health care in the u.s. and the world

Martin DonohoeMartin Donohoe

Determinants of HealthDeterminants of Health EraEra Socioeconomic statusSocioeconomic status SexSex RaceRace LocationLocation EnvironmentEnvironment GeneticsGenetics Health HabitsHealth Habits Access to CareAccess to Care

The State of U.S. Health The State of U.S. Health CareCare

52 million uninsured52 million uninsured 45,000 deaths/year45,000 deaths/year

30 million more underinsured30 million more underinsuredRemain in dead-end jobsRemain in dead-end jobsGo without needed care Go without needed care and/or prescriptionsand/or prescriptions

MarryMarry

Reasons for No Health Insurance Reasons for No Health Insurance Coverage (2009)Coverage (2009)

The State of U.S. Health The State of U.S. Health CareCare

US ranks near the bottom US ranks near the bottom among westernized nations in among westernized nations in overall population health (#24), overall population health (#24), life expectancy (#42), infant life expectancy (#42), infant and maternal mortality, etc.and maternal mortality, etc.

15% of Americans live in 15% of Americans live in povertypoverty

22% of US children live in 22% of US children live in povertypoverty

Health Care Expenditures Health Care Expenditures per Capitaper Capita

U.S. = $7,960U.S. = $7,960 Canada, Australia, Japan, Canada, Australia, Japan,

Europe: $3,000 to $6,000Europe: $3,000 to $6,000Average for low income Average for low income developing nations = $22-developing nations = $22-2525

Who Pays for Health Who Pays for Health Care?Care?

Government (federal, state, and local)Government (federal, state, and local) Medicare, Medicaid, VA, IHS, jails and Medicare, Medicaid, VA, IHS, jails and

prisonsprisons Private insurancePrivate insurance

Primarily employer-basedPrimarily employer-based Out-of-pocketOut-of-pocket Health care costs = 17.6% of GDP (1/2 of Health care costs = 17.6% of GDP (1/2 of

worldwide health care costs)worldwide health care costs)

Health Insurance Health Insurance IndustryIndustry

DelistingDelisting

Cherry pickingCherry picking

Pre-existing conditionsPre-existing conditions


High administrative costsHigh administrative costs 15-30% (vs. 2-3% for Medicare and 15-30% (vs. 2-3% for Medicare and

Medicaid)Medicaid) Average full-time physician spends Average full-time physician spends

over $85,000/yr on billing and over $85,000/yr on billing and insurance functionsinsurance functions

17,849 different billing codes (in 17,849 different billing codes (in 2012 increases to 141,058)2012 increases to 141,058)


Amount actually spent on patient Amount actually spent on patient care referred to as “medical loss care referred to as “medical loss ratio”ratio”

Large profit marginsLarge profit margins Median pay of health care CEOs = $10.6 Median pay of health care CEOs = $10.6

million (2010)million (2010)

Loyalty: shareholders (not patients)Loyalty: shareholders (not patients) CorruptionCorruption

Distribution of National Health Distribution of National Health ExpendituresExpenditures

Some Reasons for Rising Some Reasons for Rising Health Care CostsHealth Care Costs

Aging populationAging populationChronic diseasesChronic diseases

Technological advancesTechnological advances Exploding drug costsExploding drug costs Increasing specialist referralsIncreasing specialist referrals

Some Reasons for Rising Some Reasons for Rising Health Care CostsHealth Care Costs

Procedural variabilityProcedural variability Overuse of diagnostic tests, Overuse of diagnostic tests,

medications, and therapeutic medications, and therapeutic proceduresprocedures

Administrative costsAdministrative costs

Drug Companies’ Cost Drug Companies’ Cost StructureStructure

Innovation:Innovation:Published Research Leading to DrugsPublished Research Leading to Drugs

Premature Deaths in the Premature Deaths in the U.S.U.S.

