YES !!YES !! To Universal Medical To Universal Medical Coverage in GeorgiaCoverage in Georgia

----------The case for The case for

Georgia SecureCareGeorgia SecureCare

March 2005

What do What do General MotorsGeneral Motors and and Atlanta’s southwest communityAtlanta’s southwest community have in common?have in common?

Hint: …... see items from Hint: …... see items from recent Atlanta newspapersrecent Atlanta newspapers

By DANNY HAKIM -

DETROIT

January 9, 2005

George Jetson, Meet the Sequel

General Motors' latest hydrogen car prototype, called the Sequel, …

… a glimpse of a possible, very different, automotive future. … it runs on a hydrogen fuel cell, so its only tailpipe emission is water vapor, not the smog-forming pollutants and greenhouse gases that come out of gasoline-powered cars. …….(But)…"There's no sign by General Motors that they have any inclination to act in the here and now," said David Doniger, policy director of the climate center of the Natural Resources Defense Council …..

…… G.M. is also hamstrung by its obligation to provide health care to 1.1 million Americans, a large number of whom are retirees. The obligation makes G.M.'s own health no small matter for the United States, but the nation's medical system puts G.M. at a disadvantage. Rivals in Japan and Germany, countries with socialized medical systems, do not have to bankroll retiree health care.

……. G.M. has estimated that it will spend more than $60 billion on health care for its retirees and current workers after they retire over the next several decades.

……. By contrast, Toyota has said in financial filings that its retiree health care liability is not even large enough to require disclosure.

Copyright 2005 The New York Times Company

Southwest Hospital goes out of businessBoard hopes facility can reopen

By DAVID A. MARKIEWICZ The Atlanta Journal-Constitution -- January 9, 2005

…… The shutting of Southwest means the sick and injured who used it, many of them indigent, will have to go elsewhere for care……

…… Southwest … ran out of cash. One of only a few black-owned or -controlled hospitals in the country, it has been operating under Chapter 11 bankruptcy protection since September.

…… Hospital officials said Southwest decided Tuesday to close because of a delay in receiving $1.45 million in expected government funding ….. a dispute between the state and three other urban hospitals …. over a formula for dividing more than $200 million designated for indigent care. The disagreement has delayed payments to all hospitals.

…… Beyond that, Southwest faced financial problems similar to those of other small, independent hospitals serving patients who are uninsured, underinsured or in government programs like Medicaid and Medicare.

The healthcare The healthcare AmericansAmericans get: get:

1/3 are uninsured or underinsured1/3 are uninsured or underinsured

HMOs deny care to millions more with expensive HMOs deny care to millions more with expensive illnessesillnesses

Death rates higher than other wealthy nations’Death rates higher than other wealthy nations’

Costs Costs per capitaper capita (PPP$) are highest in world; in (PPP$) are highest in world; in 2002 we spent at more than double the rate of 2002 we spent at more than double the rate of Netherlands, Sweden, Australia, Italy, UK, JapanNetherlands, Sweden, Australia, Italy, UK, Japan

Executives and investors making billionsExecutives and investors making billions

Destruction of the doctor/patient relationshipDestruction of the doctor/patient relationship

Georgians for a Common Sense Health Plan: Georgians for a Common Sense Health Plan: GCSHP GCSHP GoalsGoals ------ ------

Universal - covers everyone with full choice of Universal - covers everyone with full choice of providerprovider

Comprehensive - all needed care, no co-pays*Comprehensive - all needed care, no co-pays*

Single, public payer - simplified reimbursementSingle, public payer - simplified reimbursement

Discourage investor-owned HMOs, hospitals, etc.Discourage investor-owned HMOs, hospitals, etc.

Improved health planningImproved health planning

Public accountability for quality and cost, but Public accountability for quality and cost, but minimal bureaucracyminimal bureaucracy

Are our ideals realistic for Georgia?Are our ideals realistic for Georgia?

Are Georgians concerned?Are Georgians concerned?

Would financing reform in our State be Would financing reform in our State be affordable and sustainable?affordable and sustainable?

‘‘Feasibility?’: How deep and wide is Feasibility?’: How deep and wide is Georgia political support?Georgia political support?

Grant support from Healthcare Georgia Foundation

Georgia phone survey of 800 households, September 2003Georgia phone survey of 800 households, September 2003

Gender and age Men 18-49 27%

Men 50 and over 22%

Women 18-49 28%

Women 50 and over 24%

Income <$30,000 27%

$30-50,000 25%

$50-80,000 19%

>$80,000 17%

Don’t know/refused 13%

Race White 63%

African-American 28%

Other/Refused 9%

Party identification (ID) Democrat 38%

Republican 34%

Independent 28%

Difficulty with health care?Difficulty with health care?

