Older competition that used to be held for Young Athletes between ages 6 for 15 to show their skills in nfl. It was called the punt, pass and kick competition. It appears that thats actually being discontinued. The announcement came in may after more than 55, 56 years of it. But it looks like the senate is up to the task in terms of punting, passing, and the more throw to the side sense or kicking approach. Well see how much more of that competition renews when the senate is back next week and perhaps for the balance of the month as well. Had to be careful with this because the nfl is rather agressive on its trade name protection so this is a news shot as opposed to violating any nfl ordinances or pass, punt and kick in fact theyre leave it behind and want to give everybody a certificate for being on the field like soccers. Were starting a today a different series of Health Policy events. Everybody has been caught up in the politics and i thought id try something different, which is flesh out people are doing in Real Research as opposed to just moving dollars around. So i want to talk about given no mart what youre spending we could do a better job in the health care and the health we deliver by perhaps taking apart what is conventionally considered the current benefits and then reassembling it in more creative pays which Pay Attention to those receiving benefits and might have some voice in saying what works for them. So todays version of unbundling the benefits talk about how health civilization Health Savings accounts could be used and well talk about service for patients hits with highcost, highrisk conditions, giving them more intensive care unit type approach in order to head off things. Thats coming up on september a 5th and take around how to move around the dollars in medicaid benefits and perhaps retarget and prioritize them in a different way in order to ideally get better results and maybe look at the distinction between what is said to be equal benefits for everything the same for everybody as opposed to what might be more equitable benefits in people what they need. Today we are looking at new ways to development with Health Savings conditions. At the end of the day Health Savings accounts they have a long history are tax advantaged Health Benefits, you can move that around. There are other ways to do it. In fact some people talked about using hsas in aso many ways its almost like a Swiss Army Knife. Of course if you dont have any money in now health civilization account its a good hypothetical tool but a little dull in terms of where it can cut. Credit to this on the product, think, that victor is the only manufacturer of the Swiss Army Knife. I took some shots on that so theres a logo in there or mac s integrated in one form with Health Insurance. Youll hear from our speakers. Some current proposals as to how to change the contures of hsas and also more creative and thoughtful ways to reach beyond even tweaking here and there on the margins. We have three speakers. The first one will talk about having a more Precision Approach to hsas, an early way to think about this and ill introduce the three speakers separately. Warren roth has just again a new appointment Teaching Health law and legal righting at st. Johns University School of law, known as the red men but that became unfastabled and now the red storm on the campuses. Warren is also served as associate director of the Wiring Program and acting assistant professor in nyu school of law,ern a ph. D in Political Science from Columbia University and a law degree from harvard, has clerked. Done Legal Research and writing work at seton hall, and as a hometown connection, i suppose, because she graduated from george was university. I ran across a fascinating article by warren, thinking bat different way to think about health. Its a combination of how we can produce Better Health with a broader apray of tools, including investments in some of the social services and ways to improve social determinants of health to got the results we want as opposed to paying people who have healthcare bills. So laurens article witness be in the cornell journal of public policy, date to be determined as they says, but lets have lauren talk about a different way to look at hsas and a number of approaches to getting it. Thank you. And thank you for having me here, because i will say that typically im talking only to academics so its nice to have a broader audience here to talk about hsas. I wrote this article immediately following the election, thinking, what are some areas where there is potential bipartisan support, and hsas seemed to be an obvious one. I think the kansas conversation is even more urgently needed given what is going on. ll give a brown on hsas, hoping not stepping on toes 0 the other presentations ump expand the amount of Background Information because i was with a friend and he says i think i might halve a Health Savings account and it turn out he did not in fact have a Health Savings account. He had a flexible savings account. So i think this person is one of the smartest people i know, lawyer in d. C. I think its people like him dont understand very much about hs as, my guess is a lot of other people have no idea and dont understand how to use them. So, theres been a lot of talk about hsas in the media, following the politicians so Health Savings conditions, or hsas, are part of the movement for Consumer Directed Health plan, cdhp, a whole lot of acronyms involved in the movement, fsa, msa, hra. Maybe thats why people have trouble distinguishing between them because they get lost in the alphabet soup. So its all part of the general shift that started with pensions, from a defined benefit