Top Ten Myths About Healthcare in the US

The greatest enemy of the truth is very often not the lie--deliberate, contrived, and dishonest, but the myth -- persistent,

persuasive, and unrealistic.

Belief in myths allows the comfort of opinion without the discomfort of thought.

John F. Kennedy

DisclosurePaul Gorman, MD

$

National Story:Healthcare Spending Crisis

• “Health spending will hit $2.5 trillion this year

• “devouring 17.6 percent of the economy

• “The United States spends more on healthcare than any other country

• “but its system is widely considered inefficient and it lags many other nations in key quality measures”

Reuters, Feb 24, 2009

Oregon Story:57 Y F in extremis

• ED: lethargy, high pCO2, large pleural effusion

• ICU: Stabilized, improved, extubated

• able to provide Past History:

• Noted breast lump months before

• Spouse lost job, waited for insurance

• Seen in clinic, mammogram ordered

• Dx: Malignant effusion, Metastatic breast cancer

We have the best health care system in the world.

Myth Number 10

Health Adjusted Life Expectancy 2002 WHO data

1 Japan 753 Sweden 73.34 Switzerland 73.27 Italy 72.78 Australia 72.69 Spain 72.611 Canada 7212 France 7213 Norway 7214 Germany 71.816 Austria 71.417 Israel 71.419 Netherlands 71.220 Belgium 71.122 Greece 7123 New Zealand 70.824 United Kingdom 70.626 Denmark 69.827 Ireland 69.828 Slovenia 69.529 United States of America 69.332 Cuba 68.333 Republic of Korea 67.8

slide: PNHP IN/Rob Stone

It’s their fault - Uninsured are different from you & me.

Myth Number 9

“They” Are You and Me,Typical Americans

• 50 million Americans

• 1 in 6 Oregonians

• ages 19-30

• ~10 M children

• 80% employed

• $20,000 - $60,000/yr

• self employed, service sector, small business

• outsourced middle aged couples

It’s our faultOur lifestyle and diversity are the problem

Myth Number 9 b

no higher than eighth in overall survival gains.Population Diversity One explanation for

poor US performance is that the population ofthe United States is more diverse than those ofmost of the comparison countries. According tothis argument, lower health status or lower sur-vival gains for ethnic or racial minorities wouldtend to depress overall health outcomes for

Americans relative to the residentsof othercoun-tries. To address this potential confounding fac-tor, Exhibit 2 presents results for American non-Hispanic whites as well as for Americans overall.In most cases, the relative US performance

deteriorated fromdecade to decade. Relative sur-vival gains for non-Hispanic whites between1995 and 2005 were the lowest among nations

Exhibit 1

Per Capita Health Spending And 15-Year Survival For 45-Year-Old Women, United States And 12 Comparison Countries,1975 And 2005

Thou

sand

s of d

olla

rs

USCanada

UK

Australia

Belgium

Austria France

Japan

NetherlandsSweden

Switzerland

US

BelgiumCanada

Netherlands

UK

Austria

France Sweden

Switzerland

JapanAustralia

SOURCE Authors’ analysis based on data from the sources described in the text. NOTES The dashed line separates 1975 values (bluecircles) and 2005 values (red squares). Values are presented for the percentage of forty-five-year-old women surviving fifteen years.

Exhibit 2

Gain In 15-Year Survival Rates For Men And Women, Ages 45 And 65, United States And 12 Comparison Countries, 1975–2005

Interval/outcome

45-year-old men 45-year-old women 65-year-old men 65-year-old women

All White All White All White All White1975–1985Mean gain of comparison countries 2.2 1.3 5.7 6.7US gain 2.7 2.7 1.2 1.1 5.1 5.6 3 3.5US ranka 3rd 3rd 8th 10th 8th 6th 13th 11th1985–1995Mean gain of comparison countries 2.4 0.9 7.1 5.5US 1.8 1.7 0.7 0.7 6.1 6 2 1.8US ranka 10th 11th 9th 9th 9th 9th 13th 13th1995–2005Mean gain of comparison countries 1.7 0.7 8.9 5.3US 1.2 0.42 0.6 0 6.4 5.4 2.7 2.1US ranka 12th 13th 8th 13th 13th 13th 13th 13th1975–2005Mean gain of comparison countries 6.3 2.9 21.6 17.4US 5.7 4.8 2.5 1.8 17.6 17 7.7 7.5US ranka 8th 11th 9th 11th 11th 11th 13th 13th

SOURCE Authors’ analysis based on data from the sources described in the text. NOTE Data for gains are in percentage points. aRank of the United States in fifteen-yearsurvival relative to the twelve comparison countries.

Web First

4 Health Affairs November 2010 29: 1 1

Not smoking, obesity, homicide, diversity or statistical artifact

Safety Net CareEqual access to quality care for

people without insurance

Myth Number 8

No Prenatal Care for 11%Why not?

