It was Ronald Reagan who said “freedom is always just one generation away from extinction. We don’t pass it to our children in the bloodstream; we have to fight for it and protect it, and then hand it to them so that they shall do the same, or we’re going to find ourselves spending our sunset years telling our children and our children’s children about a time in America, back in the day, when men and women were free.”

WASHINGTON – July 1, 2012 Republicans have said repeatedly that the landmark health care reform law, upheld as constitutional by the Supreme Court last week, must be repealed and replaced. But the GOP leader in the U.S. Senate gave a surprising answer on "Fox News Sunday" when asked how Republicans would provide health care coverage to 30 million uninsured Americans. "That is not the issue," Sen. Mitch McConnell said. "The question is how to go step by step to improve the American health care system. It is already the finest health care system in the world.""Fox News Sunday" host Chris Wallace interrupted, "You don't think 30 million uninsured is an issue?""We're not going to turn the American health care system into a western European system," McConnell said. "That's exactly what is at the heart of Obamacare. They want to ... have the federal government take over all American health care. The federal government can't handle Medicare or Medicaid."

5 Consequences Of The GOP’s Bill To Repeal PPACA

1) Millions without coverage. A Congressional Budget Office analysis of the GOP’s repeal measure from 2011 found that “32 million fewer nonelderly people would have health insurance in 2019, leaving a total of about 54 million nonelderly people uninsured. The share of legal nonelderly residents with insurance coverage in 2019 would be about 83 percent, compared with a projected share of 94 percent under current law (and 83 percent currently).”2) Health insurance costs increase. The same analysis concluded that “many people would end up paying more for health insurance— because under current law, the majority of enrollees purchasing coverage in that market would receive subsidies via the insurance exchanges, and [repeal] would eliminate those subsidies.” What’s more, “Premiums for employment-based coverage obtained through large employers would be slightly higher.”3) Americans with pre-existing conditions will lose access to coverage. Republicans have said that they would not replace the Affordable Care Act’s federal rules prohibiting insurers from discriminating against people with pre-existing conditions. Instead, they would encourage states to form expensive high-risk pools to cover the sick or, alternatively, leave them to find their own coverage in the individual market — where many will likely go uninsured.4) Medicare in disarray. Approximately 100 million Medicare claims are processed each month using a formula that was altered by the Affordable Care Act. Should the law be repealed, new rates could not be calculated under the old, pre-ACA formula until after a rulemaking process that can take months before is completed. The result would be that Medicare would not be able to pay doctors for what could be many months.5) Deficits increase by billions. The CBO predicts that “as a result of changes in direct spending and revenues is likely to be an increase in the vicinity of $230 billion.” Repeal would also “increase federal deficits in the decade after 2019 by an amount that is in a broad range around one-half percent of GDP.”

Understanding theThe Patient Protection and Affordable Care Act

“HEALTHCARE IS A HUMAN RIGHT” HAS REAL MEANING

THE MORAL AND ETHICAL IMPERATIVE INHERENT in the CORE VALUES of a DEMOCRATIC SOCIETY

(1) MAXIMIZE PERSONAL POTENTIAL (HEALTHY STATES, food, housing, education, employment, security) (2) COMPASSION and CARING (relieve individual pain, suffering and anxiety) (3) SOCIAL and ECONOMIC JUSTICE (provide for the vulnerable ) (4) CIVIC RESPONSIBILITY (society as a participatory commonwealth)

(1) MAXIMIZE PERSONAL POTENTIAL (HEALTHY STATES, food, housing, education, employment, security) (2) COMPASSION and CARING (relieve individual pain, suffering and anxiety) (3) SOCIAL and ECONOMIC JUSTICE (provide for the vulnerable ) (4) CIVIC RESPONSIBILITY (society as a participatory commonwealth)

Based on nationwide telephone polls from March 21 through June 3, 2012 with 976 adults

How the Justices Ruled on the Health Care Law

Individual mandate upheld as a tax.

Majority opinion by Chief Justice Roberts“The Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”

Dissenting minority opinion.“The Court regards its strained statutory interpretation as judicial modesty. It is not. It amounts instead to a vast judicial overreaching. It creates a debilitated, inoperable version of health-care regulation that Congress did not enact and the public does not expect.”

Medicaid expansion upheld, but limited

Majority opinion by Chief Justice Roberts“Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that states accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize states that choose not to participate in that new program by taking away their existing Medicaid funding.”

Dissenting minority opinion“Those states that decline the Medicaid expansion must subsidize, by the federal tax dollars taken from their citizens, vast grants to the states that accept the Medicaid expansion. If that destabilizing political dynamic, so antagonistic to a harmonious union, is to be introduced at all, it should be by Congress, not by the judiciary.”

John Roberts, insurance industry shillBy Matt Miller Posted at 02:25 PM ET, 06/28/2012 THE WASHINGTON POST

Conservatives are predictably pillorying Chief Justice John Roberts as a traitor or worse. But constitutional arguments aside, anyone who understands health policy and insurance markets knows that Roberts’s historic hand on the scale Thursday was the only way to preserve a central role for private insurers in American health care in the years ahead. In this sense, Roberts’ epic choice is therefore not only small “c” conservative as a matter of judicial temperament but economically conservative to boot. What the chief justice has done is nothing less than save shortsighted partisans bent on overturning Obamacare from themselves.

As I and others have long argued, a successful drive to overturn the Affordable Care Act, combined with a continued surge in the ranks of the uninsured, would almost certainly have put America on a path to a single-payer system, about whose constitutionality there has never been any doubt. The only way to move toward universal coverage via private health plans is to require everyone to be in the insurance pool and to offer subsidies to lower-income folks who’d otherwise be unable to buy a policy. Conservatives understood these facts and supported this approach until President Obama decided to adopt their ideas and put real money behind them.There are therefore so many policy ironies accompanying Thursday’s decision that its hard to keep track. The left is (rightly) cheering the vindication of Romneycare, which the president now has a legal green light to take national. Mitt Romney is assailing his own pioneering policy and vowing to scrap it at the federal level if he gets the chance. And Roberts is being trashed by supposed champions of the private sector, whose role in health-care finance has in fact been preserved by Roberts’s surprise switcheroo. That may not have been the chief justice’s intent — his real motives and reasoning in this historic exercise of power may be known only to his wife — but it’s the result. If conservatives had any sense of their long-term interests they’d be thanking him.

GOP Governors May Turn Down $258 Billion In PPACA Funds, Leave 9.2 Million Americans Uninsured

The CBO study estimated that about 4 million, or just 1.2 percent of the population, will actually pay the penalty in 2016. The other 98.8 percent already have coverage, would get coverage under the Affordable Care Act (which would make coverage affordable to many for the first time), would be exempt from the mandate, or would owe the penalty but try to evade it.

The penalty-tax will be phased in incrementally from 2014 to 2016. The minimum penalty-tax in 2016 will be $695 per person and up to 300 percent of that per family. The $695 per-person penalty-tax only applies to those making between $9,500 and ~$37,000 per year. Individuals making less than ~$9,500 are exempted and those earning more than ~$37,000 will pay a penalty-tax calculated by the following formula: 2.5 percent of any household income above the level at which one is required to file a tax return. That level is currently set at $9,500 per person and $19,000 per couple. The penalty on any income above this threshold is 2.5 percent. The IRS will collect the “fine” here, a fact that no doubt proves this is a tax, not a penalty.

