you bet your life: why we need a national health program
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You Bet Your Life: Why We Need a National Health Program. Richard D. Quint, MD, MPH Health Sciences Clinical Professor of Pediatrics, Emeritus (UCSF) California Physicians Alliance. Universal Health Care: The International Communist Conspiracy. US National Health Program Efforts Pre-WWII. - PowerPoint PPT PresentationTRANSCRIPT
You Bet Your Life: Why We Need a National Health Program
Richard D. Quint, MD, MPHHealth Sciences Clinical Professor of Pediatrics,
Emeritus (UCSF)California Physicians Alliance
Universal Health Care:The International Communist
Conspiracy
US National Health Program Efforts Pre-WWII
• American Association for Labor Legislation, 1915
• Social Security, 1935
The Road to Employment-Based Private Insurance in the US
The Provider - Insurer Pact
• Health insurance plans initially sponsored by hospital and physician organizations
• Hospitals and physicians wrote “cost-based” payment rules
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
The sincerest form of flattery...
Here Comes the AMA Again...
Proposition Proposition 186186
1994
Number Uninsured
California: 6.6 million
PNHP, 2004; California Healthcare Foundation, 2005
Health Care Options Project (HCOP)
• Convened by California Health and Human Services Agency in 1999
• Examined options for extending health care coverage in California
• Analyzed and compared by consultants from The Lewin Group and AZA Consulting
How do the HCOP Plans Compare?
Incremental Example
Pay or Play Example
Universal Care Example
Reduction in Uninsured
2.6 5.7 6.6
Change in Total Health Spending
+ $1.4 billion + $3.0 billion
-($7.6) billion
2006: Where do we go from here?
First, let’s look at what we’ve got
High quality?Cost efficient?Ready for change?
Overall Health System Performance
The US ranks 37th out of the 191 WHO member states, placing it below
Colombia, Saudi Arabia, and Portugal
WHO 2000 World Health Report
Lack of insurance increases morbidity and mortality
• 18,000 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 2002“Sicker and Poorer”, Medical Care Research and Review, June 2003
Life Expectancy
78.5 78.479.4 79.7 79.9
81.8
77.2
70
75
80
U.S. U.K. Germany France Canada Italy Japan
Ranking: 21/30; OECD, 2005
Infant Mortality per 1000 Births
5.44.8 4.7
4.2 3.9
3
7
0
1
2
3
4
5
6
7
8
U.S. Canada Australia Italy Germany France Japan
Source: OECD Health Data 2005
MRI Units per Million People
2.7 4.2 5.58.6
10.4
35.3
8.2
0
5
10
15
20
25
30
35
40
France Canada Germany U.S. Denmark Italy Japan
OECD, 2004 (2002 Data, U.S., Canada, and Germany are 2001)
How hard is it to get care?
21
15 15 15
28
0
5
10
15
20
25
30
U.S. Canada New Zealand Australia U.K.
% f
ind
ing
it
dif
ficu
lt t
o g
et c
are
Commonwealth Fund Survey, 1998
Continuity of Care
52%57%
65% 65%
45%
0%
20%
40%
60%
80%
100%
U.S. NewZealand
Canada Australia U.K.
% w
ith
sam
e d
oct
or
> 5
yea
rs
Commonwealth Fund Survey, 1998
Financing healthcare in the U.S.
Individuals / Businesses
Government [payer]
Health Service Providers
Private Insurers [payers]
Direct or Out-of-Pocket Payments
Medicare, Medicaid, etc.
Taxes
Premiums
Public employees’ premiums
Provider Payments
|------Collection of funds-------||---------Reimbursement--------|
Percent of GDP Spent on Health 2003
The Economist, January 27, 2006
Cost Excesses in the US
• Administrative waste
• Over-utilization of non-beneficial high-tech care
• Inadequate, inefficient primary care infrastructure
• Excess pricing of pharmaceuticals
D.McCanne, Quote of the Day, PNHP
Health-care spending per capita, 2005
$3,001
$2,996
$2,903
$2,520
$2,231
$2,139
$5,635U.S.
Canada
Germany
France
Sweden
U.K.
Japan
$ Per Capita
Source: OECD Health Data 2005
Health-care spending per capita, 2005
$3,001
$2,996
$2,903
$2,520
$2,231
$2,139
$5,635U.S.
Canada
Germany
France
Sweden
U.K.