MMWR 5/12/2000; 49:393

22%

31%

47%No money or insuranceUnable to get appointmentOther reason

More Deaths Among Uninsured With Trauma

• 174,921 kids National Trauma Data Bank

• Controlled for injury, severity, age, race, type of hospital

• Uninsured kids: 2.97 times higher deaths

• Medicaid kids: 1.19 times higher deaths

No Insurance Means Poor Outcomes

• up to 1.25x higher mortality overall

• up to 3.2 x higher in-hospital mortality

• delays in Dx of colon cancer, melanoma

• poorer outcomes for breast cancer

• avoidable admissions for asthma, bleeding ulcers, diabetes, etc.

• up to 3x more likely to have adverse outcomes

Some Major Public Health Problems

Diabetes 72449Influenza, pneumonia 56326Colon cancer 50610Second hand smoke ~50000No insurance 44840Breast cancer 40470Traffic deaths 37261Prostate cancer 26328

Our system is good for people with insurance

Myth Number 7

Schoen,  Health  Affairs  6/10/08

                           Already

☠  1  in  3  with  insurance  defer  needed  care  now

slide: PNHP IN/Rob Stone

slide: PNHP Nick Skala

Choice?  Employer  Health  Benefit  Plans  Offered

Kaiser/HRET  Survey  of  Employer-­‐Sponsored  Health  Benefits,  2008. slide: PNHP IN/Rob Stone

Health Affairs 2000; 19(3):158

“Consumer Choice” in U.S.Reason for Change in Health Plan

9%

17%

74%Employer ChangeLess ExpensiveBetter Care

Insurance  Premiums  •  Workers’  Earnings  •  InflaCon  1999-­‐2008

0%

38%

75%

113%

150%

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008

Health  Insurance  PremiumsWorkers'  EarningsOverall  InflaCon

Kaiser/HRET  Survey  of  Employer-­‐Sponsored  Health  Benefits,  2000-­‐2008.    Bureau  of  Labor  StaJsJcs,  Consumer  Price  Index slide: PNHP IN/Rob Stone

Medical Bankruptcy62% of Personal Bankruptcies

61%24%

8%6%

Insurance at Onset of Illness

MedicareMedicaidUninsuredPrivate

Health Affairs 2002

Our system is good for business

Myth Number 6

Rising Insurance Costs

»Source: “A Perfect Storm” National Coalition on Heatlh Care, November 2001

10. Bottom up list

Small Business Climate:

Unhealthy

John Schmitt and Nathan Lane, Center for Economic and Policy Research

Pay, health care keep strike goingSanta Cruz Sentinel, CA …issues keeping the two sides from reaching a deal, namely health care benefits ...

Strike looms, teachers consider pay, health benefitsBurlingtonFreePress.com, VT …Questions about health care costs and coverage have emerged as a huge

TWU threatens strike over health care $philly.com, PA ...ready to strike because the health plan

Machinists Union Strike for Pensions and Health ...Emediawire WA Union members voted to strike ... Their vote centered on issues of pensions, health care and job security. ...

Strikes and Layoffs in Headlines

Our system is good for health professionals

Myth Number 5

Nurses Believe Quality Has Declined

Nurses Exhausted and Discouraged

US Doctors Waste Time on Paperwork

Source: Modern Healthcare, 9/21/95:172.

Doctors Urged to Turn Away the Very Sickest

“[We can] no longer tolerate patients with complex and expensive-to-treat conditions being encouraged to transfer to our group.”

-letter to faculty from academic hospital chief

Our system is good for society

Myth Number 4

THECOMMONWEALTH

FUND

37Number of Practicing Physicians per 1,000 Population, 2007

0

1

2

3

4

NETH NOR SWITZ ITA SWE* GER FR OECD MedianAUS* UK US NZ CAN

* 2006Source: OECD Health Data 2009 (June 2009).

THECOMMONWEALTH

FUND

38Average Annual Number of Physician Visits per Capita, 2007

0

2

4

6

8

GER ITA** AUS FR OECD MedianCAN* NETH UK NZ SWITZ US* SWE*

2.83.84.0

4.75.05.75.8

6.36.36.37.0

7.5

* 2006 ** 2005Source: OECD Health Data 2009 (June 2009).

THECOMMONWEALTH

FUND

39Hospital Discharges per 1,000 Population, 2007

0

75

150

225

300

FR GER NOR SWITZ SWEOECD MedianAUS* ITA* NZ US* UK NETH CAN*

* 2006Source: OECD Health Data 2009 (June 2009).

THECOMMONWEALTH

FUND

40Average Length of Hospital Stay for Acute Myocardial Infarction, 2007

0

3

6

9

12

GER UK ITA* SWITZ NETH OECD Median CAN* FR AUS* US* SWE NOR

* 2006Source: OECD Health Data 2009 (June 2009).

Days

THECOMMONWEALTH

FUND

41Hospital Spending per Discharge, 2007Adjusted for Differences in Cost of Living

0

2,000

4,000

6,000

8,000

10,000

12,000

14,000

16,000

18,000

US* CAN* NETH SWITZ NOR* SWE NZ OECD Median AUS* FR GER

* 2006Source: OECD Health Data 2009 (June 2009).

