Is It “Rest in Peace” for a National Health Program?

Richard Quint, MD, MPHCalifornia Physicians AllianceHealth Sciences Clinical Professor of Pediatrics (Emeritus), UCSF

The Health Care Crisis

1. Description

2. Causes

3. Solution

Illustrative Case: Ms. Jones

52 yo divorced woman , twin 18 yo sons, has family health insurance through her job as a store clerk. Bored.

Becomes a real estate agent (no job benefits). Uses COBRA to buy an interim policy. Income $60,000 per year.

Develops breast cancer while on COBRA. Receives potentially curative surgery, radiation, and chemotherapy. COBRA expires.

Shops for individual policy. Insurers either refuse to sell her a policy or offer an outrageously expensive one ($ 2,300 per month with a $5,000 per year deductible).

She becomes uninsured. Unable to afford daily drug to prevent breast cancer recurrence and so takes it only every 3rd day.

0

10

20

30

40

50

60

70

80

10% 10% 10% 10% 10% 10% 10% 10% 10% 10%

Source:Agency for Healthcare Research and QualityMEPS, 1999

Percentof health CareExpenditures

1% 1% 2% 4% 6%

13%

73%

0% 0% 0%

80% uses less than $1000 of care per year

Ms. Jones just went from here…..

0

10

20

30

40

50

60

70

80

10% 10% 10% 10% 10% 10% 10% 10% 10% 10%

Source:Agency for Healthcare Research and QualityMEPS, 1999

Percentof health CareExpenditures

1% 1% 2% 4% 6%

13%

73%

0% 0% 0%

20% use 86% of the care

…..To here:

Physician21%

Dental/Other Professional

10%

Nursing home/home health

8%

Drugs/Medical Supplies

13%

Insurance Administration

7%

Investment7%

Govt.Health Activities3%

Hospital

Source: Centers for Medicare&Medicaid Services

70% spent on services &infrastructure

30%

U.S. Health Expenditures 2008:

$2.2 trillion

The Health Care Crisis in USA

High Cost • ~$7000 spent per capita is double that of other

industrialized nations: >16% of our GDP• Costs are rising rapidly and 2-3X faster than CPI

Decreased Access• 47 million uninsured• > 60 million underinsured

Impaired Quality• Chaotic “system”• Poor health outcomes

Major Causes of Rising Costs

• Aging population, burden of chronic disease

• Rising cost of health insurance premiums

• Expensive new technology

• Administrative waste

• Pharmaceuticals

• Unnecessary care

• Delayed care sicker patients

0

20

40

60

80

100

2000 2001 2002 2003 2004 2005 2006

Year

Per

Cen

t

Health InsurancePremiums for aFamily of Four

Worker Earnings

Inflation

Changes in Health Insurance Premiumsvs. Workers’ Earnings & Inflation

Bureau of Labor Statistics

Decreased Access: Falling Job-Based Insurance & Rising Uninsurance

60

62

64

66

68

70

1987 1989 1991 1993 1995 199714

15

16

17

18

19

% with employmentbased coverage % uninsured

Custer WS 1999

Impact of the Economic Collapse

• 1% increase in unemployment 1.1 million more uninsured

• Since January, 2008: 4 million uninsured/under-insured

• Increased out-of-pocket expenses, medical debt: increased personal bankruptcy

Kaiser Family Foundation ReportOctober, 2008

47 Million Uninsured = Combined Population of 24 States

N DakotaS DakotaMontanaOklahomaIowaKansasArkansas

Mississippi

AlaskaOregonIdahoNevadaNew MexicoArizonaUtahHawaii

MaineVermontNew HampshireDelawareConnecticutRhode IslandW VirginiaMissouri

In addition, 1/5 of those with insurance are really underinsured (drug costs, deductibles, out of pocket expenses, etc.)

Quality of Care

Too little care• Uninsured or underinsured can’t access care• Hurried office visits• Crowded ER’s , closed trauma centers

Too much care• Unnecessary care • Duplicated care

Uncoordinated care• Many specialists, few primary care doctors• Changing insurance carriers

Poor outcomes• 45,000 deaths per year due to lack of health coverage• USA ranked 37th in overall quality by WHO

Root Causes of Health Care Crisis

I. Dysfunctional health insurancePrivate insurance– Job-based– For-profit– Multiple plans, pools– Fee for service (FFS)– FFS rewards procedures

Public insurance– Limited eligibility– Tied to state budgets

II. No real health care systembased on population needs.

Most adults 21-65 excludedEligibility/means testingCapricious, low fundingLow reimbursementFew providers accept itCost shifting

Covers only workersEmployer’s discretionExcludes or penalizes sickestComplex administrationCostlyUninusuranceOpen ended expensesAnswers to investors

No way to rationally allocate resources, plan or budget

2009: Where do we go from here?

