
• “Strange bedfellows”
• Political leadership & compromise
• A “must do” moment
• Federal cooperation
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Challenges to state health reform:
Rising health care costs
State budget deficits
Balanced budget requirements
Taxing authority Cross-state competition
Need for federal support & cooperation
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Why is National Reform Important to State Advocates?
States need strong federal partnership to help finance, support and sustain Medicaid, SCHIP and other public coverage
States have limited authority over employer health plans (under ERISA guidelines)
Federal government has a greater ability to create larger risk pools and finance re-insurance
Federal government can use Medicare to drive the cost agenda and support states in cost containment approaches
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The shape of reform will depend on:
Level of Public Concern Presidential LeadershipCongressional SupportOrganized Political PressureEconomy and the Budget Deficit Pressure from States
Will National Reform Happen in 2009?How Comprehensive Will it Be?
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Level of Public Concern
Health care ranks 3rd among top issues for voters in their choice for President
Health care is also a top concern for those who list the economy as their #1 issue
5%
5%
7%
7%
9%
13%
21%
29%
43%
Education
Morality issues
Taxes
Immigration
Terrorism
Corruption/Frustration withgovernment
Health care
Iraq
Economy
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Presidential Leadership
• McCain proposes a market-based solution with less government involvement
• Health care is not a high priority to the Republican base
Significant divisions exist between health care agendas of Democrats and Republicans
• Obama has health care plan that includes expanded health coverage and greater regulation
• Health care is a high priority to the Democratic base and Independents
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Congressional Makeup
What are likely projections?
Democrats likely will increase their majorities in both the Senate and House*
• 56 D Senators (+5)• 245 D Representatives (+13)
Key leaders are committed to providing strong direction
(*Cook Report estimates)
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Organized Political Pressure
• Providers– Generally support expanded coverage – Concerned about government price controls and potential
revenue loss
• Insurers– Split on the issue of coverage for all, but some support – Concerned about competition from public coverage
• Employers– Increasingly disenchanted with status quo but divided on many
key issues (e.g. continuation of employer based system; “pay or play” requirements for employers; role of government)
– Generally interested in delivery system reform and sympathetic to increased consumer cost-sharing and more “market” mechanisms
– Small employers concerned about their ability to maintain their own coverage
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Organized Political Pressure
• Labor– Supports universal coverage– Involved in multiple coalition efforts– Many unions seeking new alliances with employers on
reform
• Consumer Organizations– Organizational and strategic divisions similar to labor – Concerned about under-insurance and high out-of-pocket
costs, as well as uninsured – Have concerns about potentially regressive financing
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Budget deficit
Recession
Pay as you go (PAYGO)
How will reform be financed?
What will it cost?
Who will pay?
Economy and the Budget Deficit
Health reform financing strategy is a critical issue
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States under financial pressure
Many states have expanded children’s coverage under Medicaid or SCHIP; federal resources still needed
Status of state health reform initiatives, e.g. Massachusetts
Governors and state legislative leadership
Providers
Consumer & coalition action
Pressure from States
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Learning from our History
Is 2009 this generation’s opportunity for reform?
1991-94 Clinton Health Plan • Never came to a vote in Congress
1962-64 Medicare/Medicaid • Enacted with an overwhelming majority
1946-49 Truman’s National Health Insurance • Never came to a vote in Congress
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How does 2009 compare to other attempts?1965 1993-1994 2009
Level of Public Concern
Enormous public support for the elderly
Strong support for the uninsured, but not as strong as in ‘65
Concern has shifted more to cost, rather than coverage
Presidential Leadership
Landslide victoryStrong commitment to reform
Plurality Strong commitment to reform
TBD
Congressional Makeup
Democrats: 68 Senate 295 House
Democrats: 57 Senate 258 House
Democrats: 56 Senate (est*) 245 House (est*)*Based on Cook Political Report
Organized Political Pressure
Strong labor supportStrong opposition from the AMAHospitals and Blue Cross neutralized
Strong opposition from insurers and PharmaLukewarm support from Labor and other progressives
Health industry supports coverage, worried about cost containmentLabor/ consumers mobilizing
Economy and the Budget Deficit
Economy strong, budget deficit not yet a major concern
Significant concern about the budget; rebounding economy
Possible recession; concern about budget (especially long term)
Pressure from States
States not a major actor in the debate
States play a more prominent role in health debate as a result of Medicaid
State fiscal conditions and role of Medicaid/SCHIP are major issues
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Four potential environments for national health reform:
#1. D President, strong D Congress (e.g. 60+ D Senators)
#2. D President, narrow D Congress
#3. R President, D Congress
#4. R President, R Congress
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Environment #1: D President, strong D Congress
Best chance for sweeping reform, similar to current Democratic presidential candidates plans
Implications for state organizing and policy: • Mobilize in support of federal reform
• Focus on state-level implementation
• Development of next policy wave (e.g. delivery system issues)
• Protect state policies that benefit consumers
Four potential environments for national health reform:
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Environment #2: D President, narrow D Congress
Strong SCHIP bill, additional reforms of Medicaid, private insurance, new opportunities for state action; or
More limited federal legislation & states pursue Medicaid waivers
Implications for state organizing and policy:
• States will be locus of significant policy change with potential to catalyze future federal reform
Four potential environments for national health reform:
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Four potential environments for national health reform:
Environment #3: R president, D Congress
Partisan divisions potentially make consensus more difficult
Implications for state organizing and policy:
• Defense of public programs during economic downturn• Promote reforms that lay the foundation for future
reform work (e.g. hospital accountability, Rx reform, insurance reform)
• Renewed focus on coverage expansions as economy improves
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Environment #4: R President, R Congress
Market-based system reform initiatives by Republicans
Implications for state organizing and policy:
• Defense of public programs
• Lay groundwork for future health reform
Four potential environments for national health reform:
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Community Catalyst’s Assumptions
Successful reform will:
Appeal to an organizable / mobilizable base
Address the concerns of the general public around both coverage and (their own) costs
Avoid unifying the health care industry in opposition
Create new opportunities for movement building and successive waves of reform
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Quality affordable health care for all through comprehensive reform: push for the best possible outcome within the limits of the political environment
We will focus on :• Building the capacity of consumers in state environments to
influence the national effort
• Facilitating participation by state advocacy groups in policy design and implementation activities and strategies
• Promoting policy that is supportive of state programs
• Working to protect vulnerable populations
Community Catalyst’s Goal for a National Reform Process
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Core Messages for State Advocates
Strong health advocacy base in states will be critical for passage, implementation, monitoring, and follow-up on reform strategies
Advocates need to seek common ground and alliances with the employer community and health industry players
Reform likely to be an ongoing process, not a one shot deal
Primary focus of action likely to shift back and forth between the state and federal level