10% due to inadequate 10% due to inadequate medical caremedical care

60% due to behaviors, social 60% due to behaviors, social circumstances, and circumstances, and environmental exposuresenvironmental exposures

Address Social Factors Address Social Factors Responsible for Illness and Responsible for Illness and

DeathDeath Deaths in 2000 attributable to:Deaths in 2000 attributable to:

Low education: 245,000Low education: 245,000Racial segregation: 176,000Racial segregation: 176,000Low social support: 162,000Low social support: 162,000 Individual-level poverty: Individual-level poverty:

133,000133,000 AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465



Income inequality: 119,000 Income inequality: 119,000 (population-attributable (population-attributable mortality – 5.1%)mortality – 5.1%)

Area-level poverty: 39,000 Area-level poverty: 39,000 (population-attributable (population-attributable mortality – 1.7%)mortality – 1.7%)

AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465



AMI – 193,000AMI – 193,000CVD – 168,000CVD – 168,000Lung CA – 156,000Lung CA – 156,000

AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465

Major Contributors to Major Contributors to Illness and DeathIllness and Death

40% of US mortality due to 40% of US mortality due to tobacco, poor diet, physical tobacco, poor diet, physical inactivity, and misuse of alcoholinactivity, and misuse of alcohol

Every $1 invested in programs Every $1 invested in programs covering above items saves covering above items saves $5.60 in health care costs$5.60 in health care costs

PreventionPrevention

2-4% of national health care 2-4% of national health care expendituresexpenditures

Every $1 spent on building biking Every $1 spent on building biking trails and walking paths would save trails and walking paths would save nearly $3 in medical expensesnearly $3 in medical expenses

Every $1 spent on wellness Every $1 spent on wellness programs, companies would save programs, companies would save over $3 in medical costs and almost over $3 in medical costs and almost $3 in absenteeism costs$3 in absenteeism costs

Public Health SpendingPublic Health Spending

Public health spending minimalPublic health spending minimal

Mortality rates fall 1-7% for Mortality rates fall 1-7% for every 10% increase in public every 10% increase in public health spendinghealth spending

ComplianceCompliance

33% of prescriptions go unfilled33% of prescriptions go unfilled Only 50-65% of patients take medicines as Only 50-65% of patients take medicines as

prescribedprescribed Noncompliant patients more likely to be Noncompliant patients more likely to be

hospitalized and to diehospitalized and to die Noncompliant patients have twice the Noncompliant patients have twice the

annual medical care costs of those who annual medical care costs of those who are compliantare compliant

Cost, health literacy contribute to Cost, health literacy contribute to noncompliancenoncompliance

Poverty and HungerPoverty and HungerUS: 15% of residents and 22% US: 15% of residents and 22% of children live in povertyof children live in poverty

Rates of poverty in Blacks and Rates of poverty in Blacks and Hispanics = 2X WhitesHispanics = 2X Whites

Poverty associated with worse Poverty associated with worse physical and mental healthphysical and mental health

Economic DisparitiesEconomic DisparitiesWomen 75 centsWomen 75 cents/$1 Men/$1 MenMedian income of black Median income of black

U.S. families as a percent U.S. families as a percent of white U.S. families of white U.S. families 62%62%60% in 196860% in 1968

63% for Hispanic families63% for Hispanic families

Educational ApartheidEducational Apartheid

High levels of de facto school High levels of de facto school segregation by race and SESsegregation by race and SES

Gross discrepancies in per-pupil Gross discrepancies in per-pupil spending and teacher salariesspending and teacher salaries

Achievement and graduation gaps Achievement and graduation gaps growinggrowing

Urban/Rural DisparitiesUrban/Rural Disparities

25% of the U.S. population 25% of the U.S. population lives in rural areaslives in rural areas

Only 10% of U.S. physicians Only 10% of U.S. physicians practice in rural areaspractice in rural areas

Racial Disparities in Racial Disparities in Health Care CoverageHealth Care Coverage

Percent uninsured:Percent uninsured: Whites = 12%Whites = 12% Asians = 17%Asians = 17% African-Americans = 21%African-Americans = 21% Hispanics = 32%Hispanics = 32% Undocumented immigrants = 100% Undocumented immigrants = 100%

(emergency care exception)(emergency care exception) CA Proposition 189CA Proposition 189

Racial Disparities in Health Care:Racial Disparities in Health Care:African-AmericansAfrican-Americans

Higher maternal and infant Higher maternal and infant mortalitymortality

Higher death rates for most Higher death rates for most diseasesdiseases

Shorter life expectanciesShorter life expectanciesLess health insuranceLess health insuranceUndergo fewer diagnostic tests / Undergo fewer diagnostic tests / therapeutic procedurestherapeutic procedures