Status of Current Health Reforms

• Oregon

• Tennessee

• Vermont

• Minnesota

• Washington

• Maine

• Massachusetts

Principles for Reforming Health Care

• Universal coverage

• Comprehensive scope of coverage: all necessary care

• Equitably distributed and portable

• High quality with improvement in health

• Choice

• Affordable

• Shared responsibility for funding: individuals, employers, government

• Sustainable funding mechanism

• Accountable, transparent

Institute of Medicine, 2004

Real vs. Phony

Universal + Mainly the healthyComprehensive + Exclusions, high

deductiblesPermanent + High loss potentialAffordable + High contributions relative to

income, stripped-down benefits

Choice + Restricted lists of providersQuality fostered Poorer pay less, get lessEfficiency promoted Administrative waste

SB 810

HR 676 HR 3200, Sen. Finance

The Only Rational Solution for Health Care Reform:“Medicare For All”

How it works:

• Everyone in single insurance pool• All private insurance replaced by a single public insurer• Funding:

– Fold in existing public programs for poor, disabled, elderly, gov’t workers, (veterans)– Replace all premiums and out-of-pocket expenses

with an equitable tax on employers, workers, and individuals

• Delivery of Care: remains private (not socialized)• Governance: public agency with representation of various stakeholders

Challenge for Current Legislation: How to Balance...

Paying for healthcare with accessibility and quality of care

www.washingtonpost.com/wp-dyn/content/article/that2009/11/02/AR2009110201285.html

Health insurance will be mandated

1. Can people afford it (i.e., how high will deductibles and copayments be)?

2. Will government subsidies be high enough?

3. Will coverage be adequate?

Real impact will be on the middle class

Is the Public Option a diversion from the issue of affordability?

Can we hold private insurers accountable on costs other than through a government option?

No.Why?Because there are no caps or controls on premium costs in the legislative proposals.

“Providing health care to all Americans would require aredistribution of wealth.” (Altman)

“A single payer system is the simplest, most efficient,and equitable method of redistributing wealth inorder to provide truly universal healthcare.” (McCanne)

Drew Altman, Washington Post interview, 2 November, 2009Don McCanne, former president PNHP, 3 November, 2009

Another Balancing Act

Benefits packages

Premiums to be charged

Unregulated premium increases

Eligibility for insurance exchanges

The size of deductibles, copayments, and co-insurance

Financial support for out-of-pocket expenses

Payment for non-covered out of network services

Variable contribution rates for employers

Federal and state budget limits on levels of government spending

Financing Medicaid programs

Financing administrative services

Taxes on healthcare products and/or insurance plans……

Challenge for Current Legislation

Paying for healthcare while assuring accessibility and quality of care…

…can be accomplished best with a single payer,or “Medicare for All” system.

Is It “Rest in Peace” for a National Health Program?

The Return of SB810

• Inpatient and outpatient• ER visits• All physician services,

including pregnancy• Prescription drugs• Mental health and

substance abuse treatment

• Rehabilitation

• Vision care, incl. glasses• Hearing exams and aids• Durable Medical

Equipment• Home health and adult

daycare• Dental care• Laboratory and diagnostic

tests

What can you do?

• Educate yourself and others

• Organize sessions on changing the healthcare system

• Participate in grass-roots organizing

• Support “Medicare for All” legislation

• Write op-ed pieces, letters to editors

• JOIN AMSA (www.amsa.org) and CaPA (www.capa.pnhp.org)

FIN

From Krugman & Wells, NY Review of Books,March 23, 2006

What are we getting for our money?

Overall Health System Performance

The US ranks 37th out of the 192 WHO member states, placing it below

Colombia and Portugal

WHO 2000 World Health Report

Uninsured Californians

• 54% are Latinos• Ages 0-64: 28% Latinos vs. 9% whites

uninsured• Employer-based insurance: 43% Latinos vs.

73% whites• Children 0-17: Latinos 21% vs. whites 6%

(nationwide)

Latino Coalition for a Healthy California, January 2005; Pediatrics 2008

Health Disparities: Diabetes Mellitus (DM)

• Adults >50 y with DM: 20% Latinos vs. 10% whites• 68% Latinos with DM take their medications vs. 78%

whites• Medication use (Latinos): 73% insured vs. 49%

uninsured• Glucose monitoring (Latinos): 39% insured vs. 22%

uninsured

Latino Coalition for a Healthy California, 2005

Health Disparities: Latinos and Cancer (CA)

• Women have the highest rate of cervical CA in California

• Latinas twice as likely as whites to develop cervical CA and die from it

• PAP smears: obtained by 92% of Medi-Cal recipients and only 80% of uninsured

• 60% Latino males never screened for prostate CA

Latino Coalition for a Healthy California, 2005

Latino Migrant Workers

• 40% female migrant workers and 56% of migrant workers’ children have never seen a dentist

• Male migrant workers have never: visited an M.D. or clinic (33%); seen a dentist (50%); had an eye care visit (67%).