ALL Strongest Subgroup Responses

Yes 32% No health insuranceSouth GA<$30,000Democrat (ID)Democrat (history)Employed part-time/bothAfrican-American$30-50,000Not registered to voteRuralNot marriedChildren

53%47%44%40%40%40%39%39%38%38%38%36%

No 68% >$80,000Republican (history)Republican (ID)Men 50+North GASuburban60 and overHas health insuranceMetro AtlantaMarried

89%78%77%75%75%74%74%73%72%72%

Concerned about health care or insurance?Concerned about health care or insurance?

ALL Strongest Subgroup Responses

Very concerned 36% <$30,000No health insuranceDemocrat (ID)African-AmericanDemocrat (history)South GANot registered to voteNot marriedRuralEmployed part-time/both

52%48%45%45%44%44%43%42%41%41%

Somewhat concerned 23% --

Not very concerned 15% Republican (history)>$80,000Republican (ID)$50-80,000

23%23%21%20%

Not at all concerned 25% >$80,00060 and overIndependent (ID)MenMen 18-49Men 50+Republican (history)North GA

32%30%30%29%29%29%29%29%

Yes, Georgians are concernedYes, Georgians are concerned

But … the underlying problem(s) are not But … the underlying problem(s) are not clear to everyoneclear to everyone

-- it’s not simply ‘poverty’-- it’s not simply ‘poverty’

Number uninsured/in poverty 1967-2001Number uninsured/in poverty 1967-2001

Source: Social Security Bul, HIAA, CPS

November 16, 2003

For Middle Class, Health Insurance

Becomes a Luxury

 By STEPHANIE STROM

 

Who Are The Uninsured?Who Are The Uninsured?

Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS

*Students>18, Homemakers,

Disabled, Early retirees

»Employed»50%

»Children»25%

»Unemployed»5%

»*Out of labor »force»20%

Unmet Health Needs of the Unmet Health Needs of the UninsuredUninsured

Within the USA, Within the USA, adult mortalityadult mortality is related to insurance is related to insurance status (adjusted for 27-factor propensity score)status (adjusted for 27-factor propensity score)

McWilliams JM et al. Health Affairs 2004: 23: 223-33

Many with insurance lack choice;Many with insurance lack choice;42% are offered only 1 plan42% are offered only 1 plan

Source: Health Affairs 1998; 17(5):184

Note: Those without choice were 70% more likely to give their plan a low rating

»35%»39%»49%»53%»65%

0%

20%

40%

60%

<$10K $10,000-$19,999

$20,000-$29,999

$30,000-$49,999

$50,000-$99,999

»Income Group

Per

cent

With

No

Cho

ice

Illness and medical costs - a major Illness and medical costs - a major

cause of personal bankruptcycause of personal bankruptcy46% of all personal bankruptcies 46% of all personal bankruptcies involve a involve a medical medical reasonreason (direct costs, lost income) or (direct costs, lost income) or large medical debtlarge medical debt

--- another --- another 99% attributed to addiction, uncontrolled gambling, % attributed to addiction, uncontrolled gambling, birth, or the death of a family memberbirth, or the death of a family member

Most bankrupted families (2001 sample) initially had Most bankrupted families (2001 sample) initially had medical insurance, but they commonly lost their medical insurance, but they commonly lost their coveragecoverage

Source: Himmelstein DU et al. Health Affairs 2005

What has brought us to this What has brought us to this situation in the past 2 decades?situation in the past 2 decades?

Growth of Registered Nurses Growth of Registered Nurses and Administrators, 1970-2002and Administrators, 1970-2002

Source: Bureau of Labor Statistics & Himmelstein/Woolhandler/Lewontin Analysis of CPS data

0%

500%

1000%

1500%

2000%

2500%

1970 1975 1980 1985 1990 1995 2001

Gro

wth

sin

ce 1

97

0

Administrators RNs

Growth of Physicians Growth of Physicians and Administrators, 1970-2002and Administrators, 1970-2002

Source: Bureau of Labor Statistics & NCHS

0%

500%

1000%

1500%

2000%

2500%

1970 1975 1980 1985 1990 1995 2000

Gro

wth

sin

ce 1

970

Administrators Physicians

HMOs: good & badHMOs: good & bad

Three decades ago………Three decades ago………

Organization, coordinated, accountableOrganization, coordinated, accountable

Prevention or private profit?Prevention or private profit?