Japan
$ Per Capita
Source: OECD Health Data 2005
Insurance Overhead Spending
$0
$50
$100
$150
$200
$250
$300
$350
U.S. Canada France Australia Germany
$ p
er
cap
ita
OECD, 2003
U.S. Overhead Spending
16.3%
19.9%
26.5%
0%
10%
20%
30%
Medicare Non-Profit Blues CommercialCarriers
Investor-OwnedBlues
International Journal of Health Services 2005; 35(1): 64-90
U.S. Overhead Spending
16.3%
19.9%
26.5%
3.1%
0%
10%
20%
30%
Medicare Non-Profit Blues CommercialCarriers
Investor-OwnedBlues
International Journal of Health Services 2005; 35(1): 64-90
HMO Overhead Spending
14.1%17.3% 17.8% 18.5% 18.9% 19.7% 21.2%
2.4%
0%
10%
20%
30%
Managed Care Magazine July, 2003; Kaiser data: CMA Knox-Keane Report, May 2005
Which administrative costs should we reduce?
Source: Kenneth Thorpe, 1992.
Government Health Insurance for All, Even if Taxes Increase?
Oppose30%
Favor65%
No opinion5%
Slice 40%
Pew Report, May 2005
No opinion 5%
The Institute of Medicine recommends that health-care should…
• Be universal: Everybody in, nobody out• Be comprehensive and continuous• Be affordable to individuals and families• Use an insurance strategy that is affordable and
sustainable for society• Enhance health and well-being by promoting access to
high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable
Institute of Medicine Report, 2004
2006: What are Solutions?
• Market (consumer driven health care)• Incremental Reform • More Major Reform (“national” health care,
“universal” health care, “Medicare for All” or “single payer health care”)– California
• SB 840
– US• HR 676 "Expanded & Improved Medicare For All Bill
(Conyers)"
What does Dobie Gillis have to do with healthcare in California?
State Senator Sheila Kuehl (D, Santa Monica)
California Single Payer SB 840Eligibility
• All state residents eligible.
• Individuals lacking legal immigration status (i.e., “undocumented”) included if they document residence.
California Single Payer SB 840Benefits
• Inpatient and outpatient• ER visits• All physician services• Prescription drugs• Laboratory and diagnostic
tests• Mental health and
substance abuse treatment
• Vision care, incl. glasses• Hearing exams and aids• DME• Home health and adult
daycare• Rehabilitation• Dental care
Single payer financing: simplified
Individuals / Businesses
Government [payer]
Health Service Providers
Direct or Out-of-Pocket Payments
CHIRA
(SB 840)Taxes
|------Collection of funds-------||---------Reimbursement--------|
Projected Savings SB 840: 2006-2015 (in billions)
Year State/local Total2006 0.9 8.02007 1.6 12.32008 2.2 17.02009 2.8 22.42010 3.6 28.42011 4.5 35.02012 5.3 42.22013 6.4 50.22014 7.6 59.22015 8.8 68.9
43.7 331.3
Lewin Report, 2004
Single payer financing: reality
Individuals / Businesses
Government [payer]
Health Service Providers
Direct or Out-of-Pocket Payments
CHIRA
(SB 840)Taxes
|------Collection of funds-------||---------Reimbursement--------|
Private insurers (non-
covered services)
Premiums Provider Payments
California Single Payer SB 840Administration
• Health Care Agency• Elected commissioner• Statewide boards/offices: Health Policy;
Consumer Advocacy; Medical Practice Standards.
• … responsible for financial management of the system; establishing eligibility and benefits; negotiating reimbursement.
California Single Payer SB 840Delivery system
• Private and public, as currently.
• Fee-for-service and capitated (integrated health delivery systems such as Kaiser Permanente). Providers and participants choose one.
• Maintains choice
After SB 840: Anticipated Changes
• Decreased emergency room use• Increased access to care• Improved continuity of care• Increased emphasis on preventative
care and health education• More integrated systems?• Regionalization of high risk services?
Advantages of single payer to…
• Patients:– Improved health
– Free choice of provider
– Portability of coverage
Advantages of single payer to…
• Physicians– Restoration of clinical autonomy
– Lower malpractice premiums
– Improved patient care
– Simplified billing
Advantages of single payer to…
• Businesses– Decreased health care costs
– Level the playing field
– Improved global competitiveness
Potential disadvantages
• Threat of underfunding by hostile government
• Strength of special interests that would seek to undermine the system
• Potential imbalance between quality controls and expenditure growth
Potential disadvantages
• Transition from current system will be difficult
• Important tradeoffs: will America make them?– You can’t give every health care intervention to every person
– Less choice in insurance plan
– More government control for less private control
Sounds Great….How About Political Reality?