Latino Coalition for a Healthy California, 2005; California Migrant Worker Health Survey, 1999

Cost Excesses in the US

• Administrative waste

• Excess pricing of pharmaceuticals

• Over-utilization of non-beneficial high-tech care

• Inadequate, inefficient primary care infrastructure

D.McCanne, PNHP 2006

Failures of Our Current System

• Many uninsured• Benefits not comprehensive• Coverage may be transient

• Low affordability• Limited choice

• Fragmented, inefficient, and wasteful• Inconsistent quality

• Negative impact on business

Real vs. Phony

Universal + Mainly the healthyComprehensive + Exclusions, high

deductiblesPermanent + High loss potentialAffordable + High contributions relative to

income, stripped-down benefits

Choice + Restricted lists of providersQuality fostered Poorer pay less, get lessEfficiency promoted Administrative waste

SB 840

HR 676 Democrats’ plans………

Number Uninsured

California: 6.9 million

PNHP, 2004; California Healthcare Foundation, 2006

Phony vs. Real Reform

Phony

• Choice of HMO/insurer

• Coverage = Copays, exclusions etc.

• Security = Lose it if you can’t work or can’t pay

• Savings = Less care

Real

• Choice of doctor and hospital

• Coverage = First $, Comprehensive

• Security = For everyone, forever

• Savings >$300 bil on bureaucracy

Cost Excesses in the US

• Administrative waste• Excess pricing of pharmaceuticals• Unnecessary care and overuse of expensive

technology• Inadequate, inefficient primary care infrastructure

D.McCanne, PNHP 2006

….Not a healthcare system,rather an illness shouldn’t industry

Impact of the Economic Collapse

• 1% increase in unemployment 1.1 million more uninsured

• Since January, 2008: 3 million uninsured/under-insured

• Increased out-of-pocket expenses, medical debt: increased personal bankruptcy

Lack of insurance increases morbidity and mortality

• 22,000 excess deaths per year due to lack of health coverage

• People without health insurance:– Receive less medical care and receive it later– Are sicker when diagnosed– Have 25% higher mortality rates– Earn less because of poorer health– 81% are from working families

“Care Without Coverage”, Institute of Medicine, May 2007“Sicker and Poorer”, Medical Care Research and Review, June 2003

Effects On the Health Care “System”

• Increased eligibility for state health insurance programs increased burden of care

• Delayed care increased ER visits• Delayed care sicker patients

increased costs of care• Increased morbidity and mortality

Status of Current Health Reforms

“It’s unethical to prescribe a placebo when an appropriate treatment exists”

D. Himmelstein, paraphrased, 10/25/2008

Single Payer Health Insurance Would Satisfy IOM Criteria

Universal coverage Comprehensive scope of coverage: all necessary care Equitable High quality of process and outcomes of care Choice Affordable Shared responsibility for funding: individuals, employers, government Accountable, transparent Sustainable funding mechanism

Number Uninsured

California: 6.9 million

PNHP, 2004; California Healthcare Foundation, 2005

The sincerest form of flattery...

Health-care Desiderata

• Universal• Comprehensive

• Permanent, portable• Affordable

• Maintains choice• High quality

• Enables efficiency

Institute of Medicine, 2004; Lakoff, et al., 2007

Universal Health Care:The International Communist

Conspiracy

National Health Programs

• Germany: 1883

• UK: 1912, 1948

• Canada: 1947, 1971

• Japan: 1922, 1961

• Australia: 1994

• Taiwan: 2002

The Road to Employment-Based Private Insurance in the US

1943-1948: The Murray Wagner Dingell Bill

Keep Politics Out of This Picture

When the life – or health – of a loved one is at stake, hope lies in the devoted service of your Doctor. Would you change this picture? Compulsory health insurance is political medicine. It would bring a third party – a politician – between you and your doctor. It would bind up your family’s health in red tape. It would result in heavy payroll taxes – and inferior medical care for you and your family. Don’t let that happen here!

1965

• Medicare

• Medicaid

1970-19741970-1974

Nixon vs. Kennedy Proposals

The Watery Demise of Health Care Reform

California Activism 1985-89

• Anti-patient dumping legislation • Proposals for Universal Coverage• Birth of California Physicians’ Alliance and

Physicians for a National Health Program

Proposition Proposition 186186

1994

What can you do?

