Here is a fuller version of the 'Health Care Reform in Half an Hour' presentation.

1. Health Care Reform
in the United States
WILLIAM M. SAGE, MD, JD
THE UNIVERSITY OF TEXAS AT AUSTIN
APRIL 2012

2. America’s Health Care Cost Problem
 Approximately $3.5 trillion aggregate annual cost
 Spending over $8,000 per capita
 Premium for family coverage=$12,106 in 2007
 Rising much faster than wages
 A year's salary at minimum wage= $12,168
 More than half is publicly funded, amounting to a
substantial part of government spending

3. International Spending on Health:1980–2006
Average spending on health per capita ($US PPP*)
$7,000
United States
$6,000 Germany
Canada
Netherlands
$5,000 France
Australia
$4,000 United Kingdom
$3,000
$2,000
$1,000
$0
80
82
84
86
88
90
92
94
96
98
00
02
04
06
19
19
19
19
19
19
19
19
19
19
20
20
20
20
* PPP = Purchasing Power Parity.
Data: OECD Health Data 2008, June 2008 version.

4. THE
COMMONWEALTH
FUND
Publication: R. E. Leu, F. F. H. Rutten, W. Brouwer et al., The Swiss and Dutch Health Insurance Systems: Universal Coverage and
Regulated Competitive Insurance Markets, The Commonwealth Fund, January 2009

5. What is a potential solution to U.S.
federal health care spending?
1. Preventing any growth in
pension spending (social
security)
2. Eliminating politicians’ pet
projects (“pork” or
“earmarks”)
3. Cutting back all discretionary
federal spending
4. Renting out the U.S. military
to other countries

6. What is a potential solution to U.S.
federal health care spending?
1. Preventing any growth in
pension spending (social
security)
2. Eliminating politicians’ pet
projects (“pork” or
“earmarks”)
3. Cutting back all discretionary
federal spending
4. Renting out the U.S. military
to other countries

7. Federal Budget Trends

8. Health and State Budgets
Components of total state spending, fiscal 2006
Medicaid, 21.5%
Elementary/secondary education, 21.4% (largest until ‘03)
Higher education, 10.4% (2nd largest until 1990)
Transportation, 8.1%
Corrections, 3.4 %
Public assistance, 1.8%
All other expenditures, 33.4%
Source: NGA/NASBO Dec. 2007 Survey

9. America’s Health Care Access Problem
 47 million Americans (15%) did not have health
insurance in 2006
 Institute of Medicine estimates that 18,000
Americans die every year from lack of care
 There are large racial, ethnic, and socioeconomic
disparities in diagnosis, treatment, and medical
outcomes

10. Number of Nonelderly Uninsured Americans,
1994 – 2006
Previous Method 1999 Revised Method 2004 Revised Method
50 46.5
44.7 45.5 44.4
43.1 43.9 43.3 43.0
41.7 42.1
40.6 40.9
39.8 40.0 39.6
25
44.8
0
‘94 ‘95 ‘96 ‘97 ‘9 '99* ‘00 ‘01 ‘0 ‘03 ’04* ‘05 ‘06
8 2
* The Census Bureau periodically revises its CPS methods, which means data before and after the revision are not comparable.
Comparison across years can be made between 1994 and 1999, 1999 through 2004, and 2004 though 2006.
SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.

11. Patient Protection
and Affordable Care Act of 2010
 Title I: “Quality, Affordable Care for All Americans”
 Insurability reforms
 Title II: “Role of Public Programs”
 Affordability reforms
 Title III: “Improving the Quality and Efficiency of Health
Care”
 Delivery system reforms
 Title IV: “Prevention of Chronic Disease and Improving
Public Health”
 Health reforms
 Title V: “Health Care Workforce”
 Education reforms

13. Uninsured Nonelderly vs. All Nonelderly,
by Family Poverty Level, 2006
300% + 19%
200% - 299% 16% 49%
100% - 199% 29%
16%
17%
Under 100% 36%
17%
Uninsured All Nonelderly
46.5 Million 260.0 Million
NOTES: The Federal Poverty Level for a family of four in 2006 was $20,614 (according to the U.S. Census
Bureau’s poverty threshold). Family size and total family income are grouped by insurance eligibility. Data may
not total 100% due to rounding.
SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of March 2007 CPS.

14. Uninsured Rates Among Nonelderly
by State, 2005-2006
NH
VT
WA ME
MT ND
MN MA
OR NY
ID SD WI
RI
MI
WY CT
PA
IA NJ
NE OH
NV IL IN DE
UT WV VA
CA CO MD
KS MO KY
NC DC
TN
OK SC
AZ AR
NM
AL GA
MS
AK TX
LA
FL
HI
<13% Uninsured (13 states)
National Average = 18% 13 to 17% Uninsured (18 states & DC)
≥18% Uninsured (19 states)
SOURCE: Kaiser Commission on Medicaid and the Uninsured and Urban Institute analysis of the March Current
Population Survey, 2006 and 2007, two-year pooled data.