Medicaid HMOs:Medicaid HMOs:Poor access and satisfactionPoor access and satisfaction

Source: Lillie-Blanton & Lyons. Hlth Affairs 1998; 17(3):238 - Kaiser/Commonwealth Survey

28%21%

53%

16% 14%

45%

0%

20%

40%

60%

ProblemGetting Care

Dissatisfiedwith Care

Used ERPast Year

Medicaid HMO Medicaid F-F-S

Medicare HMOs:Medicare HMOs:The healthy go in, the sick go outThe healthy go in, the sick go out

* Data are for 12 month period before joining HMO** Data are for 3 month period after leaving HMOSource: N Engl J Med 1997; 337:169

66%

180%

100%

0%

50%

100%

150%

200%

FFS Medicare BeforeJoining HMO*

AfterLeaving HMO**In

pa

tien

t cos

ts a

s %

of F

FS

Me

dic

are

For-Profit HMOs’For-Profit HMOs’increasing dominance, 1985-2000increasing dominance, 1985-2000

Source: Interstudy

0%

25%

50%

75%

100%

1985 1987 1989 1991 1993 1995 1997 1999

% o

f HM

O E

nro

llme

nt

Non-profit For-profit

Investor-owned HMOsInvestor-owned HMOsprovide lower quality careprovide lower quality care

Source: Himmelstein, Woolhandler, Hellander & Wolfe - JAMA 1999; 282:159

64 69 6959

35

54

72 75 77 71

4862

0

25

50

75

100

Imm

unize

d Tod

dlers

Mam

mog

raph

y

Pap S

mea

rs

Beta

Blocke

r Pos

t MI

Diabet

ic Eye

Exa

ms

Overa

ll Sat

isfac

tion

Ave

rag

e ra

te (

pe

rce

nt)

For-Profit

Not-For-Profit

““Productive” physicians, worse careProductive” physicians, worse care

Note: Fast physicians = those seeing more pts./hour than average Slow Physicians = those seeing fewer pts./hour than averageSource: Arch Int Med 1999; 159:294

Physician Practice Style

0.60.53

0.25

1 1 1

0

0.25

0.5

0.75

1

HDLTesting

ProteinuriaTesting

OphthalmologyReferral

Like

lihoo

d R

atio

:O

rder

ing

for

Dia

betic

Pat

ient

s

"Fast" "Slow"

Doctors urged to shun the sickDoctors urged to shun the sick

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

--Letter to faculty from University of Letter to faculty from University of California Irvine Hospital ChiefCalifornia Irvine Hospital Chief

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

HMO overhead & profitHMO overhead & profitas percent of premiumas percent of premium

Source: BestWeek Life/Health Special Report 4/12/99 - from SEC filings

33%

26% 25% 25%

18%15% 14%

0%

10%

20%

30%

40%

CIGNA

AETNA/ U.S. HEALTHCARE

WELLPOINT

UNITED HEALTHCARE

HUMANA

PACIFICARE

Private insurers’ High OverheadPrivate insurers’ High Overhead

Why are for-profit hospitals costlier?Why are for-profit hospitals costlier?Higher administrative and non-personnel costsHigher administrative and non-personnel costs

Source: Woolhandler & Himmelstein - NEJM 3/13/97 - Analysis of data from 5201 acute care hospitalsNote: Costs are for FY 1994, adjusted for hospital case mix and local wages

$8,115$7,490

$6,507

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

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

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

»$0

$2,500

$5,000

$7,500

$10,000

For-Profit Not-For-»Profit

Public

Cos

t per

hos

pita

l sta

y

Clinical Personnel All Other Costs Administration

Death rates are higherDeath rates are higherat for-profit hospitalsat for-profit hospitals

* 85.5% Non-Profit, 14.3% Government, 0.2% For-ProfitSource: NEJM 1999; 340:293

100%

93%

75%

50%

75%

100%

For-ProfitNo Teaching

Non-ProfitNo Teaching

MajorTeaching*

Ad

just

ed D

eath

Rat

e A

s P

erce

nt

of

Rat

e at

Fo

r-P

rofi

t H

osp

ital

s

Investor-owned careInvestor-owned careSummary of EvidenceSummary of Evidence

Hospitals: Costs 3%-11% higher, fewer nurses, Hospitals: Costs 3%-11% higher, fewer nurses, higher overhead, death rates 6%-7% higher, higher overhead, death rates 6%-7% higher, fraudfraud

HMOs: Higher overhead, worse quality, HMOs: Higher overhead, worse quality, collaboration with tobacco industrycollaboration with tobacco industry

Dialysis: Death rates 20% higher, less use of Dialysis: Death rates 20% higher, less use of transplants & peritoneal dialysis, fraudtransplants & peritoneal dialysis, fraud

Nursing Homes: More citations for poor quality, Nursing Homes: More citations for poor quality, fraudfraud

Rehab Hospitals: Costs 19% higherRehab Hospitals: Costs 19% higher

Other countries?Other countries?

Some comparisons with other Some comparisons with other industrial democraciesindustrial democracies

Percent of population withPercent of population withgovernment-assured insurancegovernment-assured insurance

Note: Germany does not require coverage for high-income persons, but virtually all buy coverageSource: OECD, 2002 - Data are for 2000 or most recent year available

92%100% 100% 100% 100% 100%

45%

0%

20%

40%

60%

80%

100%

U.S. Germany France Canada Australia Japan U.K.

