HEALTH CARE FOR ALL

Myths and Reality

Rob Stone MD FACEP

THE PROBLEM OF THEUNINSURED

• 46 Million is 16% of the population.

• Indiana has 800,000 uninsured

• To get 46 million take all of Indiana, plus Texas, Florida, and Connecticut.

Uninsured Americans

CPS and NHIS Data

Who are the uninsured?

Employed54%

Children19%

Unemployed5%

*Out of labor force

22%

*Students>18, Homemakers,

Disabled, Early retirees

Source: Himmelstein & Woolhandler - Tabulation from CPS

Lack of Insurance Increases Mortality

• 18,000 excess deaths per year due to lack of health coverage

• People without insurance:- Receive less care and receive it later

- Have 25% higher mortality rates- Receive poorer care when they

are in hospitals• This is the fifth leading cause of death in the US• The safety net is full of holes

Care Without Coverage, Institute of Medicine, May 2002

Medical Bankruptcy in Indiana

• 2004 estimate: 55,000 bankruptcies

• Almost 28,000 related to medical costs

• Affecting 77,000 family members

• 75% had coverage at start of illness

• Average out of pocket medical expenses leading to bankruptcy - almost $12,000.

Himmelstein et al, Health Affairs 2/2/05

A Brief History

• Wage and price controls in WW II

• Truman pushes for National Health Insurance 1949. AMA opposes.

Red Baiting

“Would socialized medicine lead to socialization of other phases of life? Lenin thought so. He declared socialized medicine is the keystone to the arch of the socialist state.”

AMA Pamphlet 1949

A Brief History (continued)

• The birth of the Blues• The Great Society: Medicare

and Medicaid 1965• The Clinton Health Plan 1993• The death of the not-for-profit

Blues

Anthem (formerly Blue Cross)Now Wellpoint

• CEO Larry Glassock is in Indianapolis

• The highest paid executive in Indiana

• Bonus announced in 2003 was $42.5 Million

Indianapolis Star 4/7/04

Where Does the Money Come From?

And Where Does It Go?

Per Capita National Health Spending Reached $4,637 in 2000

$82 $105 $141 $202$341

$582

$1052

$1733

$2690

$3637

$4637

1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000

SOURCE: Centers for Medicare and Medicaid Services

US Versus Other Countries

$2,930

$2,820

$2,740

$2,520

$2,160

$2,080

$5,270U.S.

Canada

Germany

France

Sweden

U.K.

Japan

$ Per Capita

OECD, 2004 & Health Affairs 2002; 21(4): 99

2004 data Health Affairs 1/06: $1.9 trillion or $6,280 per capita

And Where Does It Go?

• The money is going to:

- Overhead

- Inefficiency

- Waste

- Profit

- And graft

Growth of Physicians, RNs & Administrators 1970-

1998

0

500

1000

1500

2000

2500

1970 1975 1980 1985 1990 1998

AdministratorsRNsPhysicians

Bureau of Labor Statistics, NCHS

Percentage Growth

What Do Administrators Do? Cost Shifting.

• The $5 aspirin pill

• The $500 ER bill

• “Skimming the cream off the top”: Avoiding the costly, the very sick, and the uninsured

It’s called “GAMING THE SYSTEM” or “SURVIVOR”

What Are We Paying for?

• A Very Complex System• 7000+ private health plans

– An army of people to deny health insurance coverage and payments

– And an army of people to try to maximize and receive health insurance payments

– An army of people to determine who is eligible for what program

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

Health Care Administration US and Canada

• US administrative spending = $399.4 Billion or 31% of total health care costs.

• Canada spends 17% on administrative overhead.

• Potential savings = $286 Billion, enough to cover the uninsured and then some.

Woolhandler et al. NEJM 349:768-75 8/21/2003, CBO, GAO

…. And Graft

“Investor ownership has been shown to compromise quality of care in hospitals, nursing homes, dialysis facilities, and HMO’s; for-profit hospitals are particularly costly. A wide array of investor-owned firms have defrauded Medicare and been implicated in other illegal activities.”

Journal of the American Medical Association, 8/13/03

Columbia/HCA

• Fined $1.7 Billion in 2003 for Medicare fraud, the largest fine in Medicare history.

• No one went to jail.

• CEO Richard Scott left with a $10 million severance package and over $300 million in stock.

Woolhandler, Canadian Medical Journal 6/8/04

And What Do We Get For All Our Money?

• The most expensive health care in the world, no doubt.

• The best health care in the world?

• How would you measure the best health care in the world?