Supreme Court health care ruling allows states to cut off Medicaid to those now enrolled By Phil Galewitz | Kaiser Health News, McClatchy News, July 3, 2012WASHINGTON — Starting in 2014, things could get worse for people on Medicaid: Not only might some states opt out of increasing the number of adults in the government health-insurance program for the poor as a result of the Supreme Court’s ruling, but they also might cut people who now are enrolled. This wasn’t supposed to happen under President Barack Obama’s health law, which was designed to expand coverage for 30 million Americans, in part by adding 17 million people to Medicaid. But the impact of the Supreme Court’s ruling last week making the expansion voluntary is likely to be compounded by another provision in the law that the justices left intact: In 2014, states no longer are barred from making it harder for adults to qualify for Medicaid.

Since 2009, when Congress approved the federal economic-stimulus law, which included additional Medicaid funding, states have been prohibited from reducing eligibility or increasing the cost-sharing requirement for people enrolled in Medicaid. The health law extended that prohibition until 2014, when the expectation was that every state would have a new online insurance market and would have expanded Medicaid to everyone whose income is less than 133 percent of the federal poverty level.But the high court struck down the penalty for states that didn’t expand, saying the threatened loss of their existing federal Medicaid dollars was "coercive.“

Another way states might choose to minimize their costs is by shifting people who are eligible for federal subsidies to buy private insurance out of the Medicaid program and into the new online markets created by the law. That saves states money because the federal government pays the entire cost of the subsidies – unlike Medicaid, in which states share in the costs.The federal subsidies are available for those with incomes from 100 percent of the federal poverty level ($23,050 annually for a family of four) to 400 percent ($92,200 for a family of four).States would have an incentive, then, to set eligibility for Medicaid at 100 percent of the poverty level – rather than at the law’s 133 percent (about $31,000 for a family of four) – to minimize their financial exposure. Pushing people just over the poverty level into the federal subsidy program could be enticing for cash-strapped states,

Some Governors Might Opt Out

According to The Hill's "Healthwatch," the Boston Globe and the Wall Street Journal, the following 17 states might not participate or are considering not participating in the expansion, based on recent statements from governors and other officials: Colorado; Florida; Indiana; Iowa; Louisiana; Maine; Mississippi; Missouri; Nebraska; New Hampshire; New Jersey; Ohio; Pennsylvania; South Carolina; Texas; Virginia; and Wisconsin.

In recent days, Florida Gov. Rick Scott (R), Louisiana Gov. Bobby Jindal (R) and Texas Gov. Rick Perry (R) have issued statements or made public comments confirming that they will not expand Medicaid in their states and instead will assist efforts to repeal the law.

The Congressional Budget Office projected that states would pay approximately $73 billion, or 7 percent of the cost of the Medicaid expansion between 2014 and 2022, while the federal government pays $931 billion, or 93 percent.

E.J. Dionne Jr. Opinion Writer THE WASHINGTON POSTJudicial activists in the Supreme CourtLiberals should learn from this display that there is no point in catering to today’s hard-line conservatives. The individual mandate was a conservative idea that President Obama adopted to preserve the private market in health insurance rather than move toward a government-financed, single-payer system. What he got back from conservatives was not gratitude but charges of socialism — for adopting their own proposal.The irony is that if the court’s conservatives overthrow the mandate, they will hasten the arrival of a more government-heavy system. Justice Anthony Kennedy even hinted that it might be more “honest” if government simply used “the tax power to raise revenue and to just have a national health service, single-payer.” Remember those words.

The Great DealmakerThe Obama Administration made a series of deals to pass PPACA:

The insurance industry: Assured that everyone would be required to buy their product -- and there would be no public option

The drug industry: No negotiation on pricesThe AMA: No cut in physician feesHospitals: No cut in reimbursements, only

slower growth in paymentsEmployers: Continued control of health

benefitsNervous members of the public: “You can

keep what you have”

Elizabeth J. Fowler, PHD, JDVice President for Public Policy and External AffairsWellPoint, Inc.Elizabeth J. Fowler serves as Vice President of Public Policy and External Affairs for WellPoint, Inc. Liz has more than 15 years experience in health services research and health policy. Prior to current job, she served as the Chief Health and Entitlements Counsel for the U.S. Senate Committee on Finance. In this capacity, she was responsible for overseeing health policy issues within the Committee's jurisdiction, including Medicare, Medicaid, SCHIP, health tax issues and initiatives to provide health coverage for the uninsured. She played a key role in the 2003 Medicare Prescription Drug, Improvement and Modernization Act (MMA).

The Honorable Max BaucusChairmanCommittee on FinanceUnited States Senate219 Dirksen Senate Office BuildingWashington, D.C. 20510

Health Reform Provisions That Took Effect September 23, 2010:Emergency Room Patient Protections: No prior authorization or higher cost sharing

Lifetime/Annual Limits: Phases in elimination of lifetime limits on healthcare benefits.

OB/GYN Patient Protections: Prohibits requiring a referral to see an obstetrician or gynecologist.

Preventive Health Services: Requires no copayment or deductible for certain preventive services.

Dependent Coverage: Allows adult children under the age of 26 to stay in a parent's health plan..

Pre-existing Condition Exclusions for Children: Prohibits denying coverage to individuals under the

age of 19 based on a preexisting condition.Rescission: Prohibits insurers from rescinding coverage

Appealing Insurance Company Decisions: Provides consumers a way to appeal coverage determinationsTax Credit to Small Businesses who Purchase Commercial Health InsuranceHealth Reform Provisions That Took Effect January 1, 2011Establishes State and Federal Preexisting Condition Insurance Programs:Minimum Loss Ratio for Insurers: 85% for large group and 80% for small group insurance. Closing the Medicare Drug Gap: Drug makers give a 50% discount in the donut hole. Medicare Primary Care Payments: 10% bonus to primary care docs and shortage area surgeons.Medicare Prevention Benefits: Co-pays and deductibles eliminated.Center for Medicare and Medicaid Innovation: Established and funded.Medicare Premiums: Raised for higher income beneficiaries.Medicare Advantage Plan Payments: Restructure to decrease federal subsidy.Medicaid Health Homes: Starts innovation to restructure care.CLASS Program: Starts voluntary insurance program for community living support servicesNational Quality Strategy: Program established.