Life expectancy for women, 1999Life expectancy for women, 1999

Source: OECD, 2002 - Data on Italy are for 1998

82

80.7

82.5

79.8

81.6 81.7

79.4

77

78

79

80

81

82

83U.S

.

U.K.

GERM

ANY

ITALY

CANADA

SWEDEN

FRANCE

YE

AR

S

Life expectancy for men, 1999Life expectancy for men, 1999

Source: OECD, 2002 - Data for Italy are for 1998

74.7 75 75 75.3

76.376.7

73.9

70

71

72

73

74

75

76

77

78

U.S.

GERMANY

FRANCEUK

ITALY

CANADA

SWEDEN

YE

AR

S

Potential Potential Years of LifeYears of Life LostLost per 100,000 per 100,000people for all causes, 1998/1999people for all causes, 1998/1999

Source: OECD, 2002- Data for Canada are for 1998

3,878 3,844 3,803

3,103 3,044

5,232

0

1000

2000

3000

4000

5000

6000

U.S. Germany U.K. Canada Japan Sweden

Yea

rs L

ost

Health spending, 1990 & 1998:Health spending, 1990 & 1998:U.S. costs rose more than other nations’U.S. costs rose more than other nations’

Source: Health Affairs 2000; 19(3):150

$0

$1,000

$2,000

$3,000

$4,000

$5,000

U.S.

Germ

any

Can.

Franc

e

Sweden

Japa

nIta

lyU.K

.Hea

lth S

pend

ing

Per

Cap

ita(1

998

U.S

. dol

lars

, adj

uste

d fo

r pu

rcha

sing

pow

er p

arity

)

»1990 »1998

U.S. U.S. public public spending per capita for health spending per capita for healthis greater than is greater than totaltotal spending in other nations spending in other nations

Note: “Public” includes benefit costs for govt. employees & tax subsidy for private insuranceSource: NEJM 1999; 340:109; Health Affairs 2000; 19(3):150

$1,670

$1,750

$1,850

$2,230

$2,430

$2,620

$1,760$2,600

$0 $1,000 $2,000 $3,000 $4,000 $5,000

U.K.

Sweden

Japan

France

Canada

Germany

U.S.

$ Per Capita

Total Spending U.S. Public U.S. Private

… … and the PUBLIC fraction continues to expand and the PUBLIC fraction continues to expand (US data, Centers for Medicare & Medicaid Services, Office of the Actuary)(US data, Centers for Medicare & Medicaid Services, Office of the Actuary)

NHE $ 4098 $ 5317 $ 6040 $ 6830(per capita)

Heffler S et al. Health Affairs 2005

We’re We’re payingpaying for national health insurance, for national health insurance, but we’re but we’re notnot getting it ! getting it !

We outspend other societies for health care, We outspend other societies for health care, but we don’t provide universal coverage.but we don’t provide universal coverage.

Why is this ?Why is this ?

Could it be related to unique circumstances in Could it be related to unique circumstances in US health care ?US health care ?

Elderly as percent of total population, 2000Elderly as percent of total population, 2000

Source: Health Affairs 2000; 19(3):192

12.1% 12.8%

15.9% 16.0% 16.4% 17.1%

12.5%

0%

5%

10%

15%

20%

U.S

.

Aus

tral

ia

Can

ada

Fra

nce

U.K

.

Ger

man

y

Japa

nPer

cent

of

Pop

ulat

ion

Old

er T

han

65

Physician visits per capitaPhysician visits per capita

Source: OECD, 2002 - Data are for 2000 or most recent available year

5.46.4 6.4 6.5 6.5

16

5.8

0

5

10

15

U.K.

U.S.

Austra

lia

Canad

a

Germ

any

Franc

e

Japa

n

Phy

sici

an V

isits

Hospital inpatient days per capita, 2000Hospital inpatient days per capita, 2000

Source: OECD, 2002

1.1 1.2

2.42.6 2.7

4

0.8

0

1

2

3

4

U.S.

Canad

aU.K

.

Franc

e

Austra

lia

Germ

any

Japa

n

Day

s/pe

rson

MRI Units/Million Population, MRI Units/Million Population, 19991999

Difficulties getting needed careDifficulties getting needed care

Source: Commonwealth Fund Survey, 1998

2118

15 15

28

0

5

10

15

20

25

30

35

U.S.

Canad

a

New Z

ealan

d

Austra

liaU.K

.

% f

indi

ng it

ext

rem

ely,

ver

y or

som

ewha

t di

ffic

ult

to g

et c

are

whe

n ne

eded

Continuity of careContinuity of care

Source: Commonwealth Fund Survey, 1998

52%57% 59% 59%

45%

0%

20%

40%

60%

U.S.