Dollars

Source: Moy et al. JAMA 1997; 278:217

0.800

0.925

1.050

1.175

1.300

1986 1988 1990 1992 1994Num

ber o

f gra

nts

rela

tive

to 1

986 Low Medium High

Managed Care Penetration

NIH Clinical Research Grants Fall in High Managed Care Areas

Innovation:Published Research Leading to Drugs

55% 30%

15%

Drug CompaniesForeign labsNIH Funded Labs

Sources: Internal NIH document available from Public Citizen; also Zinner, Health Affairs, Sept-Oct 2001; also Boston Globe 4/5/98

slide: PNHP/Marcia Angell

3

5

7

9

11

13

0% 1-20% 21-40% 41-60% 61-84% >84%

Hou

rs o

f Cha

rity

Car

e/M

onth

% of Practice Revenue from Managed Care

Low Medium HighHMO Penetration in Region

Managed Care Drives Out Charity Care

We can’t afford to cover everyone

Myth Number 3

Health  Care  Expenditures

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

$7,000

United States Canada France Netherlands Germany AustraliaUnited KingdomOECD Median Japan New Zealand

$113$28

$148$370$354$342

$906

$444$483

$2,572

$359$389$396$582

$313

$238

$239$472

$803

$1,611$1,832$1,917$2,176$1,940$2,350

$1,894$2,475$2,210

$2,727

Public SpendingOut-of-Pocket SpendingPrivate SpendingOut-of-Pocket Spending

Source: The Commonwealth Fund, calculated from OECD Health Data 2006.

Per  Capita,  Adjusted  for  Differences  in  Cost  of  Living

slide: PNHP IN/Rob Stone

slide: PNHP Claudia Fegan

slide: PNHP/Oliver Fein

Invisible HandPrivate sector and market forces deliver

best quality & value

Myth Number 2

Source: Woolhandler & Himmelstein - NEJM 3/13/97

$0

$2,500

$5,000

$7,500

$10,000

For-ProfitNot-For-Profit Public

$1,432$1,809$2,289

$2,166$2,385$2,872

$2,909$3,296$2,954Cos

t per

hos

pita

l sta

y

Clinical Personnel All Other Costs Administration

“Another beautiful theory destroyed by an ugly fact...”

Private For Profit Hospitals More Expensive

“It’s a Non Starter”There’s No Support for a Single Payer

Myth Number 1

Public  Support  –  Single  Payer  

Polls  from  20091  April,  Kaiser  Family  FoundaJon2  January,  Grove  Insight  Opinion  Research3January,  New  York  Times/CBS  News

☤49%  favor  coverage  from  a  single  govt.  plan1

☤59%  prefer  a  system  like  Medicare  for  all2

☤59%  say  government  should       provide  na?onal  health           insurance3

slide: PNHP IN/Rob Stone

“In principle, do you support or oppose government legislation to establish national health insurance?”

Ann Intern Med 2008;148:566-567

Single-Payer: “Politically Feasible?”

Abolition of Human Slavery (1860s)

Women’s Suffrage Movement(1840-1920)

Civil Rights Act(1964)

Other “Politically Infeasible” Movements

slide: PNHP Nick Skala

Expensive, Inefficient, Inequitable

• No system in the industrialized world is as heavily commercialized, and none is as expensive, inefficient, and inequitable

• In short, the U. S. experience has shown that private markets and commercial competition have made things worse, not better, for our health care system.

Arnold S. Relman, MD

Goals

• Health care for every Americanno exceptions, cradle to grave.

• Free choice of doctors and hospitalslike Medicare patients have

• Patients and doctors make care decisionsnot in the backroom or the board room

• Health policy is public policywith accountability and transparency.

• No one goes bankrupt because of illnessnot patients, not businesses, not governments

Do we keep rearranging the deck chairs on the Titanic?

"...the greatest tragedy of this period … was not the strident clamor of the bad

but the appalling silence of the good people”

Dr. Martin Luther King Jr.

Nobody can do everything, but everybody can do something Gil Scott-Heron

What can we do?

Primary Care & PPACA

• Greater need • 32 million new insured

• need for prevention,

continuity, coordination

• Inadequate supply • 30% of MDs (vs 50-60%)

• 30-60% lower salaries

• greater workload

• diminishing resources

• Workforce expansion• fund residencies (favor track

record primary care)

• loans for 10 y promise

• Payment reform• RBRVS reform (10% increase)

• Medicaid/Medicare increase

• New models of care• Patient centered medical home

• Accountable care organization

• Access? No. Millions still uninsured, thousands will die because of no access

• Choice? No. Insurance companies choose who you see, what you can get, how much you pay

• Affordability: No. Billing and claims waste unchanged. Prices still set to guarantee big insurance profit. Bankruptcies persist for individuals, businesses, governments

Current bills like unecessary surgery“We have to do something”

Current Bills Fail to Improve

• Portability? No. You still lose insurance when you change jobs, get laid off, etc. Discontinuity -> poor outcomes

• Accountability? No. Health policy set by big insurance in private. No accountability, no transparency, no recourse

• Quality? No. Continues tweaking system that’s been failing for decades