New Health Official Faces Hostility in SenateBy ROBERT PEAR THE NEW YORK TIMES Published: July 26, 2010

WASHINGTON — Unlike many other health policy experts, Dr. Donald M. Berwick, the new chief of Medicare and Medicaid, has extensive real world experience…. He led efforts to reduce medical errors, eliminate hospital-acquired infections, standardize treatments and cut waste. One of his students, Dr. John S. Toussaint, former president of ThedaCare in Appleton, Wis., said his hospital had reduced the cost of inpatient care by about 25 percent, “using principles of continuous improvement espoused by Dr. Berwick.” But two weeks after taking office, Dr. Berwick is still struggling to tamp down a furor over past statements in which he discussed the rationing of health care and expressed affection for the British health care system. And he is finding his ability to do his job clouded by the circumstances of his appointment, with many Republicans in open revolt over President Obama’s decision to place him in the post without a Senate confirmation vote. Maureen A. Bisognano, who succeeded Dr. Berwick as president of the Institute for Healthcare Improvement, said he had “praised the British system when it works, but also offered prescriptions for change,” prodding officials to make improvements. For those efforts, Dr. Berwick received an honorary knighthood from Queen Elizabeth II in 2005. In speeches and articles celebrating the 60th anniversary of the British system in 2008, Dr. Berwick said, “I am romantic about the National Health Service; I love it.” Among its virtues, he cited a strong emphasis on primary care and a commitment to equity. He praised Britain as “recognizing that sick people tend to be poorer and that poor people tend to be sicker, and that any health care funding plan that is just, equitable, civilized and humane must — must — redistribute wealth from the richer among us to the poorer and less fortunate.” In short, he said, Britain guarantees health care as a human right.

Obama's Health Care Aid to Small Firms DisappointsBy RICARDO ALONSO-ZALDIVAR Associated Press WASHINGTON May 30, 2012 (AP)

A health insurance tax credit for small businesses, part of President Barack Obama's health care law that gets strong support in public opinion polls, has turned out to be a disappointment. Time-consuming to apply for and lacking enough financial reward to make it attractive, the credit was claimed by only 170,300 businesses out of a pool of as many as 4 million potentially eligible companies in 2010.That's put the Obama administration in the awkward position of asking Congress to help fix the problems by allowing more businesses to qualify and making it simpler to apply. It doesn't help the administration's plea that the biggest small-business lobbying group (The National Federation of Independent Business) is a lead plaintiff asking the Supreme Court to overturn the Affordable Care Act. Small businesses represent the crumbling edge of the nation's system of employer-based health care. Only about 30 percent of companies with fewer than 10 workers offer health coverage, and they often pay more for insurance than large businesses. The credit, which once had support in principle from lawmakers of both parties, was supposed to help businesses already providing coverage afford the premiums. The average credit claimed in 2010 was about $2,700, although some companies qualified for much more. Complexity has been another obstacle. IRS Form 8941, which employers must complete to claim the credit, has 25 lines and seven worksheets, the GAO said. Some tax preparers told the agency it took clients from two to eight hours to pull together supporting information and tax professionals another three to five hours to calculate the credit.

High-risk health care plans fail to draw crowd By Christine Vestal, Stateline Tuesday, September 06, 2011

Throughout the rancorous public debate over the national health law, this provision has maintained broad public support: a federally subsidized insurance plan for people whose medical conditions make them uninsurable in the private market.The health law’s lifeline for sick people who can’t get insurance anywhere else has been a virtual nonstarter. A year into the program, only 21,000 out of an estimated 25 million uninsured people with “high-risk” conditions such as cancer, heart disease and diabetes have signed up. When the law was enacted last year, administration officials projected enrollment would reach 375,000 and many worried that funding would run out. So far, only 2 percent of the $5 billion subsidy has been spent. The high-risk program was intended to be a bridge to 2014, when state-run health insurance exchanges will offer affordable coverage for everyone, regardless of health status. The biggest sticking point, according to a new report from the U.S. Government Accountability Office, is that only people who have been uninsured for at least six months are eligible. Congress added that provision to limit the number who would qualify. Others say the cost of premiums in the high-risk pool—though generally lower than for other available policies—is still too high for most patients to afford. Cost is clearly the biggest deterrent, says Amie Goldman, chair of the National Association of State Comprehensive Health Insurance Plans. State officials who have run their own high risk insurance programs for decades continually struggle with the problem. Sick people cost more to cover, but you still have to offer benefits that they can afford, Goldman says.When the federal government announced its high-risk insurance program in April 2010, states were asked to choose whether they wanted to run their own plans or let the federal government do it. Pennsylvania and 26 other states elected to run their own programs and set their own rates; 23 states and the District of Columbia opted for the federal plan, in which rates are equal to the market price for healthy people. More than a year later, one thing is clear. The state-run plans have been more successful than the federal program, at least relatively speaking. States have garnered more than 15,000 subscribers; the feds have signed up just 6,000.

Health Law to Be Revised by Ending a ProgramBy ROBERT PEAR THE NEW YORK TIMES October 14, 2011

WASHINGTON — The Obama administration announced Friday that it was scrapping a long-term care insurance program created by the new health care law because it was too costly and would not work. Kathleen Sebelius, the secretary of health and human services, said she had concluded that premiums would be so high that few healthy people would sign up. The program, which was intended for people with chronic illnesses or severe disabilities, was known as Community Living Assistance Services and Supports, or Class. “We have not identified a way to make Class work at this time,” Ms. Sebelius said….

The program was intended for people with severe disabilities who wanted to live in the community, though benefits could also have been used to help pay for nursing home care or assisted living. It would have been financed with premiums paid by workers, through voluntary payroll deductions, with no federal subsidy. Premiums were supposed to have ensured the solvency of the program over 75 years. But Ms. Sebelius said she agreed with actuaries who feared that “not enough young, healthy people” would enroll. “This could have led to a vicious cycle where premiums would have to be set higher and higher to cover the likely costs of benefits, leading fewer and fewer healthier people to sign up for the program,” Ms. Sebelius said.

Exhibit 2. System Improvement Provisions of Affordable Care Act of 2010

Affordable Care Act of 2010, 03/30/09

Insurance Standards, Plans, and Premium Review

State or regional exchanges; private and co-op plans offered; essential health benefits 60%–90% actuarial value, four tiers

plus young adults policy; insurers must meet medical loss ratio of 80 percent for individual and small groups, 85 percent for

large groups; review of premium reasonableness

Primary Care, Prevention, and Wellness

Primary care 10% bonus for 5 years; Medicaid payment rates to primary care physicians no less than 100% of Medicare rates in

2013 and 2014; annual wellness visit and/or health risk assessment for Medicare beneficiaries; preventive services

without cost-sharing; local and employer wellness programs

Innovative Provider Payment Reform CMS Innovation Center; Medicaid medical home designation; test bundled payment for acute and post-acute care; value-

based purchasing

Accountable Care Organizations ACOs to share savings in Medicare

Controlling Health Spending

Independent Payment Advisory Board recommendations to meet Medicare expenditure target; total system spending non-binding recommendations; productivity improvement update

factor

Quality Improvement and Public Reporting Direct HHS to develop national quality strategy, public reporting

Medicare Private Plan CompetitionLevel the playing field between Medicare Advantage and

traditional Medicare FFS plans

Cost-Conscious ConsumersIntroduce a 40% excise tax on high premium health insurance

plans beginning in 2018

Note: ACO = accountable care organization; PCP = primary care physician; AHRQ = Agency for Healthcare Research and Quality. HHS = Department of Health and Human ServicesSource: Commonwealth Fund analysis.