New Z

ealan

d

Canad

a

Austra

liaU.K

.

Per

cent

with

sam

e do

ctor

mor

e th

an 5

yea

rs

Thanks to Jan Eliot, Stone Soup, 11 Oct 2003

Are our ideals realistic for Georgia?Are our ideals realistic for Georgia?

Are Georgians concerned?Are Georgians concerned?

Would financing reform in our State be Would financing reform in our State be affordable and sustainable?affordable and sustainable?

‘‘Feasibility?’: How deep and wide is Feasibility?’: How deep and wide is Georgia political support?Georgia political support?

Grant support from Healthcare Georgia Foundation

SecureCareSecureCare: A Georgia health program: A Georgia health program

single plansingle plan operated by the state or a non-profit operated by the state or a non-profit

replacereplace allall existing public and private health existing public and private health insuranceinsurance

not connected to your jobnot connected to your job

choose any primary care doctor you wantchoose any primary care doctor you want

no deductibles; -- a $25 co-payment only for no deductibles; -- a $25 co-payment only for visits to a specialist without a referralvisits to a specialist without a referral

generous, comprehensive coveragegenerous, comprehensive coverage, including , including hospitals, doctors, emergency care, hospitals, doctors, emergency care, prescriptions, dental care, and long-term care.prescriptions, dental care, and long-term care.

What would What would SecureCareSecureCare look like? look like?

• everyone receives a health care card assuring payment everyone receives a health care card assuring payment for all needed carefor all needed care

• complete free choice of doctor, hospital, other providerscomplete free choice of doctor, hospital, other providers

• doctors and hospitals remain independent and non-profit, doctors and hospitals remain independent and non-profit, negotiate fees and budgets with negotiate fees and budgets with SecureCareSecureCare

• local planning boards allocate major capital expenditures local planning boards allocate major capital expenditures & expensive technology& expensive technology

• progressive taxes (“premiums”) go to progressive taxes (“premiums”) go to SecureCareSecureCare Trust Trust FundFund

• consolidated public agency processes and pays billsconsolidated public agency processes and pays bills

• accountability and quality control through periodic accountability and quality control through periodic reviews (reviews (macromacro patterns) patterns)

Long Term Care under Long Term Care under SecureCareSecureCare• a universal right to social and medical LTC servicesa universal right to social and medical LTC services

• coverage for full continuum of home, community & coverage for full continuum of home, community & institutional careinstitutional care

• spread risk through social insurancespread risk through social insurance

• consumer choice & quality improvementconsumer choice & quality improvement

• independent livingindependent living

• support informal caregiverssupport informal caregivers

• for-profit providers phased outfor-profit providers phased out

Source: Harrington et al. JAMA 1991; 266:3023

Georgia health spending, 2003, Georgia health spending, 2003, in millionsin millions

Status quo: Total by all payers:Status quo: Total by all payers: $ $ 37,15037,150

SecureCare: SecureCare: ↑ utilization↑ utilization $ 3,840$ 3,840

SecureCare: ↓ administr costs ($ 3,815)SecureCare: ↓ administr costs ($ 3,815)

SecureCare: bulk purchasing ($ 741)SecureCare: bulk purchasing ($ 741)

Net change in health spending: Net change in health spending: ($ 716)($ 716)

SecureCareSecureCare: Proposed funding sources: Proposed funding sources

government spending for discontinued health programs government spending for discontinued health programs ($12.8 billion)($12.8 billion)

employer payroll tax equal to 9.1% of wages and salaries employer payroll tax equal to 9.1% of wages and salaries for all employees ($14.2 billion)for all employees ($14.2 billion)

increase in tobacco taxes of 50increase in tobacco taxes of 50¢¢ per pack with per pack with proportionate increases in taxes for other tobacco taxes proportionate increases in taxes for other tobacco taxes ($215 million)($215 million)

increase in taxes on alcoholic beverages ($52 million)increase in taxes on alcoholic beverages ($52 million)

increase in the state sales tax on non-grocery items of increase in the state sales tax on non-grocery items of one % point ($1.25 billion)one % point ($1.25 billion)

income tax payment for all Georgians computed to be income tax payment for all Georgians computed to be equal to about 22.2% of each taxpayer’s federal income equal to about 22.2% of each taxpayer’s federal income tax ($6.0 billion)tax ($6.0 billion)

Age of Family Head

- $537

$384

-$916

- $2,299

-$122

- $3,000

- $2,500

- $2,000

- $1,500

- $1,000

- $500

$0

$500

$1,000

Under 24 25 - 34 35 - 44 45 - 54 55 - 64 65 and

Over

Total

$761$592

Change in average family health spending by Age of Family Head under the Georgia SecureCare program in 2003: after wage effects

The Lewin Group, October 2003

-$986-$1,934

-$1,536 -$1,428-$957 -$704

$903

$2,285

$4,570

$8,820

-$4,000

-$2,000

$0

$2,000

$4,000

$6,000

$8,000

$10,000

Less than$10,000

$10,000-$19,999

$20,000-$29,999

$30,000-$39,999

$40,000-$49,999

$50,000-$74,999

$75,000-$99,999

$100,000-$124,999

$125,000-$149,999

$150,000or More

Change in average health spending per family under the Georgia SecureCare program by Family Income in 2003: after wage effects

The Lewin Group, October 2003

Are our ideals realistic for Georgia?Are our ideals realistic for Georgia?