What can you do?
First, remember Pogo:
What can you do?
• Educate yourself and others
• Organize sessions on universal health insurance
• Participate in grass-roots organizing
• Support universal health-care legislation
• Write op-ed pieces, letters to editors
• JOIN PNHP and CaPA
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
CaPA-Medical School Organizing Project
Thanks to……
Bree Johnston, M.D., MPH (UCSF, CaPA)
Kevin Grumbach, M.D. (UCSF, CaPA)
Kao-Ping Chua (MS IV, Washington U.)
Physicians for a National Health Program
In Summary
• Our health Care System is a Disgrace• Part of our Role as Professionals should be
advocating for a system that serves our patients well
• What Can We Do?– Urge our professional societies to support universal
health insurance– Dispel Myths about “Government Run Health Care”– Join groups working for reform
Results by Specialty
0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%
Anesthesiology
Surgical Subspecialty
Family Practice
Obstetrics/Gynecology
Medical Subspecialty
General Surgery
Emergency Medicine
General Internal Medicine
General Pediatrics
Psychiatry
Pediatric Subspecialty
Percent Supporting
Governmental Legislationto Establish NHI
Federal Government asSole Payer for NHI
Ann Intern Med. 2003 Nov 18;139(10):795-801
What would it look like?
• Everyone gets a US NHI card
• Complete choice of doctor and hospital
• Doctors and hospitals remain independent
• Govt processes and pays bills
Other savings
• No more co-pays
• No more deductibles
• No more premiums
• NO MORE OUT OF POCKET EXPENSES
Summary: Universal health care…
• Leads to better outcomes
• Would cost no more or save money
• Americans want it
• So do MDs, but won’t come out for a single-payer approach
• Can be accomplished in California
California Single Payer SB 840Cost-sharing
• No cost sharing for 2 years.
• After 2 years, cost-sharing option with limits of $250 per person/$500 per family per year.
• Exemption for individuals who meet income rules, and for prevention.
“Would you prefer the current system or Universal Health Insurance…”
NHI, 62%
Current, 32%
Don't Know, 6%
Washington Post/ABC News Poll, 10/20/03
Managed Care:
• Another Socialist Conspiracy:– Prepaid Group Practices
• Nixon-Ellwood Conservative Reinvention:– HMOs
Inpatient Days per Capita
1.0 1.01.1 1.1
1.2
0.7
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
U.S. Canada Australia U.K. France Switzerland
OECD, 2004, (2001 Data)
Impact of SB 840 on State and Local Government Health Spending: 2006-2015
(billions)
Current Spending
Net Transfer to Single-Payer
Net Savings
2006 $18.7 $17.7 ($0.9)
2007 $20.0 $18.4 ($1.6)
2008 $21.4 $19.2 ($2.2)
2009 $22.9 $20.1 ($2.8)
2010 $24.5 $20.9 ($3.6)
2011 $26.3 $21.8 ($4.5)
2012 $28.2 $22.9 ($5.3)
2013 $30.5 $24.1 ($6.4)
2014 $32.8 $25.2 ($7.6)
2015 $35.2 $26.4 ($8.8)
Lewin Report, 2004
2005: Where are we now, and are we ready for universal healthcare?
• Eroding safety net• Market (consumer driven health care)• Reform Proposals
– California• Children’s “100% Campaign”• SB 840
– US• The United States National Health Insurance Act (HR676 - C
onyers) ("Expanded & Improved Medicare For All Bill")
• Physician’s Proposal (PNHP)
Gov’t Insurance for All, Even If Taxes Increase
0 20 40 60 80 100
Total
Enter.
Soc. Con.
Pro-Gov. Con
Upbeats
Disaffect.
Con. Dems
Dis. Dem.
Liberals
Oppose
Favor
Pew Survey, 2005
What About MDs?
1.Support or oppose governmental legislation to establish national health insurance?
2.Support or oppose a national health insurance plan where all health care is paid for by the federal government?