15. Patient Protection
and Affordable Care Act of 2010
 Title I: “Quality, Affordable Care for All Americans”
 Insurability reforms
 Title II: “Role of Public Programs”
 Affordability reforms
 Title III: “Improving the Quality and Efficiency of Health
Care”
 Delivery system reforms
 Title IV: “Prevention of Chronic Disease and Improving
Public Health”
 Health reforms
 Title V: “Health Care Workforce”
 Education reforms

17. America’s Health Care Value Problem
 Fragmented, variable, poor quality health care
delivery
 Lack of preventive care
 Poor adherence to clinical “best practices”
 Frequent medical errors
 Mediocre population health
 Life expectancy at birth ranks 40th in the world
 Epidemic obesity and associated chronic disease burden
(diabetes, cardiovascular disease)
 25% of Americans are obese
 45% of Americans have a chronic disease

18. Lack of Insurance Undermines Preventive and Chronic
Care
Percent of adults Percent of adults
100 Insured Uninsured
100
Chronic Disease Under Control:
Receipt of Recommended Screening
Diabetes and Hypertension, 1999–
81
80 and Preventive Care,* 2005 80
2004
63
60 53 60
50
46
41
40 32 40
21
20 20
0 0
Total Uninsured Uninsured Insured all
all year part year year
Diabetes under control** High blood pressure
under control***
* Recommended care includes: blood pressure, cholesterol, Pap, mammogram, fecal occult blood test or sigmoidoscopy/colonoscopy, and flu
shot within a specific time frame given age and sex. ** Refers to diabetic adults whose HbA1c is <9.0 *** Refers to hypertensive adults whose
blood pressure is <140/90 mmHg.

19. Poor Coordination: Nearly Half Report Failures to Coordinate
Care
Percent U.S. adults reported in past two years:
Your specialist did not receive basic
medical information from your 13
primary care doctor
Your primary care doctor did not
receive a report back from a 15
specialist
Test results/medical records were
not available at the time of 19
appointment
Doctors failed to provide important
medical information to other
doctors or nurses you think should 21
have it
No one contacted you about test
results, or you had to call 25
repeatedly to get results
Any of the above
47
Source: Commonwealth Fund Survey of Public Views of the U.S. Health Care System, 2008.
0 20 40 60

20. Patient Protection
and Affordable Care Act of 2010
 Title I: “Quality, Affordable Care for All Americans”
 Insurability reforms
 Title II: “Role of Public Programs”
 Affordability reforms
 Title III: “Improving the Quality and Efficiency of Health
Care”
 Delivery system reforms
 Title IV: “Prevention of Chronic Disease and Improving
Public Health”
 Health reforms
 Title V: “Health Care Workforce”
 Education reforms

22. The problem
“The American public cannot have
it both ways. They must decide
what is more important – money
and time– or comprehensive,
appropriate care.”
-A Kentucky physician opposing
retail medical clinics

23. Patient Protection
and Affordable Care Act of 2010
 Title I: “Quality, Affordable Care for All Americans”
 Insurability reforms
 Title II: “Role of Public Programs”
 Affordability reforms
 Title III: “Improving the Quality and Efficiency of Health
Care”
 Delivery system reforms
 Title IV: “Prevention of Chronic Disease and Improving
Public Health”
 Health reforms
 Title V: “Health Care Workforce”
 Education reforms

25. Obesity Trends* Among U.S. Adults
BRFSS, 1985 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14%

26. Obesity Trends* Among U.S. Adults
BRFSS, 1986 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14%

27. Obesity Trends* Among U.S. Adults
BRFSS, 1987 for 5’ 4”
(*BMI ≥30, or ~ 30 lbs. overweight
person)
No Data <10% 10%–14%

28. Obesity Trends* Among U.S. Adults
BRFSS, 1988 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14%

29. Obesity Trends* Among U.S. Adults
BRFSS, 1989 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14%

30. Obesity Trends* Among U.S. Adults
BRFSS, 1990 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14%

31. Obesity Trends* Among U.S. Adults
BRFSS, 1991 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19%

32. Obesity Trends* Among U.S. Adults
BRFSS, 1992 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19%

33. Obesity Trends* Among U.S. Adults
BRFSS, 1993 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19%

34. Obesity Trends* Among U.S. Adults
BRFSS, 1994 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19%

35. Obesity Trends* Among U.S. Adults
BRFSS, 1995 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19%

36. Obesity Trends* Among U.S. Adults
BRFSS, 1996 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19%

37. Obesity Trends* Among U.S. Adults
BRFSS, 1997 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% ≥20%

38. Obesity Trends* Among U.S. Adults
BRFSS, 1998 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% ≥20%

39. Obesity Trends* Among U.S. Adults
BRFSS, 1999 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% ≥20%

40. Obesity Trends* Among U.S. Adults
BRFSS,overweight for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs.
2000
No Data <10% 10%–14% 15%–19% ≥20%

41. Obesity Trends* Among U.S. Adults
BRFSS, 2001 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

42. Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs. overweight for 5’ 4” person)
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

43. Obesity Trends* Among U.S. Adults
BRFSS, 2003 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

44. Obesity Trends* Among U.S. Adults
BRFSS, 2004 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% 20%–24% ≥25%

45. Obesity Trends* Among U.S. Adults
BRFSS, 2005 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

46. Obesity Trends* Among U.S. Adults
BRFSS, 2006 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

47. Obesity Trends* Among U.S. Adults
BRFSS, 2007 for 5’ 4” person)
(*BMI ≥30, or ~ 30 lbs. overweight
No Data <10% 10%–14% 15%–19% 20%–24% 25%–29% ≥30%

48. Patient Protection
and Affordable Care Act of 2010
 Title I: “Quality, Affordable Care for All Americans”
 Insurability reforms
 Title II: “Role of Public Programs”
 Affordability reforms
 Title III: “Improving the Quality and Efficiency of Health
Care”
 Delivery system reforms
 Title IV: “Prevention of Chronic Disease and Improving
Public Health”
 Health reforms
 Title V: “Health Care Workforce”
 Education reforms