• Educate yourself and others (www.kff.org/healthcare/sidebyside.cfm)

• Organize sessions on changing the healthcare system

• Participate in grass-roots organizing• Support “Medicare for All” legislation• Write op-ed pieces, letters to editors• Join CaHPSA and CaPA

(www.capa.pnhp.org)

Administrative Overhead

14.1%17.3% 17.8% 18.5% 19.7%

21.2%

3.1% 2.4%

0%

10%

20%

30%

Managed Care Magazine July, 2003; Kaiser data: CMA Knox-Keane Report, May 2005International Journal of Health Services, 2005

Percent of GDP Spent on Health 2005

The Economist, January 27, 2006

Challenge for Current Legislation: How to Balance...

Affordability with accessibility and quality of care

www.washingtonpost.com/wp-dyn/content/article/that2009/11/02/AR2009110201285.html

Health insurance will be mandated

1. Can people afford it (i.e., how high will deductibles and copayments be)?

2. Will government subsidies be high enough?

3. Will coverage be adequate?

Real impact will be on the middle class

Is the Public Option a diversion from the issue of affordability?

Can we hold private insurers accountable on costs other than through a government option?

No.Why?Because there are no caps or controls on premium costs in any legislative proposals.

“Providing health care to all Americans would require aredistribution of wealth.”

“A single payer system is the simplest, most efficient,and equitable method of redistributing wealth inorder to provide truly universal healthcare.”

(How willing do you think we are to do that?!)

Drew Altman, Washington Post, 1 Nov. 2009Don McCanne, Physicians for a National Health Program, 2 Nov. 2009

Another Balancing Act

Benefits packages

Premiums to be charged

Unregulated premium increases

Eligibility for insurance exchanges

The size of deductibles, copayments, and co-insurance

Financial support for out-of-pocket expenses

Payment for non-covered out of network services

Variable contribution rates for employers

Federal and state budget limits on levels of government spending

Financing Medicaid programs

Financing administrative services

Taxes on healthcare products and/or insurance plans……

Challenge for Current Legislation

Paying for healthcare while assuring accessibility and quality of care…

…can be accomplished best with a single payer,or “Medicare for All” system.

Is It “Rest in Peace” for a National Health Program?

Challenges and Hurdles

• Status quo is deeply entrenched

• Satisfaction with health care arrangements

• Expansion of government authority

• Paying for health care reform

• The vested interests

• How long will the window of opportunity stay open?

NEJM 10/25/2007

Reason for Optimism

• Current system is not financially sustainable

• Every other industrialized country has successful universal health care systems

• Increasing dissatisfaction amongst patients and providers

• Increasing support for reform, particularly a national health program: public opinion and M.D. polls; Academy of Family Physicians; RNs; U.S.

Council of Mayors; city councils and county boards

Speaker Nancy Pelosi: (202) 225-0100 or (415) 556-4862;http://speaker.house.gov/contact/“Keep your promise to have votes on the Wiener and Kucinich amendments”

Rep. Henry Waxman: (202) 225-3976 or (310) 652-3095;http://waxman.house.gov/Contact/

Rep. George Miller: (202) 225-2095 or (925) 602-1880;http://georgemiller.house.gov/contactus/2007/08/post_1.html“Please be sure that the Wiener and Kucinich amendmentsare voted on.”

Act Now and Call or Contact:

Real or Phony Health Care: The Case for a National Health

Program

Richard Quint, M.D., MPHCalifornia Physicians Alliance

UCSF Health Sciences Clinical Professor of Pediatrics (Emeritus)

What You Can Do

Join the California Health Professional Students Association (CaHPSA): www.cahpsa.org Join PNHP and CaPA: www.capa.pnhp.orgContact your legislatorsWrite letters and op-ed piecesEducate yourself and others (www.kff.org/healthcare/sidebyside.cfm) Organize in your community

What Should Be the Role of Government?

Protection

Police, fire, military, disaster assistance, public health, food safety, environmental protection, Social Security

Empowerment

Business and commerce, public education, infrastructure, courts, Technology development

Lakoff, 2007

Is It “Rest in Peace” for a National Health Program?

What is CaPA?

• The California Physicians Alliance, a chapter of Physicians for a National Health Program (PNHP)

(www.pnhp.org)• CaPA’s goals are to:

– Promote universal health access in California and the US

– Protect the provider-patient relationship– Promote justice in health care

• Basic assumptions are:– Health care is a human right– Equity in health care

What You Can Do

Join the California Health Professional Students Association (CaHPSA): www.cahpsa.org Join PNHP and CaPA: www.capa.pnhp.orgContact your legislatorsWrite letters and op-ed piecesEducate yourself and others (www.kff.org/healthcare/sidebyside.cfm) Organize in your community