Are Georgians concerned?Are Georgians concerned?

Would financing reform in our State be Would financing reform in our State be affordable and sustainable?affordable and sustainable?

‘‘Feasibility?’: How deep and wide is Feasibility?’: How deep and wide is Georgia political support?Georgia political support?

Grant support from Healthcare Georgia Foundation

Trial 1:Trial 1: Would you support Would you support SecureCareSecureCare??ALL Strongest Subgroup Responses

Strongly support 52% African-American<$30,000No health insuranceDemocrat (ID)Not registered to voteDemocrat (history)Not marriedSouth GAUrbanEmployed part-time/bothRuralWomen 18-49

69%67%66%65%65%63%61%59%58%58%57%57%

Somewhat support 20% $50-80,000 24%

Somewhat oppose 5% --

Strongly oppose 13% >$80,000Republican (history)Republican (ID)Men 50+WhiteMarried

27%25%23%17%17%17%

Don’t know 11% Women 50+60 and overNo partisan vote pattern (history)

16%15%15%

Trial 2:Trial 2: Would you support Would you support SecureCareSecureCare??ALL Strongest Subgroup Responses

Strongly support 33% No health insuranceDemocrat (ID)<$30,000African-AmericanDemocrat (history)Not registered to voteSouth GANot marriedChildrenEmployed part-time/bothRural18-39$30-50,000

52%45%44%43%42%42%42%40%39%39%38%38%38%

Somewhat support 29% $50-80,000UrbanWomen 18-49$30-50,000

37%35%34%33%

Somewhat oppose 9% --

Strongly oppose 17% >$80,000Republican (history)Republican (ID)Men 50+Married

29%28%25%22%22%

Don’t know 13% 60 and overWomen 50+

26%24%

$21

$1,112

$668

$246

$829

$-115

$122

$2,595

$2,417

$2,152$2,069

$1,966

$2,643

$2,453

$0

$500

$1,000

$1,500

$2,000

$2,500

$3,000

$3,500

Under 10 10 - 24 25 - 99 100 - 499 500 - 999 All

Workers

Currently Offer Coverage Currently Do Not Offer Coverage

1,000 orMore

Change in private employer health spending per worker by firm size and current insuring status under the Georgia SecureCare program in 2003: before wage effects

Harris Poll: “Government should provideHarris Poll: “Government should providequality medical coverage to all adults . . .”quality medical coverage to all adults . . .”

Source: USA Today/Harris Poll - 11/23/98

77%

53% 52%47%

0%

20%

40%

60%

80%

GeneralPublic

Employers StateLegislators

Congressional Aides

Per

cent

agr

eein

g

56% of medical students & faculty56% of medical students & facultyfavor favor single payer single payer ;;

Majority of med school deans concurMajority of med school deans concur

Source: NEJM 1999; 340:928

22%

56%

3%19%

Managed Care Single PayerNo Preference Fee-for-service

“What is the best health care system for the most people?”

How do we know it can be done?How do we know it can be done?

Every other industrialized nation has a Every other industrialized nation has a healthcare system that assures medical healthcare system that assures medical care for allcare for all

All spend less than we do; most spend All spend less than we do; most spend less than halfless than half

Most have lower death rates, more Most have lower death rates, more accountability, and higher satisfactionaccountability, and higher satisfaction

We have what it takes:We have what it takes:

Excellent hospitals, empty bedsExcellent hospitals, empty beds

Enough well-trained professionalsEnough well-trained professionals

Superb researchSuperb research

Current spending is sufficientCurrent spending is sufficient

Thanks for your attention!Thanks for your attention!

Some useful websites:Some useful websites:

www.commonsensehealthplan.orgwww.commonsensehealthplan.org

www.physiciansproposal.orgwww.physiciansproposal.org

www.pnhp.orgwww.pnhp.org

Medical Savings Accounts: No savingsMedical Savings Accounts: No savings

Sickest 10% of Americans use 72% of care. MSA's Sickest 10% of Americans use 72% of care. MSA's cannot lower these catastrophic costscannot lower these catastrophic costs

The 15% of people who get no care would get The 15% of people who get no care would get premium “refunds”, removing their cross-subsidy for premium “refunds”, removing their cross-subsidy for the sick but not lowering use or costthe sick but not lowering use or cost

Discourages preventionDiscourages prevention

Complex to administer - insurers have to keep track Complex to administer - insurers have to keep track of all out-of-pocket paymentsof all out-of-pocket payments

Congressional Budget Office projects that MSAs Congressional Budget Office projects that MSAs would increase Medicare costs by $2 billion.would increase Medicare costs by $2 billion.