paradigm for Employee Benefits to employee. With the defined benefit paradigm your employer promises you a benefit now or in future. You get 2,000 a month for retirement income. Ill pay for all of your Health Care Expenses, minus maybe some copayments to a shift where the employer will place some amount of money, if youre lucky, into an account and you have the control and freedom to figure out what to do with that. Your benefit priorityes. Now the problem, as we talk about, is if theres not enough money in the account which ill return to its not that much help. If you dont have money to provide for needs those conditions which have potential are not that useful. So theres a big divide, political divide, about these individual accounts. So republicans, including president bush, who enacted the legislation for hsas, tend to really love the individual accounts. It goes along with the american ethos of individuality and control and ownership, the idea that people can decide for themselves what their needs or and act on those needs. You dont have is in employer telling you what to too, and providing for your benefits in the way they think is appropriate. Democrats, on the other hand, tend to think that individual accounts shift the risk to the people who are least able to bear it. So democrats are focused on the fact theres not enough money in the accounts. Maybe the conditions no theory would be a good idea if they were fully funded but theyre not. Right . So democrats see it as a way of cutting back on benefits. So talking about the basics of hsas. So, the way it works is that hsas must be combined with a High Deductible Health mon ohdhp north add to our alphabet soup. Instead of traditional private Health Insurance that covers all of your medical care needs with an exception for some copayments, maybe some coinsurance, but covers your medical needs starting from day one, with an hdhp your traditional Health Insurance coverage doesnt start until you reach a pretty high threshold, and before that time either youre responsible for paying out of pocket or use your hsa, if it has money in it to cover the costs. And i remember when i graduated from law school in 2004 i spent my whole first year to work with employers and put in place the hsas and hdhp. At the time people were up and arms about the hsss a and thinking this wont be good enough, people wont have enough of their and ins covered. Today people are lucky if they have the hsas but a whether they want to or not most people have been shifted towards higher deductible halve Insurance Plans and hey just would love to have an hsa with money it in. Ill talk about the High Deductible Health plans dont kick in until the threshold except for Preventive Care. The aca requires they cover in Preventive Care but beyond that theres a whole between before your insurance kicks in where you have to pay for expenses. Ill talk about in the numbers about professor ye is going to talk about the Tax Advantages of hsas. She mentioned in her article its an incredible Savings Vehicle. Triple tax savings. Right . So, the your contributions to the hsa are deductible from income. The earning growth tax rate and withdrawals from the account are not tacked not taxed if used for qualified expenses. The focus of my article, what account holders allowed to spend their money on how i think it should be different. Money can only be used for medical care as defined next sects 213d of the Internal Revenue code. This is a definition that originally applied to a deduction in the tax code for people who have excessively high healthcare expenses. Right now the threshold is 10 of income, which is an extraordinarily high amount before the deduction kicks in, bull when the hole where dhp, consumer driven heck care plan moment kicks in. This i replies to the whole alpha debt soup. All the accounts use that definition which is out of date. And well talk about how health law scholars are focused on other thingson traditional medical care. So, what you see now, these are the 2017 numbers for hsas and hdhps. Hdhps have an annual deductible of 1300 for single or 2600 for family coverage, and theres a maximum for annual out of pocket expenses deductibles, copayments but its a high maximum. 13,000 for a family is for most people they would start rationing their healthcare far before they got to that point. Employers and employees can contribute up to the maximum aggregate limit, which is the congressional proposals work on expanding this limit but right now its 3400 per single coverage, 6750 for family and theres a catchup contribution for people who are 55 and over. So, right now, roughly 19 of employees are enrolled in an hsaqualified hdhp. Thats very careful language. Doesnt necessarily moon they have opened up an hsa or thats any money in the hsa. So, it makes it you can see from the numbers below that, 25 receive no employer contributions at all. And the average employer contribution of 1,200 for family needs to be balanced against the current average annual detickettable for a family of over 4,300. Theres a 3,000 gap between what the average employer is contributing to the hsa and the deductible where the insurance kicks in. There are as people have discussed and continue discussing there are lot of drawbacks to hsas, i dont think their insurmountable but the biggest drawback, which we mentioned before you need to have money to fun them. Sarah rosenbaum, a Health Policy professor at gw said its a nonstarter for people with low incomes. I think thats true right now in terms of the amount of money goes into hsas. Doesnt need to be true. Its another vehicle for getting money allocated for health care to people. Thats all these conditions are. So, it has