Community Health Centers Expand May 1, 2012

A provision by Sen. Bernie Sanders (I-Vt) in the 2010 health care law (ACA) authorized $11 billion to build, expand, and operate more community health centers nationwide, and an additional $1.5 billion to increase the number of primary care providers in underserved areas. The funding for these critical primary-care centers was designed to double to 40 million the number of patients served by health centers regardless of their ability to pay. 

Nationwide, the health care law already has supported 190 construction and renovation projects at health centers and supported the creation of 67 new health center sites across the country. During the next two years, the law will support more than 485 new health center construction and renovation projects and create at least 245 new community health center sites.Open to everyone, the centers care for patients covered by Medicaid, Medicare and private insurance, as well as those who have no insurance. Payments are on a sliding scale, so people with low or moderate incomes can afford the services. 

Happy Birthday Health Reform, a look back at health reform’s achievements in its first two years:

1.Prescription drugs are more affordable for 5.1 million seniors and people with disabilities. 5.1 million Medicare beneficiaries have saved more than $3.2 billion2.Two and a half million young adults up to age 26 have gained health insurance.3.Tens of millions of Americans are getting free preventive care. 87 million Americans received a free preventive health care service last year, according to HHS:  54 million through private insurance and 32.5 million through Medicare.4.Insurance companies can no longer deny coverage to sick children. This rule will apply to adults, too, starting in 2014.5.Insurance companies can no longer impose “life time limits” and cut off care for people who need expensive medical care. Before health reform, 105 million Americans had insurance plans with lifetime limits.6.The year-old Center for Medicare and Medicaid Innovation already has a number of initiatives under way, including 32 Pioneer Accountable Care Organizations (ACOs), an Advanced Primary Care Demonstration at 500 community health centers, projects evaluating bundled payment that rewards high-value, coordinated care; programs aligning financing and care for people who are dually eligible for Medicare and Medicaid; and the Partnership for Patients, targeting safety and readmissions.  7.Mechanisms are now in place to help prevent unreasonable premium increases and, beginning in August, insurers will provide rebates to enrollees when they spend more than 15 to 20 percent of enrollees' premiums on administration and profits.

By 2012 'Obamacare' In California: President's Affordable Care Act Has Been 'Lifesaving' For Golden State

**About 8,600 Californians with pre-existing medical conditions have gained access to affordable health insurance. Patients who have illnesses such as cancer or multiple sclerosis - who face high costs or denials on the open market - can buy insurance through the program.**More than 350,000 young adults have been able to stay on their parents' health insurance plans until they are 26.**More than 370,000 low-income people have been covered by an expansion of Medi-Cal, the health insurer for low-income Californians, that is part of the state's "bridge to reform" waiver to alter the state-federal program.** Consumers saved more than 100 million dollars when health insurance rate increases were rolled back or withdrawn as a result of increased regulatory power to review those increases. ** Seniors saved171 million dollars in prescription drug costs in a plan to close the Medicare limits in coverage. **12 million people who currently have health insurance no longer face a cap on coverage in case of a catastrophic illness.

ACA EXPENDITURES UP TO JUNE, 2012

ITEM AMOUNT PERCENT * Employer/Businesses to subsidize the cost of health insurance through tax relief $5.71B 41.7%• State Exchange development $3.33 B 24.3%• Community Health Center Expansion $1.74 B 12.7%• Medicare & Medicaid Experiments $1.07 B 7.8%• Maternal and Pregnancy Care $592 M 4.3%• Prevention and Public Health $522 M 3.8%• Work Force Training $ 512 M 3.7%• Health Care Facilities and Clinics $223 M 1.6%

• TOTAL $13.7 B 100%• ? Pre-existing condition Insurance expenses (70,000 enrollees) $1 B

Source: The New York Times, June 21, 2012 from a Kaiser Foundation study

Impact of Health Reform on:

Health Care Costs (Expansions)

All figures reflect spending through 2019

Copyright ©2008 American Cancer Society

From Ward, E. et al. CA Cancer J Clin 2008;58:9-31.

FIGURE 10 Cancer Survival by Insurance Status*

Impact of Health Reform on:

Health Care Costs (Savings)

All figures reflect spending through 2019

Medicare Tax Increase to Help Fund Health Care Reform Will Affect Few Taxpayers

Under PPACA the Medicare tax increase will help fund the reform. It will affect very few taxpayers.Under this provision, only individuals with incomes over $200,000 and couples with incomes over $250,000 will see their Medicare taxes rise. They will pay an additional tax on earnings above those amounts at the rate of 0.9 percent, and a new 3.8 percent Medicare tax on unearned income like capital gains, dividends, and interest.

Starting in 2014: The Insurance Mandate• Citizens and legal immigrants required to be

insured. Penalties up to 2.5% of income.• Insurers required to take everyone.• State-based insurance “exchanges” for individuals

and small employers • Subsidies up to 400% Federal poverty level so

premium (only) is less than 9.5% of income • “Hardship waiver” if premium greater than 8% of

income Can remain uninsured.• Medicaid for all below 133% poverty level

Annual premium amount paid by policy holder and premium tax credit*

Exhibit 16. Annual Premium Amount and Tax Credits for a Family of Four Under the Affordable Care Act, 2014

* For a family of four, policy holder age 40, in a medium-cost area in 2014. Premium estimates are based on an actuarial value of 0.70. Actuarial value is the average percent of medical costs covered by a health plan. FPL refers to federal poverty level.Source: Premium estimates are from Kaiser Family Foundation Health Reform Subsidy Calculator, http://healthreform.kff.org/Subsidycalculator.aspx.

Full premium =

$12,130Required premium payment by policy holder

Premium tax credit

Contribution capped at 3.3% of income

Contribution capped at 4.0% of income

Contribution capped at 6.3% of income

Contribution capped at 8.05% of income

Contribution capped at 9.5% of income

$32,326 $35,137 $46,850 $58,562 $70,275 $117,125

Let's use the Health Reform Subsidy Calculator (from Kaiser Family Foundation http://healthreform.kff.org/SubsidyCalculator.aspx#incomeAgeTables) to check a few examples. In each example, we will assume that the policyholder is 45, has a family of four, and does not have employer coverage available. For this family living in a region with a medium cost factor, the predicted premium for the silver plan (70% actuarial value) is $14,245. In the examples, we will change the level of income only.

Income:  $31,155 (133% of poverty)Premium payment:  None - covered by MedicaidMaximum out-of-pocket costs:  None - covered by MedicaidIncome:  $31,156 (133% of poverty plus $1)Premium payment:  $935Maximum out-of-pocket costs:  $4,167Total Family Cost: $5102 (17% of family income)Income:  $93,700 (400% of poverty)Premium payment:  $8,901Maximum out-of-pocket costs:  $8,333Total Family Cost: $17,234 (18% of family income)Income:  $93,701 (400% of poverty plus $1)Premium payment:  $14,245Maximum out-of-pocket costs:  $12,500Total Family Cost: $26,745 (28% of family income)

 One of the major flaws of the Affordable Care Act is that underinsurance will become the new standard for health insurance in the United States. The most common plans that will be purchased in the state insurance exchanges will fall well below the coverage that most people have today.The cheapest plans in the exchanges - bronze plans with an actuarial value of 60% (patient pays an average of 40% of covered costs) - will have deductibles of $4,375 for an individual ($8,750 for families) with coinsurance of 20% (the patient pays 20% of the amount over the deductible). The deductible can be reduced to $3,475 for an individual but then the patient faces a staggering coinsurance of 40%.