What's wrong withWhat's wrong withtax subsidies and vouchers?tax subsidies and vouchers?

• Taxes go to wasteful private insurers, overhead >13%Taxes go to wasteful private insurers, overhead >13%

• Amounts too low for good coverage, especially for the Amounts too low for good coverage, especially for the sicksick

• High costs for little coverage - much of subsidy replaces High costs for little coverage - much of subsidy replaces employer-paid coverageemployer-paid coverage

• Encourages shift from employer-based to individual Encourages shift from employer-based to individual policies with overhead of 35% or morepolicies with overhead of 35% or more

• Costs continue to rise (e.g. FEHBP)Costs continue to rise (e.g. FEHBP)

• Many are unable to purchase wisely - e.g. frail elders, Many are unable to purchase wisely - e.g. frail elders, severely ill, poor literacyseverely ill, poor literacy

Thanks to Jan Eliot, Stone Soup, 20 Oct 2003

Thanks to Jan Eliot, Stone Soup, 21 Oct 2003

Out-of-Pocket Payments, 2000Out-of-Pocket Payments, 2000

Ackermann & Carroll, Ann Int Med, 18 Nov 2003

Ackermann & Carroll, Ann Int Med, 18 Nov 2003

1. For millions of Americans, insurance coverage is sporadic.

During a recent 2-year span 1 out of every 3 Americans younger than age 65 years lacked coverage for at least 1 month.

2. Approximately half of uninsured persons are of white, non-Hispanic

ethnicity.

Members of minority groups have a higher overall risk for lacking coverage.

3. Uninsured adults are less likely to obtain preventive care, primary care, and the chronic disease treatment they need.

They tend to be sicker and to die sooner than people with health insurance.

Institute of Medicine's Committee on the Consequences of Uninsurance, January 2004

4. Uninsured women receive fewer prenatal care services and have poorer birth outcomes.

Uninsured children are less likely to obtain needed health screenings, medical services, or prescription medications thaninsured children.

Failure to detect correctable problems in early childhood can adversely affect language development, school performance, and ultimately success in life.

5. When even 1 member of a family lacks health insurance, the entire family is exposed to the health and financial consequences of a catastrophic illness or injury.

Ironically, the uninsured are often charged more for the same health service because they don't have a large insurer to negotiate

discounts.

Institute of Medicine's Committee on the Consequences of Uninsurance, January 2004

6. In communities with high rates of uninsurance, rising levels of uncompensated care can lead to the loss or reduced availability of key hospital services, loss of "on-call" specialist coverage, relocation of physician practices, and cutbacks in essential public health programs.

These adverse effects can have consequences for everyone in the community, not just those who are uninsured.

7. On average, uninsured persons suffer an annual health loss valued at between $1600 and $3300 per person.

This equates to an annual societal cost of between $65 and $130 billion per year

Institute of Medicine's Committee on the Consequences of Uninsurance, January 2004

Gruen RL, … Physician-Citizens- Public Roles and Professional Obligations. JAMA 2004; 291: 94-8.

We encourage consideration of professional responsibilities in 2 main areas…..

1. …… to promote systems of care that ensure that all patients in their community have access to needed care.

2. …… involvement in addressing socioeconomic factors most directly associated with poor health outcomes.

Gruen RL, … Physician-Citizens- Public Roles and Professional Obligations. JAMA 2004; 291: 94-8.

Woolf SH.  Patient safety is not enough --.  Ann Intern Med 2004; 140: 33-6

The urgency may be less palpable to those …. whose narrower

perspective may obscure larger priorities. Clinicians or researchers

battling a single disease may not consider whether expending the same

effort on more threatening conditions or solving deeper, systemic root

causes may be more beneficial……

… by not addressing larger deficiencies in quality, (physicians)

may fix problems in the branches and twigs while preserving

proximal disease in the trunks. The greatest good for the health of

the population comes from a global perspective that views the

system as a whole, judges its performance by its effect on population

health, ….. and prioritizes interventions in a rational scheme to optimize outcomes

Woolf SH.  Patient safety is not enough --.  Ann Intern Med 2004; 140: 33-6

HEALTH COSTS AS % OF GNP:HEALTH COSTS AS % OF GNP:U.S. & CANADA, 1960-2001U.S. & CANADA, 1960-2001

CANADA'S NHP ENACTED

NHP FULLY IMPLEMENTED

Source: Statistics Canada, Canadian Inst. for Health Info., & NCHS/Commerce Dept

5

6

7

8

9

10

11

12

13

14

15

1960

1965

1970

1975

1980

1985

1990

1995

2000

% o

f G

NP

CANADA

U.S.