Health Disparities Health Disparities Among LatinosAmong Latinos

Higher rates of:Higher rates of: Overweight and obesityOverweight and obesity Certain cancersCertain cancers StrokeStroke DiabetesDiabetes Asthma/COPDAsthma/COPD Chronic liver disease/cirrhosisChronic liver disease/cirrhosis HIV/AIDSHIV/AIDS HomicideHomicide

Racial Disparities in Health Racial Disparities in Health Care:Care:

African-AmericansAfrican-AmericansEqualizing the mortality rates Equalizing the mortality rates of whites and African-of whites and African-Americans would have averted Americans would have averted 686,202 deaths between 1991 686,202 deaths between 1991 and 2000and 2000Whereas medical advances Whereas medical advances averted 176,633 deathsaverted 176,633 deaths AJPH 2004;94:2078-2081AJPH 2004;94:2078-2081

Outside the USOutside the USOne billion people lack clean One billion people lack clean

drinking water and 3 billion lack drinking water and 3 billion lack sanitationsanitation13,000-15,000 deaths per day 13,000-15,000 deaths per day worldwide from water-related worldwide from water-related diseasesdiseases

Hunger kills as many individuals in Hunger kills as many individuals in eight days as died during the atomic eight days as died during the atomic bombing of Hiroshimabombing of Hiroshima

WaterWaterAmount of money needed each Amount of money needed each year (in addition to current year (in addition to current expenditures) to provide water expenditures) to provide water and sanitation for all people in and sanitation for all people in developing nations = $9 billiondeveloping nations = $9 billion

Amount of money spent annually Amount of money spent annually on cosmetics in the U.S. = $8 on cosmetics in the U.S. = $8 billionbillion

Human PovertyHuman Poverty

Percentage of population living Percentage of population living on less than one dollar per dayon less than one dollar per day

HIV PrevalenceHIV Prevalence

Malaria DeathsMalaria Deaths

OverpopulationOverpopulationWorld population - exponential World population - exponential

growthgrowth1 billion in 18001 billion in 18002.5 billion in 19502.5 billion in 19506 billion in 20006 billion in 20007 billion in 20117 billion in 2011est. 8-10 billion by 2050est. 8-10 billion by 2050

Status of WomenStatus of Women

Women do 67% of the Women do 67% of the world’s workworld’s work

Receive 10% of global Receive 10% of global incomeincome

Own 1% of all propertyOwn 1% of all property

Worldwide, every minuteWorldwide, every minute 380 women become pregnant (190 380 women become pregnant (190

unplanned or unwanted)unplanned or unwanted) 110 women experience pregnancy-related 110 women experience pregnancy-related

complicationscomplications 40 women have unsafe abortions40 women have unsafe abortions 1 woman dies from childbirth or unsafe 1 woman dies from childbirth or unsafe

abortionabortion

Reason: Lack of access to reproductive Reason: Lack of access to reproductive health serviceshealth services

Deaths in WarDeaths in War1818thth Century = 19/million population Century = 19/million population1919thth Century = 11/million population Century = 11/million population2020thth Century = 183/million Century = 183/million populationpopulation

Civilian Casualties:Civilian Casualties:10% late 1910% late 19thth Century Century85-90% in 2085-90% in 20thth Century Century

Contemporary WarsContemporary Wars

250 wars in the 20250 wars in the 20thth CenturyCentury

Most conflicts within Most conflicts within poor statespoor states•Many over oilMany over oil

War Deaths, 1945-2000War Deaths, 1945-2000

Inverse Care LawInverse Care Law

Those countries that Those countries that need the most health need the most health care resources are care resources are getting the leastgetting the least

Brain DrainBrain Drain

U.S. is largest consumer U.S. is largest consumer of health care personnelof health care personnel

Five times as many Five times as many migrating doctors flow migrating doctors flow from developing to from developing to developed nations than in developed nations than in the opposite directionthe opposite direction

TobaccoTobaccoCigarettes most heavily Cigarettes most heavily marketed products in marketed products in the worldthe world$2 billion/year in the $2 billion/year in the U.S.U.S.

