On November 16, 2017, the National Academy of Social Insurance co-hosted an educational seminar with the USC Schaeffer Center to examine America’s challenges and opportunities for health care reform. The event was held in Los Angeles at the University of Southern California and focused on “Balancing Costs, Coverage, and Quality.”
A multidisciplinary panel of six experts responded to some of the major questions (see below) facing our policymakers and health care industry leaders today. Leonard Schaeffer, USC Trustee and a Founding Member of the Academy, framed the purpose of the event in his welcoming remarks. The discussion panel was moderated by Dana Goldman, Leonard D. Schaeffer Chair and Distinguished Professor of Public Policy, Pharmacy and Economics, Schaeffer Center for Health Policy & Economics, at the University of Southern California. Goldman facilitated a robust discussion with a number of provocative questions about the evidence to support various policies around improving population health and social determinants, as well as universal coverage and costs.
Read on for a few highlights. To hear the full conversation, please visit the Academy’s Facebook page. We invite you to add your questions and remarks by using the comment box below.
Q: WHAT CAN WE DO TO PROTECT OUR SOCIAL INSURANCE PROGRAMS?
Leonard Schaeffer: We have to hold policymakers accountable for using facts and ethics as the basis for social policy… The [social insurance] programs have expanded over time and cover many Americans, but they have become more costly. The question we face is how to restructure programs to preserve social insurance, while keeping the costs borne by both government and by beneficiaries reasonable and affordable?
I want to ensure that research and informed analysis remain the basis for developing policy solutions. For that reason, the Academy’s history and its goals are extremely important. All of us want to ensure the future of social insurance, and we can achieve that by joining together to advocate for public policy that is based on facts. Therefore, I’d like to urge you to contribute to this organization in whatever way you can.
Q: SHOULD THERE BE CHANGES TO MEDICARE?
Bill Arnone: In true Academy style, we are creating a study panel to look at possible changes to Medicare. The study panel involves 20-25 of the best thought leaders on a topic who will look at both sides of an argument and collaborate on what must be done going forward based on evidence. One of the important questions the study panel will look at is whether the eligibility age for Medicare should be lowered or increased. The arguments on both sides are passionate. Those who want to increase the age want it to reflect increases in life expectancy. Those who want to lower the age say it should be synced to the early retirement age of 62. There are those who want to go even lower. As some of you know, there is a significant movement for “Medicare for All” in the House and Senate.
I’m excited not only about looking at policy options we must confront, but about issuing a report that might end up translating into actual legislative action. And we do it without being lobbyists and without being activists, but by arming others who can make sensible, evidence based arguments on either side.
Q: WHAT IS THE IMPACT OF THE AFFORDABLE CARE ACT?
Gerald Kominski: Despite the rhetoric coming out of the White House, the Affordable Care Act is alive and well, it’s not dead. It has produced the largest reduction in the percentage of uninsured since the implementation of Medicare and Medicaid in 1966, going from 18.2% down to 10.4% nationally.
Thanks to the ACA:
- There are 10.3 million Americans enrolled in exchanges.
- 84% of those get subsidies.
- 57% with income below 250% of the federal poverty level get cost sharing reductions.
- 50 million are newly enrolled in the Medicaid program.
- 3.1 million young adults under 26 are insured under their parents’ policy.
There’s room in the current Congress for a bipartisan effort to stabilize the ACA marketplaces for 2018 and beyond. But like many areas of policy matters under the current administration, the immediate future is really volatile and uncertain, leaving us to wonder where Congress is going and how Congress is going to preserve social insurance programs. Or are they going to proceed with the painful process of trying to dismantle them?
Q: WHY ARE HEALTH CARE COSTS SO HIGH?
Tom Rice: Compared to 10 European countries, the U.S. has the highest health care costs but also the highest mortality rate, so there is some issue of value in our system. Four reasons that keep U.S. costs high:
- High unit prices. Fees for hospitals, physicians and brand name drugs are high.
- Specialization. The U.S. has more specialists than any of the European countries.
- Higher administrative costs.
- Poor health habits. We have low smoking rates, but poor nutrition, more obesity, and more substantial drug abuse than other countries.
We can do more on the demand, supply and legislative side to reduce costs. On the demand side, one possible way to keep the cost of drugs down is reference pricing. If people want to pay the extra amount they can if they choose to, but they won’t do that in an environment with very high deductibles. Other countries rely on supply side to control costs in a variety of ways, but it would be very hard to make those changes in this country. Finally, what makes us an outlier in the legislative side is our prohibition against basing coverage for particular services on anything to do with costs. It’s the opposite of what they do in England.
Q: WHO WOULD BE MOST AFFECTED BY CUTS TO THE ACA?
Seth Seabury: Medicaid, one of the most important social insurance programs in America, has been a real target in the efforts to repeal the ACA. Those most affected by reforms will be the underserved and vulnerable members of our society: children, the elderly, and those with mental health issues.
- As of 2015, Medicaid had 70 million enrolled beneficiaries.
- Together with CHIP, Medicaid provides coverage for nearly 1/3 of American children.
- It’s the largest provider of long-term care for adults.
- Medicaid is the single largest provider of mental and behavioral health services in the U.S. Almost 1/5 of Medicaid beneficiaries have a moderate to serious mental health illness.
- It’s also of growing importance in providing treatment for substance abuse and for fighting the opioid epidemic. In some states with the highest opioid overdoses, Medicaid provides 35-60% of medically assisted treatment for opioid disorders.
Health care reform requires hard choices, but it’s important to keep in mind that as long as a large portion of the spending is going to a vulnerable population, when you cut spending you’re going to take away treatments from people and in some cases you’re going to have worse outcomes. The challenge is to come up with reform efforts that allow us to preserve care and improve access to care for the people who need it most, even as we make the system more efficient and more affordable.
Q: HOW CAN PROVIDERS REDUCE COSTS AND IMPROVE OUTCOMES?
Zubin Eapen, MD: In an integrated payer and provider approach, which we use at CareMore, providers are fully at risk for patients. We serve many payers in Medicare Advantage and managed Medicaid plans in eight states under Anthem. We are a capitated group that focuses on the highest cost, highest risk patients. We want to keep these members out of the hospital, because we know every hospital admission is associated with morbidity and mortality. So, how do we do it?
Being a capitated environment allows us to invest in the wholistic care of our patients. It often involves what happens in the outpatient space. We provide robust client disease management but we also take care of non-clinical needs. For instance, we’ve partnered with the ride sharing company Lyft to provide free transportation to our clinics and care centers so there’s better utilization of services. We initiated meal programs, particularly where patients are too weak to care for themselves. We integrate oral health and have dentists working alongside physicians. We have volunteers across CareMore and Anthem who call our members to make social connection because we know loneliness can impact health in negative ways.
I never expected to be working on these programs as a physician, because they are not part of the typical fee for service system. Our ability to take full risk for a patient in a capitated system allows us to think more creatively about how we take care of people, by focusing not only on encounters in the clinic or hospital setting, but also by providing good preventative care and considering socio-economic determinants of health.
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