Because of the availability of income-indexed subsidies, it is likely that silver plans with an actuarial value of 70% will be the most commonly selected plans. These are still well below the typical employer-sponsored plans which have an average actuarial value of 82%. The deductible for the silver plans would be $2,050 for an individual with a 20% coinsurance rate. The deductible could be reduced to $650 but, again, the coinsurance rate would increase to 40%.

The 2014 limit for maximum out-of-pocket spending will be $6,350 for an individual or $12,700 for a family (on top of the portion of the premium that that must also be paid). These income-adjusted increases in cost sharing will still be excessive for most individuals and families with significant health problems and with all of the other financial problems that often are associated with ill health.

Clinical Care Transformation Model

Patient

Advanced Primary CareUnder Patient-Centered Medical Home

Medical GroupEnterprise Level Activities

Accountable Care OrganizationHospitals• Service Line Integration• Medical Staff Alignment• Incentives for Efficiency & Lean Six Sigma• Quality (SCIP, Leap Frog)• Safety

Medical Groups• Enterprise Level

Activities• PC-MH Functions

Skilled Nursing Facilities• SNFists• On-site Case Management• Efficiency Rating Systems

“Preferred Facilities”

Ancillary Services• Free-Standing ASC &

Diagnostic Testing Centers

Home Care• Home Safety Visits• Post Discharge Visits• Home Health

Coordinator of Services

Hospice• Transitions

(CHF, COPD, Frailty Syndrome, Dementia)

• PCP/SCP Incentives & Clinical Guidelines• Pay for Performance Initiatives• Hospitalists, Post Discharge Follow-Up Programs DME

• Integration & Oversight with Care Management

• Outcomes & Evidence Based Medicine

• Call Coverage• Consult Services (Stroke,

STEMI)• ER Avoidance Programs• Urgent Care• End of Life (Palliative Care)• Patient Satisfaction & Loyalty

• Personal Health Record• Patient Portal• Health Risk Assessment• Patient Engagement &

Activation

• Prevention & Wellness• Point of Care Analytics & Clinical

Decision Support• Gaps in Care• Population Management & Chronic

Care Registries• Home Visiting Teams• Generic Prescribing

Program

• Cost Effective Medical Management & Utilization of Services (SCP, Ancillary)

• Access, Same Day Appointments, e-Visits

• Patient Satisfaction & Loyalty• Provider & Office Staff Satisfaction

• Care management (Acute, Chronic, Inpatient, SNF)

• Health Coaching (Shared Decision Making)

• Transition of Care• Provider Satisfaction• Behavioral & Mental Health

ACOs and HMOs:Faith-Based Solutions

• Capitation as magic bullet• Consolidation among providers cuts costs• Prevention, care management & EMR/

computers save money• P-4-P encourages global quality• Risk adjustment can overcome gaming (cherry

picking & upcoding of diagnoses)

Defining Essential Health Benefits — The View from the IOM CommitteeJohn K. IglehartOctober 7, 2011 (10.1056/NEJMp1109982) When Congress enacted the Affordable Care Act (ACA), it mandated that a broad package of “essential health benefits” (EHBs) equivalent to that of a “typical employer plan” be offered by qualified health plans participating in newly created state-based insurance exchanges, as well as by new plans offered to individuals and small employers outside these exchanges. Congress directed the Department of Health and Human Services (DHHS) to flesh out the details. The DHHS, in turn, asked the Institute of Medicine (IOM) to recommend a process for defining and updating the EHB package — but notably, not to develop a specific list of benefits.In a report released on October 7, the IOM recommended that the initial EHB package be equivalent in scope to what could be purchased by the average premium that a small business would pay on behalf of an employee…Over time, under the ACA, an estimated 30 million uninsured individuals and employees of small businesses (fewer than 100 workers) with low-to-moderate incomes will become eligible for federally subsidized coverage through insurance exchanges or expansions of Medicaid programs…. The IOM report acknowledges that “the determination of the EHB is a politically and socially charged endeavor.”

The report said the cost trend will not be moderated only by the definition of EHBs and added: “The committee considered whether complementary Medicare-only or federal-only approaches to reducing rising health costs would be sufficient and concluded they would not be. An all stakeholder strategy is required across the public and private sectors,” and the ACA-created independent payment advisory board, even if it survives strong opposition to its creation, will not include formal engagement of the private sector. By expressing its concern over health care costs whose annual increases outstrip the growth of the economy, the committee has issued a wake-up call for policymakers, clarifying how this spending pattern squeezes out other important competing needs, particularly in a no-growth economy. However, such previous warnings, as often as they have been issued, have largely fallen on deaf ears.

TEN WAYS INSURANCE COMPANIES CAN GAME THE SYSTEM

1. Raising premiums There is no prohibition on companies raising premiums until 2014.2. Denying or revoking coverage for people with pre-existing conditions (EXCEPT FOR CHILDREN) until 2014.3. Changing your insurance plan Raising premiums, shutting down or restricting access to less costly care plans like HMOs and pushing current customers into high-deductible plans, where customers have to pay significant expenses out of pocket before the insurance company picks up a dime. 4. Making life more difficult for doctors Reducing insurance payouts by expanding prior authorization barriers, lowering provider payment rates, and making it more difficult to file claims.5. Selling across state lines Allowing insurance to escape oversight by the most competent state regulators.6. Marketing only to healthy people Making certain drugs hard (or impossible) to find on pharmaceutical formularies, limiting access to certain hospitals or centers of excellence for certain chronic diseases or putting up physical barriers at enrollment meetings will keep sicker people from applying for their insurance.7. Re-label current overhead expenses as health care When the reform finally takes full effect in 2014, insurance companies will have to spend 80 percent of their premiums on care for their customers. Thus, in order to make more money, they’ll have to increase the money you spend on care, or figure out a way to classify expenses currently deemed “overhead” as “health care for you.”8. Taking full advantage of the unhealthy behavior premium In the reform, insurers are allowed to makes premiums 50 percent more expensive for consumers who engage in “unhealthy” behaviors, which was intended to allow them to continue charging smokers higher premiums. But there are lots of behaviors which can be deemed “unhealthy,” such as unprotected sex, eating fast foods, drunk driving.9. Charging older people as much as they can The law allows insurers to charge people between 55 and 65 (the current age of Medicare eligibility) three times more than people 54 and under. 10. Increasing otherwise unregulated copayments and deductibles for medical services and pharmaceuticals.