U.S. leading exporter U.S. leading exporter of cigarettesof cigarettes

Tobacco – Weapon of Mass Tobacco – Weapon of Mass DestructionDestruction

Direct medical costs = $100 Direct medical costs = $100 billion/yr billion/yr

Lost productivity = $97 billion/yrLost productivity = $97 billion/yr Medical care and lost Medical care and lost

productivity due to tobacco use productivity due to tobacco use costs each U.S. citizen costs each U.S. citizen approximately $600/yrapproximately $600/yr

Consequences of Environmental Consequences of Environmental DestructionDestruction

Global warming: 160,000 Global warming: 160,000 deaths and 5.5 million deaths and 5.5 million disability-adjusted life years disability-adjusted life years lost per year (will double by lost per year (will double by 2020)2020)

Air pollution: 60,000 - 75,000 Air pollution: 60,000 - 75,000 premature deaths/yr. (U.S.); premature deaths/yr. (U.S.); 1.8 million worldwide1.8 million worldwide

Consequences of Consequences of Environmental Environmental

DestructionDestruction Pesticides in food Pesticides in food → → 1,000,000 deaths 1,000,000 deaths

over the last 6 years; 1 million cancers over the last 6 years; 1 million cancers in current generation of Americansin current generation of Americans

Lead and mercury exposure multi-Lead and mercury exposure multi-billion dollar problemsbillion dollar problems

Other toxins – linked with heart disease, Other toxins – linked with heart disease, asthma, cancer, infertility, Parkinson’s asthma, cancer, infertility, Parkinson’s disease, Alzheimer’s, autism, etc.disease, Alzheimer’s, autism, etc.

Toxic PollutantsToxic Pollutants

¼ US citizens live within 4 miles ¼ US citizens live within 4 miles of a Superfund siteof a Superfund site

Environmental RacismEnvironmental RacismWaste dumps/incinerators more Waste dumps/incinerators more common in lower SES common in lower SES neighborhoodsneighborhoods

e.g., “Cancer Belt” (Baton Rogue e.g., “Cancer Belt” (Baton Rogue to New Orleans)to New Orleans)

Extinction/Species LossExtinction/Species Loss

Mass ExtinctionMass ExtinctionMore than 1/2 of the top 150 More than 1/2 of the top 150

prescription drugs from plants, prescription drugs from plants, other living organismsother living organisms

More than 250,000 known More than 250,000 known flowering speciesflowering species <0.5% surveyed for medicinal <0.5% surveyed for medicinal valuevalue

Overconsumption Overconsumption (“Affluenza”)(“Affluenza”)

U.S. = 6.3% of world’s populationU.S. = 6.3% of world’s populationOwns 50% of the world’s wealthOwns 50% of the world’s wealth

U.S. responsible for:U.S. responsible for:25% of world’s energy consumption25% of world’s energy consumption33% of paper use33% of paper use72% of hazardous waste production72% of hazardous waste production

New Remote Control Can Be Operated by New Remote Control Can Be Operated by Remote: No More Leaning Forward To Get Remote: No More Leaning Forward To Get Remote From Coffee Table Means Greater Remote From Coffee Table Means Greater

Convenience For TV ViewersConvenience For TV Viewers

But Are We Happier?But Are We Happier?

Average American works 200 Average American works 200 more hrs/yr than in 1960 (#1 more hrs/yr than in 1960 (#1 in world)in world)

Vacations shorterVacations shorterNo guaranteed paid sick leaveNo guaranteed paid sick leave8/10 Americans want a new job8/10 Americans want a new job

But Are We Happier?But Are We Happier?

Fewer close friendsFewer close friendsMore loneliness/depressionMore loneliness/depressionPharmaceutical fixesPharmaceutical fixes

Worldwide Health: Can Worldwide Health: Can Aid Help?Aid Help?

US ranks 21US ranks 21stst in the world in in the world in foreign aid as a percentage of foreign aid as a percentage of GDP (0.7%)GDP (0.7%)

Foreign Aid:Foreign Aid:1/3 military1/3 military1/3 economic1/3 economic1/3 food and development1/3 food and development

Worldwide Health: Can Worldwide Health: Can Aid Help?Aid Help?