*

Life Expectancy

78.178.5

79.4 79.7 79.9

81.5

77.1

70

75

80

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

US ranked 27th, right after Barbados; OECD, 2004, (2001 Data)

Infant Mortality per 1000 Births

5.2 54.7

4.3 4.1

3.1

6.8

0

1

2

3

4

5

6

7

8

U.S. Canada Australia Italy Germany France Japan

Ranked 36th, below Cuba and Taiwan OECD, 04

WHO Global Health Rankings

• Based on outcomes AND fair distribution of care

• At the top: #1. France, #2. Italy

• US ranks 37th, between Costa Rica and Slovenia

Bartlett and Steele, Critical Condition, 2004

Satisfaction with Health Systems in Ten Nations

• Harris Poll taken in US, Canada, UK, Germany, Australia, France, Sweden, Japan, Italy, and Holland.

• The U.S. had the lowest health care satisfaction rate (11 percent) of the 10 nations.

Blendon et al. Health Affairs, Summer 1990

How Can We Pay So Much and Get So Little?

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.

Canad

a

Austra

liaU.K

.

France

Switzer

land

OECD, 2004, (2001 Data)

% Finding Difficulty in Receiving 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

Elderly 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

n

Per

cent

of

Pop

ulat

ion

Old

er T

han

65

Tobacco Smokers

18.0

24.0

27.028.6

30.9

18.4

0

5

10

15

20

25

30

35

Canada U.S. Italy U.K. France Japan

% p

op

ula

tio

n s

mo

kin

g d

aily

OECD, 2004 (2002 Data, U.K is 2001)

MRI Units per Million People

2.74.2

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)

Renal Transplants

2931

35 3538

34

0

5

10

15

20

25

30

35

40

U.K. Australia U.S. Sweden Canada France

OECD, 2004 (2002 Data, Canada and Sweden are 2001)

The Health Care System Dinosaur Stumbles Toward the Tar Pit

Our non-system of illness care

Myths

• Our “system” is fine, it just needs adjustment

• There is a safety net

• We can’t afford to cover everyone

• We have the best health care system in the world

And the Myth of “Moral Hazard”

• “If you think health care is expensive now, just wait until it’s free.” PJ O’Roarke

• The “logic” of Health Savings Accounts

• The 80/20 rule

• Some things are best not left to the marketplace

Gladwell, The New Yorker, 8/29/05

Myth Versus Realty• Every other industrialized country has come

to the same conclusion, a national program to insure health care for all.

• We can learn from the Canadian experience:National health insurance (a “single payer”) Fee for service independent doctors just like our Medicare Not-for-profit independent hospitals

International Timeline of Universal Health CareGermany 1883Switzerland 1911New Zealand 1938Belgium 1945France 1945United Kingdom 1946Sweden 1947USA 1948*Greece 1961Japan 1961Canada 1966Denmark 1973Australia 1974Italy 1978Portugal 1979Spain 1986South Africa 1996

The Health Care We Get

• 1/3 are uninsured or underinsured

• HMOs deny care to millions more with expensive illnesses

• Death rates higher than other wealthy nations’

• Costs double Canada's, Germany's, or Sweden's - and rising faster

• Executives and investors making billions

• Destruction of the doctor/patient relationship

The Health Care We Want

• Guaranteed access

• Free choice of doctor

• High quality

• Affordability

• Trust and respect

We Have What it Takes

• Excellent hospitals, empty beds• Enough well-trained professionals• Superb research• Current spending is sufficient• Polls show the people are ready for change• Large and small business are calling for

change

Government Health Insurance for All, Even if Taxes Increase?

Oppose30%

Favor65%

No opinion5%

Pew Report, May 2005

No opinion 5%

Please indicate whether you support or oppose this policy: Universal Health Insurance

Oppose17%

Unsure8%

Strongly Favor52%

Somewhat favor23%

Harris Poll, Wall Street Journal October 20, 2005

Unsure 8%

Remember Columbia/HCA?

• Senate Majority Leader Dr. Bill Frist owns $25 million in HCA stock.

• HCA is the Frist family business.

Why Health Care for Every Person, Young or Old, Rich or Poor?

“The care of human life and happiness, and not their destruction, is the first and only legitimate object of good government.”

Thomas Jefferson

“Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. “

Margaret Mead

www.HCHP.info

PHYSICIANS FOR A NATIONAL HEALTH PROGRAM

29 EAST MADISONSUITE 602CHICAGO, IL 60602TEL: (312) 782-6006

WWW.PNHP.ORG

Gallup pole 3/04: More Americans worried “a great deal” about affordability and availability of health care than a terrorist attack, 60% vs. 42%.

WHAT ABOUT MALPRACTICE?

• Democrats propose limiting “frivolous suits” thru something like the panels we have here in Indiana. Good idea.

• Republicans favor putting caps on non-medical settlements like we have here in Indiana. Good idea.

WHAT ABOUT MALPRACTICE?

• Future medical payments themselves are about 25% of total payouts.

• Many suits are triggered by anger over bills for care received.

• Both of these factors would be taken care of by a single payer system.

WHAT ABOUT MALPRACTICE?

• Malpractice costs account for ~1% of total health care spending.

• The real answer is for doctors and lawyers to come together and face their common enemy: the insurance industry.