The Consequences of Risk Adjustment in the Medicare Advantage ProgramThe National Bureau of Economic Research, NBER Digest OnLine, September 2011

Since the 1980s, people eligible for Medicare have been able to choose between the regular fee-for-service plan, under which the federal government pays a set fee to health care providers for each service provided, and Medicare Advantage (MA), whereby the government pays private health plans a fee for each individual they enroll. Almost one quarter of Medicare beneficiaries are currently enrolled in Medicare Advantage plans. Paying the same amount for every person enrolled in a health plan encourages plans to enroll low-cost people and to avoid high-cost ones. Because of this, the federal government historically overpaid for MA enrollees relative to their costs in traditional Medicare. So, in 2004 the Medicare program began to adjust its payments to private plans for enrollees health status.“How Does Risk Selection Respond to Risk Adjustment? Evidence for the Medicare Advantage Program” (NBER Working Paper No. 16977) studies individual-level data for 55,000 people from the period 1994 to 2006. Prior to risk adjustment, insurers simply had an incentive to enroll individuals with low costs. After risk adjustment, insurers instead had an incentive to enroll individuals with low costs conditional on their medical conditions. The main reason for this is that the risk adjustment formula pays the plans the average cost of the average person in a particular risk category. The authors demonstrate that, because individuals with less costly cases of diabetes and other health conditions enrolled in MA plans after the move to risk adjustment, overpayments to these plans actually increased.The risk adjustment formula that is used also explains only 11 percent of an individual’s fee-for-service costs in the year after risk is assessed. The formula systematically over-predicts costs for those with below average costs, and systematically under-predicts costs for those with above average costs. The authors find that individuals who are more expensive than the average person to insure are less likely to enroll in Medicare Advantage plans. So on balance, the government ends up paying the average cost for people who, had they stayed in fee-for-service Medicare, would have cost the government much less…. After 2004, switching from fee-for-service to Medicare Advantage increased Medicare spending by approximately $3,000 per person. Thus the shift to risk adjustment actually increased Medicare spending.

Lessons from the Physician Group Practice Demonstration — A Sobering ReflectionGail R. Wilensky, Ph.D., N Engl J Med 2011; 365:1659-1661 November 3, 2011In early August, the Center for Medicare and Medicaid Services (CMS) announced the results of the Physician Group Practice (PGP) Demonstration project. Although the headline of the press release was glowing — “Physician Group Practice Demonstration Succeeds in Improving Quality and Reducing Costs” — the reported information suggests more mixed results.1 These results should dampen unreasonable expectations, particularly in terms of potential savings, for accountable care organizations (ACOs), which were modeled after the PGP demo…. The demo began in 2005 (the first sobering fact is that it took so many years to get it started) and included 10 large PGPs. All were multispecialty groups, many with well-known names, such as the Marshfield Clinic, Geisinger, Park Nicollet, and Billings; two were associated with academic medical centers — the University of Michigan and Dartmouth. Physician groups in the demo received their regular Medicare payments for services provided to beneficiaries but could also share in the savings generated as long as they met certain quality metrics and exceeded a savings threshold of 2%. Thirty-two quality goals were used, most of them process measures related to coronary artery disease, diabetes, heart failure, hypertension, and preventive care. The savings threshold was calculated by using the per capita expenditures for a comparator group in the same geographic area and adjusting for the case mix and severity of illness.2 The PGPs did very well on the quality metrics during all 5 years of the demo. In the fourth year, all 10 groups met at least 29 of the 32 quality goals. The savings are another matter. Even with all their experience, only two of the PGP participants were able to exceed a 2% savings threshold the first year of the demo, and only half managed to surpass that threshold after 3 years…. only half of these 10 experienced PGPs were able to achieve the 2% savings threshold — these results are unexpected and, more important, they suggest (doubts) about the likelihood of success for ACOs. The minimum savings threshold that CMS has proposed for ACOs is also 2% (or 3.9% for plans with fewer patients), but plans will have to share losses as well as gains by year 3.

Effects of Care Coordination on Hospitalization, Quality of Care, and Health Care Expenditures Among Medicare Beneficiaries - 15 Randomized TrialsDeborah Peikes, PhD; Arnold Chen, MD, MSc; Jennifer Schore, MS, MSW; Randall Brown, PhDJAMA. 2009;301(6):603-618. Objective To determine whether care coordination programs reduced hospitalizations and Medicare expenditures and improved quality of care for chronically ill Medicare beneficiaries. Design, Setting, and Patients Eligible fee-for-service Medicare patients (primarily with congestive heart failure, coronary artery disease, and diabetes) who volunteered to participate between April 2002 and June 2005 in 15 care coordination programs (each received a negotiated monthly fee per patient from Medicare) were randomly assigned to treatment or control (usual care) status. Hospitalizations, costs, and some quality-of-care outcomes were measured with claims data for 18 309 patients (n = 178 to 2657 per program) from patients' enrollment through June 2006. A patient survey 7 to 12 months after enrollment provided additional quality-of-care measures. Interventions Nurses provided patient education and monitoring (mostly via telephone) to improve adherence and ability to communicate with physicians. Patients were contacted twice per month on average; frequency varied widely. Main Outcome Measures Hospitalizations, monthly Medicare expenditures, patient-reported and care process indicators. Results Thirteen of the 15 programs showed no significant (P<.05) differences in hospitalizations; however, Mercy had 0.168 fewer hospitalizations per person per year (90% confidence interval [CI], −0.283 to −0.054; 17% less than the control group mean, P=.02) and Charlestown had 0.118 more hospitalizations per person per year (90% CI, 0.025-0.210; 19% more than the control group mean, P=.04). None of the 15 programs generated net savings. Treatment group members in 3 programs (Health Quality Partners [HQP], Georgetown, Mercy) had monthly Medicare expenditures less than the control group by 9% to 14% (−$84; 90% CI, −$171 to $4; P=.12; −$358; 90% CI, −$934 to $218; P=.31; and −$112; 90% CI, −$231 to $8; P=.12; respectively). Savings offset fees for HQP and Georgetown but not for Mercy; Georgetown was too small to be sustainable. These programs had favorable effects on none of the adherence measures and only a few of many quality of care indicators examined. Conclusions Viable care coordination programs without a strong transitional care component are unlikely to yield net Medicare savings. Programs with substantial in-person contact that target moderate to severe patients can be cost-neutral and improve some aspects of care.

The Long-Term Effect of Premier Pay for Performance on Patient OutcomesAshish K. Jha, M.D., M.P.H., Karen E. Joynt, M.D., M.P.H., E. John Orav, Ph.D., and Arnold M. Epstein, M.D. March 28, 2012 (10.1056/NEJMsa1112351)

Pay for performance has become a central strategy in the drive to improve health care. We assessed the long-term effect of the Medicare Premier Hospital Quality Incentive Demonstration (HQID) on patient outcomes. We used Medicare data to compare outcomes between the 252 hospitals participating in the Premier HQID and 3363 control hospitals participating in public reporting alone. We examined 30-day mortality among more than 6 million patients who had acute myocardial infarction, congestive heart failure, or pneumonia or who underwent coronary-artery bypass grafting (CABG) between 2003 and 2009.