U.S charitable giving approximately U.S charitable giving approximately $250 billion/year$250 billion/year 2.5% of income2.5% of income2.9% at height of Great Depression2.9% at height of Great DepressionPoor donate higher percentage of Poor donate higher percentage of

their incomes than rich; blacks their incomes than rich; blacks more than whitesmore than whites

Most stays in USMost stays in US

US Charity Care SufferingUS Charity Care Suffering Public hospitals and ERs closingPublic hospitals and ERs closing

Long waits mean many leave before being seenLong waits mean many leave before being seen Free clinic demand increasing, more Free clinic demand increasing, more

patients being turned awaypatients being turned away Hospitals turning to lucrative initiatives to Hospitals turning to lucrative initiatives to

improve financial situationimprove financial situation Cosmetic surgery, luxury clinics, aggressive Cosmetic surgery, luxury clinics, aggressive

billing practices (including charging uninsured billing practices (including charging uninsured more than insured), recruiting wealthy foreign more than insured), recruiting wealthy foreign patientspatients

Maldistribution of WealthMaldistribution of WealthTop 250 billionaires worldwide Top 250 billionaires worldwide

worth $1 trillion, the combined worth $1 trillion, the combined income of bottom 2.5 billion people income of bottom 2.5 billion people (45% of world’s population)(45% of world’s population)

U.S: Richest 1% of the population U.S: Richest 1% of the population owns 50% of the country’s wealth owns 50% of the country’s wealth -poorest 90% own 30%-poorest 90% own 30%-widest gap of any industrialized -widest gap of any industrialized nationnation

Income Inequality KillsIncome Inequality Kills

Higher income Higher income inequality is associated inequality is associated with increased with increased mortality at all per mortality at all per capita income levelscapita income levels

Maldistribution of Maldistribution of Wealth is DeadlyWealth is Deadly

880,000 deaths/yr in U.S. 880,000 deaths/yr in U.S. would be averted if the would be averted if the country had an income gap country had an income gap like Western European like Western European nations, with their stronger nations, with their stronger social safety netssocial safety nets

Maldistribution of WealthMaldistribution of WealthIn countries with moderate In countries with moderate levels of wealth, happiness is levels of wealth, happiness is highest where income highest where income inequalities lowestinequalities lowestMajor league baseball teams Major league baseball teams are more successful when are more successful when players’ salaries are more players’ salaries are more equitably distributedequitably distributed

Maldistribution of wealthMaldistribution of wealth

Less than 4% of the combined Less than 4% of the combined

wealth of the 225 richest individuals wealth of the 225 richest individuals

in the world would pay for ongoing in the world would pay for ongoing

access to basic education, health access to basic education, health

care (including reproductive health care (including reproductive health

care), adequate food, safe water, care), adequate food, safe water,

and adequate sanitation for all and adequate sanitation for all

humanshumans

Health Requires EqualityHealth Requires Equality““All men are created equal”All men are created equal”

Declaration of IndependenceDeclaration of Independence

““Some people are more equal Some people are more equal than others”than others”George OrwellGeorge Orwell

Hudson River, 2009Hudson River, 2009

U.N. Declaration of Human U.N. Declaration of Human RightsRights

““Everyone has the right to Everyone has the right to a standard of living a standard of living adequate for the health and adequate for the health and well-being of himself and of well-being of himself and of his family, including food, his family, including food, clothing, housing and clothing, housing and medical care”medical care”

SolutionsSolutions

Pay as you goPay as you goInsuranceInsuranceGovernment-run Government-run programprogramVA, IHSVA, IHS

PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act

2014: 26 million uninsured adults 2014: 26 million uninsured adults with incomes under $29,327 will gain with incomes under $29,327 will gain coverage through Medicaid with little coverage through Medicaid with little or no premium or cost sharingor no premium or cost sharing

2014: Up to 17 million adults with 2014: Up to 17 million adults with incomes between $29,327 and incomes between $29,327 and $88,200 for a family of 4 will get tax $88,200 for a family of 4 will get tax credits to help purchase private credits to help purchase private health plans through new state health plans through new state insurance exchanges (sliding scale)insurance exchanges (sliding scale)


2014: No denial of coverage of higher 2014: No denial of coverage of higher premiums for preexisting conditionspremiums for preexisting conditions Up to ½ of AmericansUp to ½ of Americans

