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National Health InsuranceKenneth Brummel-Smith, M.D.

Charlotte Edwards Maguire Professor & Chair,

Department of Geriatrics

Florida State University College of Medicine

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Current “System” 1000 insurers (over 4000 different policies) Rationing happens here

Wait times for elective surgeries Preventive care for uninsured and some insured Chronic care for uninsured

Higher dissatisfaction by patients and Drs Huge profit margins of insurance companies

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Billing Clerks We have 900 billing clerks at Duke (900 bed

hospital). I’m not sure we have a nurse per bed, but we have a billing clerk per bed. It’s obscene. Dr. Uwe Reinhardt, hearing on healthcare reform, US Senate Finance Committee, November 19, 2008

This is how we do “market-based” care 30% of the health care dollar goes to

administration Canadian hospitals average 2 billing clerks

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Definitions Universal coverage – everybody has some

form of insurance coverage Socialized medicine – medical care system is

owned and managed by the government Drs are employed by government Hospitals are owned by the government

Single payer national health insurance – there is one insurance program for all

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Many ModelsSingle Payer Socialized Regulated

InsuranceMixed

Canada England Germany US

Denmark Spain France

Norway Netherlands

Australia

Taiwan

Sweden

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18,314 Adult Deaths Annually Due to Uninsurance

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Half of Americans Live Where Population Is Too Low for Competition

Source: NEJM 1993;328:148

A town’s only hospital will not compete with itself

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“Mandate” Model - Problems

Absent cost controls, expanded coverage unaffordable Computers, care management, prevention not shown to

cut costs Adds administrative complexity and cost; retains

wasteful private insurers Impeccable political logic, economic nonsense

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We Are Partly There! We already have single payer

Medicare We already have socialized medicine

Department of Defense Veterans Administration

We already have regulated insurance Federal Employees Health Benefits

We spend more than anyone else

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Funding For National Health Insurance

Income Source Medicare $ Medicaid $ DOD, VA $ Personal income tax –

top 5% Payroll tax similar to

current health payments Small tax on stock &

bond transactions

Expenditures Hospitals (operating) Hospitals (capital) Fee-for-service providers Home care agencies Long term care providers HMOs Malpractice subsidy? Education subsidy?