1. Who Makes HC Policy?

     a. State differences – access, price and coverage

     b. Individuals affected – 

          i. 17M buy insurance

          ii. 29M don’t have insurance

          iii. MCare & Medicaid not affected – State expansion of Medicaid, but higher rates of inflation in Red States

2. Hospital Closures & Medicaid Expansion

     a. ACA improving health care?

          i. Hospitals closed in States rejecting Medicaid

               1. States expanding Medicaid – lower and falling hospital closures

               2. ACA – improved hospital financial performance w/lower probability of closure for rural markets and counties w/large amt of uninsured

               3. Supreme Court left Medicaid expansion to the States

               4. Hospital closure leads to loss of well-paying and skilled jobs

3. Wall Street – Another Option for Paying For Health Care Benefits

     a. Sell wealth management to individuals

          i. Lower cost method to gain new customers

          ii. Morgan Stanley, Goldman, Fidelity, Charles Schwab, E*Trade, Amazon/JPMorgan/Berkshire Hathaway

          iii. Wall St has the analytics to redeploy investment dollars to benefits

          iv. Same as insurance brokers?

          v. TPA/PBM – middleman model to transactional model

4. Geography Matters – John Wennberg, MD

     a. Dartmouth Atlas of Health Care – cost of living, site of care, volume of services delivered, hospital/MD salaries

     b. Example – 

          i. SF Chronicle reports cost in No. CA 30% > So. Ca d/t UC Berkeley Petris Center on Health Care Markets and Consumer Welfare

          ii. Primary reasons -- D/t consolidation in hospitals, insurance and MD practices b/w 2010-2016 (adj for higher cost of living and wages)

          iii. Result – mergers/acquisitions in health care = HP+PBMs, MD practices, Plans, Pharmacies lead to higher costs

          iv. Marketplace competition, technology, telehealth, international competition, competitor ads leverage cost differences

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