At baseline, the composite 30-day mortality was similar for Premier and non-Premier hospitals (12.33% and 12.40%, respectively; difference, −0.07 percentage points; 95% confidence interval [CI], −0.40 to 0.26). The mortality remained similar after 6 years under the pay-for-performance system (11.82% for Premier hospitals and 11.74% for non-Premier hospitals; difference, 0.08 percentage points; 95% CI, −0.30 to 0.46). We found that the effects of pay for performance on mortality did not differ significantly among conditions for which outcomes were explicitly linked to incentives (acute myocardial infarction and CABG) and among conditions not linked to incentives (congestive heart failure and pneumonia)

We found no evidence that the largest hospital-based pay-for-performance program led to a decrease in 30-day mortality. Expectations of improved outcomes for programs modeled after Premier HQID should therefore remain modest.

Association Between Patient-Centered Medical Home Rating and Operating Cost at Federally Funded Health Centers ONLINE FIRST Robert S. Nocon, MHS; Ravi Sharma, PhD; Jonathan M. Birnberg, MD, MS; Quyen Ngo-Metzger, MD, MPH; Sang Mee Lee, PhD; Marshall H. Chin, MD, MPH JAMA. 2012;():1-7. doi:10.1001/jama.2012.7048 Published online June 24, 2012

Context Little is known about the cost associated with a health center's rating as a patient-centered medical home (PCMH).Objective To determine whether PCMH rating is associated with operating cost among health centers funded by the US Health Resources and Services Administration.Results Six hundred sixty-nine health centers (66%) were included in the study sample, with 340 excluded because of nonresponse or incomplete data. Mean total PCMH score was 60 (SD, 12; range, 21-90). For the average health center, a 10-point higher total PCMH score was associated with a $2.26 (4.6%) higher operating cost per patient per month (95% CI, $0.86-$4.12). Among PCMH subscales, a 10-point higher score for patient tracking was associated with higher operating cost per physician full-time equivalent ($27 300; 95% CI, $3047-$57 804) and higher operating cost per patient per month ($1.06; 95% CI, $0.29-$1.98). A 10-point higher score for quality improvement was also associated with higher operating cost per physician full-time equivalent ($32 731; 95% CI, $1571-$73 670) and higher operating cost per patient per month ($1.86; 95% CI, $0.54-$3.61). A 10-point higher PCMH subscale score for access/communication was associated with lower operating cost per physician full-time equivalent ($39 809; 95% CI, $1893-$63 169).Conclusions According to a survey of health center administrators, higher scores on a scale that assessed 6 aspects of the PCMH were associated with higher health center operating costs. Two subscales of the medical home were associated with higher cost and 1 with lower cost.

Increased Ambulatory Care Copayments and Hospitalizations among the Elderly

vol 362:320-328, JAN 26,2010Amal N. Trivedi, M.D., M.P.H., Husein Moloo, M.P.H., and Vincent Mor, Ph.D.

Results In plans that increased copayments for ambulatory care, mean copayments nearly doubled for both primary care ($7.38 to $14.38) and specialty care ($12.66 to $22.05). In control plans, mean copayments for primary care and specialty care remained unchanged at $8.33 and $11.38, respectively. In the year after the rise in copayments, plans that increased cost sharing had 19.8 fewer annual outpatient visits per 100 enrollees (95% confidence interval [CI], 16.6 to 23.1), 2.2 additional annual hospital admissions per 100 enrollees (95% CI, 1.8 to 2.6), 13.4 more annual inpatient days per 100 enrollees (95% CI, 10.2 to 16.6), and an increase of 0.7 percentage points in the proportion of enrollees who were hospitalized (95% CI, 0.51 to 0.95), as compared

with concurrent trends in control plans. These estimates were consistent among a cohort of continuously enrolled beneficiaries. The effects of increases in copayments for ambulatory care were magnified among enrollees living in areas of lower income and education and among enrollees who had hypertension, diabetes, or a history of myocardial infarction.

Our results, however, suggest that increasing copayments for ambulatory care among elderly Medicare beneficiaries may be a particularly ill-advised cost-containment strategy. Assuming an average reimbursement of $60 for an outpatient visit,33 seven annual outpatient visits per enrollee, and an average copayment increase of $8.50 per visit, a Medicare plan would receive an additional $5,950 in patient copayments and avert $1,200 in spending on outpatient visits for every 100 enrollees, for a total of $7,150 in savings for the health plan. However, assuming an average cost of $11,065 for hospitalization of a person 65 to 84 years of age in 2006,34 our estimates suggest that expenditures for inpatient care will increase by $24,000 for every 100 health plan enrollees in the year after copayments for ambulatory care are increased.

Exhibit 24. Market Share of Three Largest Health Plans, by State, 2010

Source: Authors’ analysis of Managed Market Surveyor, Healthleaders-Interstudy (Jan. 2010). HealthLeaders-Interstudy. Used with Permission. All Rights Reserved.

48%–59% (4 states)

60%–69% (12 states)

70%–79% (24 states)

80%–90% (10 states and D.C.)

WA

OR

ID

MT ND

WY

NV

CAUT

AZ NM

KS

NE

MN

MO

WI

TX

IA

IL IN

AR

LA

AL

SC

TNNC

KY

FL

OH

MI

WV

PA

NY

AK

MEVTNH

MA

RI

DE

DC

HI

CO

GAMS

OK

NJ

SD

VA

CT

MD

…and Costs Will Keep On Rising

$0.0

$0.5

$1.0

$1.5

$2.0

$2.5

$3.0

$3.5

$4.0

$4.5

$5.0

2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019

PPACA (CMS Actuary)

Current projection

PPACA (Commonwealth Fund)

National Health Expenditures (trillions)

Notes: * Modified current projection estimates national health spending when corrected to reflect underutilization of services by previously uninsured. Source: D. M. Cutler, K. Davis, and K. Stremikis, Why Health Reform Will Bend the Cost Curve, Center for American Progress and The Commonwealth Fund, December 2009. Estimated Financial Effects of PPACA as Amended, Richard Foster, CMS Actuary, April 2010

$4.67$4.5

6.4% annual growth

6.6% annual growth

6.0% annual growth

$4.7

National Health Expenditures as Percent of GDP 17.8 17.9 18.0 18.2 18.8 19.3 19.8 20.2 20.5 21.0

Health Care Reform and the Health Care Workforce The Massachusetts ExperienceNEJM | September 7, 2011 Douglas O. Staiger, Ph.D., David I. Auerbach, Ph.D., and Peter I. Buerhaus, Ph.D., R.N.

Growth in Health Care Employment per Capita since January 2001 in Massachusetts and in the Rest of the United States.