What's OK in Canada?What's OK in Canada?Compared to the U.S….Compared to the U.S….

Life expectancy 2 years longerLife expectancy 2 years longer

Infant deaths 25% lowerInfant deaths 25% lower

Universal comprehensive coverageUniversal comprehensive coverage

More MD visits, hospital care; less bureaucracyMore MD visits, hospital care; less bureaucracy

Quality of care equivalent to insured Americans’Quality of care equivalent to insured Americans’

Free choice of doctor/hospitalFree choice of doctor/hospital

Health spending half U.S. levelHealth spending half U.S. level

What's the matter in Canada?What's the matter in Canada?

• The wealthy lobby for private funding and tax The wealthy lobby for private funding and tax cuts; they resent subsidizing care for otherscuts; they resent subsidizing care for others

• Result: government funding cuts (e.g. 30% of Result: government funding cuts (e.g. 30% of hospital beds closed during 90s) causinghospital beds closed during 90s) causingdissatisfactiondissatisfaction

• U.S. and Canadian firms seek profit U.S. and Canadian firms seek profit opportunities in health care privatizationopportunities in health care privatization

• Foes of public services control many Canadian Foes of public services control many Canadian newspapersnewspapers

• Misleading waiting list surveys by right wing Misleading waiting list surveys by right wing groupgroup

Hospital billing & administrationHospital billing & administrationUnited States & Canada, 2000United States & Canada, 2000

Source: Woolhandler/Himmelstein NEJM 1991; 324:1253 & 1993; 329:400 (updated)

$372

$68

$0

$100

$200

$300

$400

$500

U.S. CANADA

$ P

ER

CA

PIT

A

Physicians' billing & office expensesPhysicians' billing & office expensesUnited States & Canada, 2000United States & Canada, 2000

Source:Woolhandler/Himmelstein NEJM 1991;324:1253 (updated)

$430

$102

$0

$100

$200

$300

$400

$500

U.S. CANADA

$ P

ER

CA

PIT

A

Infant mortalityInfant mortalityU.S. & Canada, 1955-1999U.S. & Canada, 1955-1999

Source: OECD 1999, Statistics Canada & CDF

CANADA

U.S.FIRST PROVINCE IMPLEMENTS NHP

0

10

20

30

40

1955

1960

1965

1970

1975

1980

1985

1990

1995

Dea

ths/

1000

Liv

e B

irths

CANADAU.S.

Physician services for the elderly: Physician services for the elderly: Canadians get more of most kinds of careCanadians get more of most kinds of care

Source: JAMA 1996; 275:1410

1.17

1.44

0.75

1.18

0

0.5

1

1.5

2

All Services Evaluation/Management

Procedures Tests

Can

adia

n R

ate/

U.S

. R

ate

Applicants per Medical School PlaceApplicants per Medical School Place

2.4

5.5

0.0

1.0

2.0

3.0

4.0

5.0

6.0

United States Canada

Source: JAMA; 282:892; Canadian Medical Education Statistics, 1999:150

Few Canadian Physicians Few Canadian Physicians EmigrateEmigrate

Depression management: Better in CanadaDepression management: Better in Canada

* Antidepressant prescribed + 4 or more visitsSource: JGIM 1998; 13:77

31%

55%

15%7%

0%

20%

40%

60%

Saw Professional Appropriate Care*

U.S. Canada

Source: Premier's Common Future Of Health, Excludes Out-of-Pocket Costs

Who pays for Canada's NHP?Province of Alberta

0.74 0.77 0.851

1.21.3 1.3

0

0.5

1

1.5

2

15,000 25,000 35,000 50,000 75,000 100 K 125 K

FAMILY INCOME

Sha

re o

f H

ealth

Pay

men

ts/S

hare

of

Inc

ome

Source: Oxford Rev Econ Pol 1989;5(1):89

Who pays for health care?Regressivity of U.S. health financing

3

1.75

1.31 1.27 1.23 1.15 1.1 1.07 0.99

0.64

0

0.5

1

1.5

2

2.5

3

3.5

POOREST RICHESTINCOME DECILE

Sha

re o

f H

ealth

Pay

men

ts/S

hare

of

Inco

me

Difference in Health SpendingDifference in Health SpendingPer Capita, U.S. vs. Canada, 2000Per Capita, U.S. vs. Canada, 2000

Source: Woolhandler/Himmelstein NEJM 1991; 324:1253 & 1993; 329:400 (updated)

$857

$1604

Bureaucracy All Other