2010: Uninsured with preexisting 2010: Uninsured with preexisting conditions eligible for special insurance conditions eligible for special insurance plans after 6 months without insuranceplans after 6 months without insurance

2010: Young adults up to age 26 may 2010: Young adults up to age 26 may stay on parents’ health planstay on parents’ health plan


2010: Small business tax credits to 2010: Small business tax credits to offset costs of insuring employeesoffset costs of insuring employees

2010: Insurers cannot deny 2010: Insurers cannot deny coverage to children with coverage to children with preexisting conditionspreexisting conditions

2010: No lifetime benefit limits and 2010: No lifetime benefit limits and no rescisionsno rescisions


2010: Health plans must provide 2010: Health plans must provide preventive services without cost-preventive services without cost-sharingsharing

50% cost-sharing discount for 50% cost-sharing discount for seniors in Medicare “donut hole”seniors in Medicare “donut hole”

Creates public website listing Creates public website listing payments from drug, device, payments from drug, device, biological, and medical products biological, and medical products companies to physicianscompanies to physicians


Problems:Problems:Complex, increases bureaucracyComplex, increases bureaucracyLeaves 23 – 40 million without Leaves 23 – 40 million without

insuranceinsurance40% of these eligible for, but not 40% of these eligible for, but not enrolled in, Medicaid or CHIPenrolled in, Medicaid or CHIP

22% undocumented immigrants22% undocumented immigrants


Problems:Problems:?Penalties if poor do not buy ?Penalties if poor do not buy

insurance?insurance?Benefits insurance companies, Benefits insurance companies,

continues present continues present inefficienciesinefficiencies


Problems:Problems: Inadequate numbers of primary Inadequate numbers of primary

care providerscare providersCommunities with a high number Communities with a high number of PCPs per capita have lower of PCPs per capita have lower medical costs and better medical costs and better outcomesoutcomes

Controversy over coverage of Controversy over coverage of contraceptive servicescontraceptive services

"If anyone...has a better approach "If anyone...has a better approach that will bring down premiums, bringthat will bring down premiums, bringdown the deficit, cover the uninsured, down the deficit, cover the uninsured, strengthen Medicare for seniors,strengthen Medicare for seniors,and stop insurance company abuses, and stop insurance company abuses, let me know."let me know."-- President Obama, State of the -- President Obama, State of the Union, 1/27/10Union, 1/27/10

Single PayerSingle Payer Cradle to grave, portable insurance for Cradle to grave, portable insurance for

everyoneeveryone All medically-necessary services coveredAll medically-necessary services covered Free choice of doctor and hospitalFree choice of doctor and hospital Global and local budgeting determined Global and local budgeting determined

by physicians, patients, other health by physicians, patients, other health professionalsprofessionals

Cost savingCost saving Broad supportBroad support

Single PayerSingle Payer Not socialism any more than having Not socialism any more than having

a police force and fire department a police force and fire department which serve everyone or offering free which serve everyone or offering free public education to children through public education to children through grade twelve is socialismgrade twelve is socialism Imagine if insurance companies ran the Imagine if insurance companies ran the

fire departmentfire department

What You Can DoWhat You Can Do Educate yourselves and othersEducate yourselves and others

““Information is the currency of Information is the currency of democracy” (Thomas Jefferson)democracy” (Thomas Jefferson)

Take care of your body – you only get Take care of your body – you only get one (no trade-ins)one (no trade-ins)

Live, laugh, and love – life is shortLive, laugh, and love – life is short Join groups working to improve Join groups working to improve

health carehealth care

Act Now!Act Now!

"If you think you are too "If you think you are too small to have an impact, small to have an impact, try going to bed with a try going to bed with a mosquito in your tent“mosquito in your tent“

- Anita Roddick- Anita Roddick

Further Info/References/Contact Further Info/References/Contact InfoInfo

Public Health and Social Justice WebsitePublic Health and Social Justice Websitehttp://www.phsj.org

Physicians for a National Health PlanPhysicians for a National Health Planhttp://www.pnhp.org/

Kaiser Family FoundationKaiser Family Foundationhttp://www.kff.org/

Martin DonohoeMartin [email protected]

health care in the u.s. and the world

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