After Reform Many Remain Uninsured (millions)

Lost in Translation — ¿Cómo se dice, “Patient Protection and Affordable Care Act”?James O. Breen, M.D., May 16, 2012 (10.1056/NEJMp1202039)

For the roughly 11 million undocumented persons living in the United States, the ACA is likely to make it more difficult to gain access to basic primary care services. That's because until now, the undocumented have been fellow travelers with the tens of millions of Americans without health insurance. The undocumented wait with uninsured Americans in health centers and county clinics; they apply for reduced-fee schedules from hospital systems alongside citizens. Their plight has been largely intertwined with that of uninsured Americans. Until now.With the full implementation of the ACA, tens of millions of Americans will receive access to routine health care services. This tidal wave of new patients will strain the health care infrastructure. If the claims of ACA proponents are true, the increased insurance access should all but eliminate uncompensated care and drastically reduce the need for charity care. This seemingly positive turn of events raises a disturbing question: With a diminution of public aid programs, where will the undocumented go for care?The debate surrounding the ACA makes it clear that the country lacks the economic means and political will to provide for the health care needs of undocumented immigrants. Amid the current economic austerity and polarizing political climate, there are few who openly support the concept of public coverage of medical services for undocumented immigrants. Even President Barack Obama, in his attempt to win bipartisan support for the ACA, declared that it would not expand coverage to undocumented immigrants, who would be barred from purchasing coverage in health insurance exchanges.Economics notwithstanding, physician workforce shortages loom ahead and threaten to crowd out the uninsured with a deluge of newly arrived paying patients. Although some dispute the prediction of a shortage, the Association of American Medical Colleges has stated that the burgeoning demand created by the newly insured and the swell of new Medicare enrollees will create a shortage of primary care physicians of about 29,800 in 2015 and about 65,000 by 2025.5

Key Facts on Health Coverage for Low-Income Immigrants Today and Under Health Reform Kaiser Commission on Key Facts, February 2012

As of 2010, there were 38 million immigrants residing in the United States, accounting for 12.5 percent of the total population. They include 16.7 million naturalized citizens and 21.4 million non-citizens, including both lawfully present and undocumented individuals. The Pew Hispanic Center estimates there were 11.2 million undocumented immigrants in the United States as of 2010, accounting for about 3.7 percent of the total population. In 2010, the median annual household income for non-citizens was $25,000, roughly half the amount for citizen households.Health coverage for naturalized citizens is very similar to that of U.S.-born citizens, with the majority covered through employer-sponsored or other private coverage. However, non-citizens are three times as likely as U.S.-born citizens to be uninsured due to lower rates of both public and private coverage.

Coverage Options for Immigrants Under Health Reform 

Almost all uninsured non-citizens have household incomes that would qualify for Medicaid or tax credits for exchange coverage under reform, but many will continue to face immigrant eligibility restrictions. The Medicaid expansion will make many lawfully present immigrants newly eligible for the program. However, the five-year wait for coverage will remain in place, limiting eligibility for many lawfully present immigrants. Undocumented immigrants will remain ineligible for Medicaid and will be ineligible for tax credits and prohibited from purchasing coverage through an exchange, even at full cost. Safety-net providers will remain a major source of care for immigrants.

WHOOPING COUGH EPIDEMIC MAY BE WORST IN 50 YEARS SACRAMENTO 6/23/2010Urging Californians to get vaccinated now, Dr. Mark Horton, director of the California Department of Public Health (CDPH), warned today that the state is on pace to suffer the most illnesses and deaths due to pertussis, also known as whooping cough, in 50 years. As of June 15, California had recorded 910 cases of pertussis, a four-fold increase from the same period last year when 219 cases were recorded. Five infants — all under three months of age — have died from the disease this year. In addition, 600 more possible cases of pertussis are being investigated by local health departments. Since 1998, more than 80 percent of the infants in California who have died from pertussis have been Hispanic.

State cuts affect immunization programsBy Michele Clock SAN DIEGO UNION TRIBUNEWednesday, November 17, 2010 at 7:18 p.m.

Linda Vista Health Care Center is one of a string of local clinics that deliver medical care to patients who have few other options.A new round of state budget cuts enacted last month is making that task more difficult. But providers like Roberta Feinberg, CEO of the nonprofit San Diego Family Care which runs the center, said the staff remains committed to providing care.Countywide, the state cut $660,000 for immunization services for children and teens and $348,000 for an immunization registry for children and adults. Those cuts come out of about $5.3 million overall in funding for the county’s immunization division.

Overall Consequences of PPACA• Continued reliance on private insurance• Employment-based insurance unchanged • Market competition will determine what health care costs (insurance

premiums, co-pays, deductibles) and how it works (payment and denial practices)

• Nothing but experimental pilot programs to try and reduce system costs, so there will be no likely reduction in costs or waste

Result: The program will make very little difference in the lives of most people. Why? Because there’s no change in the way we will be paying for health care.

The price problem that health-care reform failed to cureBy Alec MacGillis The Washington Post October 24, 2010[T]he Democrats' effort to sell the law to the public may be undermined by what even some ardent

supporters consider its biggest shortfall. The overhaul left virtually untouched one big element of our health-care dilemma: the price problem. There is no government "single payer" on the other side of the table…. The 2010 law does little to address this. Its many cost-control provisions are geared toward reducing the amount of care we consume, not the price we pay…. The main reason for this is politics. So there was no price fight. It is one of those fine political ironies: The law derided as socialism may have had an easier time winning favor from a skeptical public if it was, well, a little more socialist.

Many US Employers to Drop Health Benefits – McKinsey

CHICAGO (Reuters Health) Jun 07 - At least 30% of employers are likely to stop offering health insurance once provisions of the U.S. health care reform law kick in in 2014, according to a study by consultant McKinsey.McKinsey, which based its projection on a survey of more than 1,300 employers of various sizes and industries and other proprietary research, found that 30% of employers will "definitely" or "probably" stop offering coverage in the years after 2014, when new medical insurance exchanges are supposed to be up and running."The shift away from employer-provided health insurance will be vastly greater than expected and will make sense for many companies and lower-income workers alike," according to the study, published in McKinsey Quarterly…. The consultant also found that at least 30% of employers would gain economically from dropping coverage even if they compensated employees for the change through other benefit offerings or higher salaries.Losing employer-sponsored insurance would not prompt workers to leave their jobs, contrary to what many employers assume, McKinsey also predicted. The study found more than 85% of employees would remain at their jobs even if their employer stopped offering insurance, although about 60% would expect increased compensation.

Now That He Is 65, Mitt Romney Will Not Enroll In Medicare April 3, 2012 Mitt Romney is celebrating his 65th birthday today, officially making him eligible for Medicare benefits. But he will not enroll in the program, his campaign confirms.

Ann Romney Wouldn't Find Free-Market Health Care Without Mitt Romney's Millions Ann Romney suffers from multiple sclerosis, a chronic neurological disorder.Romney, who turns 63 later this month and also has a history of breast cancer, would likely be in dire straits if she had to turn to the open market for health insurance -- without her husband's millions.Romney, whose husband is Mitt Romney -- the leading Republican presidential contender, the ex-governor of Massachusetts and a former corporate honcho worth as much as $250 million -- presumably doesn't struggle to pay for her treatments, even if she doesn't consider herself wealthy. "Ann Romney would literally be unable to get health insurance in most states in America and if she could get it, she'd pay an unbelievable price," said Jonathan Gruber, an economist at the Massachusetts Institute of Technology. And it probably wouldn't cover treatments for M.S. and cancer, he said.

SINGLE PAYER IS THE REAL ALTERNATIVE

(INSURANCE COMPANIES MUST GO)