Ann. Intern. Med. 2003
Government Legislation to Establish NHI
Generally
Strongly
Generally
StronglyOppose
40%
Support
49%
Neutral
11% Ann Intern Med. 2003 Nov 18;139(10):795-801
Government as Single Payer
Generally
StronglyGenerally
Strongly
Oppose
60%
Support
25%
Neutral
14%
Ann Intern Med. 2003 Nov 18;139(10):795-801
Percent of Children Immunized (MMR)
84.5% 85.9%94.5% 99.0% 100.0%91.6%
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
U.K. France U.S. Canada Denmark Japan
OECD, 2004, (2002 Data)
Infant Deaths by Income
3.94.7
5.1 5.2
6.5 6.8
0
1
2
3
4
5
6
7
8
Wealthiest20%
Middle 20% Poorest20%
U.S.Average
EDUCATE & ADVOCATE
WORK FOR INCREMENTAL REFORMS
When a Political Opening Comes,
MOVE FAST!!
Myth: Canadians don’t get mental health services
6.311.3
26.3
37.1
3.4
10.4
27.7
52.3
0
10
20
30
40
50
60
Nodisorder
MildDisorder
ModerateDisorder
SevereDisorder
Per
cen
t re
ceiv
ing
car
e
U.S.
Canada
Health Affairs 2003; 22(3): 128
By What Criteria Should We Judge Reform Proposals? Institute of Medicine Report: 2004
• Health care coverage should be universal. • Health care coverage should be continuous. • Health care coverage should be affordable to
individuals and families. • The health insurance strategy should be
affordable and sustainable for society. • Health insurance should enhance health and
well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.
Universal healthcare should…
• Cover everybody
• Be comprehensive and continuous
• Be simpler – one payer, one plan
• Be accountable – transparent and public
• Maintain choice
Institute of Medicine Report, 2004
How would such a system contain costs?
• Set Budget• Health planning• Negotiate
reimbursement• Formulary• Prevention• Simplify
Administration
profile of the uninsured
• 45.5 million non-elderly Americans in 2004• 64% from low-income families• 81% from working families• 80% are adults• 52% are ethnic minorities• 79% are American citizens• More likely to be employed in small businesses,
service industries, and blue-collar jobs
You Bet Your Life: A Marxist
Approach to Health Care in the U.S.? (Or Why We Really Need a National
Health Plan)
Richard Quint, M.D., M.P.H.California Physicians Alliance
0
5
10
15
20
25
30
35
40
19
75
19
80
19
85
19
90
Number of Uninsured in the US
Source: US Census Bureau, Current Population Surveys
National Health Programs
• Germany: 1883
• UK: 1912, 1948
• Canada: 1947, 1971
• Japan: 1922, 1961
1992
Health Care Reform:
“An Aura of Inevitability”
-George Lundberg, JAMA
A NATIONAL HEALTH PROGRAM FOR THE UNITED STATES: A Physicians' Proposal
DAVID U. HIMMELSTEIN, M.D., STEFFIE WOOLHANDLER, M.D., M.P.H., AND THE WRITING COMMITTEE OF THE WORKING GROUP ON PROGRAM DESIGN
New England Journal of Medicine 320:102-108 (January 12), 1989
The Human Cost: Personal Bankruptcies*
Medical
Other
54%46%
*N=1771 bankruptcy filersHealth Affairs, February 2, 2005
Myths About US Health-care
• It’s the best
• A national health program would be more expensive
• Americans don’t want change
Myths about US health-care
• Better outcomes under national health programs
• A national health program would be more expensive
• Americans don’t want change
Four scenarios: Spending reductions 2006-2015 (billion)
0
200
400
600
800
1000
1200
Mandates Expansion FEHB Single-payer
National Coalition on Health Care, May 2005
Myths about US health-care
• Universal healthcare leads to better outcomes
• Universal health care would save money
• Americans don’t want change
Summary: Universal health care…
• Leads to better outcomes
• Saves money
• Americans want it
• What are the prospects for changes?
FINANCING UNIVERSAL HEALTHCARE
MEDICARE
MEDICAID
EMPLOYERPAYROLL
TAX
EMPLOYEEPAYROLL
TAX
SINGLE PAYER HEALTHCARE
FUND
$$$$$$$$$$
Rx
EYE CARE
DOCTOR
Lewin 2004
Objectives: Understand…
History of universal healthcare movement
Current state of US health-care system
Universal health insurance legislation in California