Great Potential in my view. The great risk shift, which i talked about, a lot of research on this. Employees now are paying if they get switched from a traditional Health Insurance plan to an hdhp theyre paying more of their medical anded than they used to. The this is where professor yes work is coming in. Not everyone is getting switched. Some people are gaining new coverage. Employee employees are bearing more of the costs than theyve did before. And the idea is that may not be such a bad thing. Healthcare expenditures are tremendous. We want to find ways to limit them. We want people to think more carefully, are the using Unnecessary Services . Are there ways this could force people to think more carefully about their medical needs . But the problem with that is that studies have shown that consumers are not fully rational when it comes to Health Expend did tours and theres a lot of reasons for this. First of all, unlike other goods you mightship around, its hard to shop around and look for competitive prices when youre sick. Obviously if youre in a hospital, and you need emergency services, this is difficult, but even if youre just not feeling well the idea of calling five pharmacies to fine the best price on a medication is pretty unappealing to most people and you can imagine this would add burdens to the system that are not currently if there the families and insurance company, everybody had to be there answering individual questions about the prices of services. The other problem is services may not be comparable. How do you value cancer treatments at sloankettering versus the same treatment at a local hospital. How do you deal with the fact that people have a very subjective attachment to their doctors, and may we billing to pay more than may be willing to pay more than they should to see a particular doctor. A couple other reasons. Hard to know if the services are even necessary. So forgetting it may be hard to compare prices, people rely on their doctors and experts who know more about medical care than they do, to understand this if they even need these tremendous. So its a little bit hard for individuals without a medical degree to secondguess the doctors and help to remarks their own health care. The final point i want to make is that studies are showing i list a couple here that people are rationing their own healthcare and avoiding needed until treatment because they dont have enough money in their accounts. The idea is that you want people to feel the costs. With traditional Health Insurance people have no skin the game no incentive to limit services they consume, but here maybe now theres a little too much skin in the game. Right . Maybe people are choosing to spend the money on other things which is where my research comes in, and material n terms of being complicated. Like my friend, if you are not sure you have an hsa and opening the account and making sure you have enough money and then using it, getting reimbursed. Its difficult. Current legislative proposals i wont say too much here because its in such a state of flux but the beyond the most recent proposal i heard from senator cruz, the ahca and the senate bill, the last vs. I knew, were focused on doubling the contribution limits to hsa to 5,000 for single coverage and 10 house 10,000 for family coverage. This is a nice idea but if a lot of people dont have money in the condition, upping the contribution limit doesnt help that much. Focus on giving people more flexibility. Some of the things i mentioned, the most important one is reducing the tax penalty when money is not used for qualified medical care. And the reason for that it you have people avoiding putting money in savings account but a its un predictable. If people are going to have a really large penalty if they pull the money out and use it for Something Else, they may be reluctant to use these vehicles. So, now to my proposal which ill spend the rest of my presentation talking about. My proposal is for something im calling precision hsas and these are hsas funds by moyers and, employees, and also the government. They can be used for a broader array of goods and services, depending on the account holders Family Income level. And i list ill go back in detail but i list the steps and youll notice that step one is to fund the accounts because its hard to experiment and use the money for interesting things if only the wealthiest americans can afford to fund their accounts. Step two is to allow physicians or other health workers, because there are huge costs to the sim from having physicians prescribing better housing for you, lets say to prescribe a broader array of goods services. This where the catch phrase social determinant of Health Company comes in. Step three issue dont believe my proposal requires amending the definition of medical care under the tax code. Its more about having agencies and courts reinterpret this phrase, given the changing state of medical care. The changing research on the impact that the social determinants of health have on health outcomes. So, the current definition of medical care is that youre allowed to get a Tax Deduction or to use your hsa money for expenses that are, quote, for the diagnosis, cure, mitigation, treatment, or prevention of disease or for the purpose of affecting any structure or function of the body. So, its a pretty broad definition. But the definition is the same for everyone, and its focused on traditional medical treatments instead of other thing that might improve health. Were thinking about housing and education, things that are being linked in research, thats being done to help outcomes. The u. S. Spends an enormous amount of money on health care, and i say Health Care