29 East Madison, Suite 602 Chicago, Il 60602 312-782-6006 THE EVIDENCE FOR SINGLE PAYER Margaret Flowers, M.D. Congressional.

29 East Madison, Suite 602Chicago, Il 60602312-782-6006www.pnhp.org

THE EVIDENCE FORSINGLE PAYER

Margaret Flowers, M.D.Congressional Fellow

HEALTH CARE HISTORY HEALTH CARE HISTORY IN 2 SLIDES:IN 2 SLIDES:

1940’s: Europe: The destruction of WWII required the restoration of

security through social institutions. Created a system based on human rights.

The US retained an employment-based system of health care.

1960s belief: Private insurance industry would respond quickly to a changing

medical economy and cover everybody within 10 years.

HEALTH CARE HISTORY HEALTH CARE HISTORY IN 2 SLIDES:IN 2 SLIDES:

1980’s:1980’s:Fundamental shift occurred to private investor-owned health Fundamental shift occurred to private investor-owned health

corporations. corporations.

Health care was perceived as a fertile field for profit seeking Health care was perceived as a fertile field for profit seeking

businesses. In this new environmenbusinesses. In this new environment,t,

Health became a Health became a commodity, commodity, patients became patients became consumers.consumers.

MARKET FAILURE:MARKET FAILURE:

• Expensive• Poor outcomes• Increasing disparities• Preventable deaths• Losing (esp. primary care)

doctors• Underinsurance/Uninsurance

US Public Spending Is More Than the Total Spending in Other Nations

Sources: OECD 2008; Health Affairs 2002;21(4)88 – Data are for 2006

PNHP.org

Life Expectancy, 2003 Infant Mortality, 2002/2003Deaths in 1st Year of Life/ 1000 Live Births

Maternal Mortality, 2002/2003Deaths / 100,000 Births

MRI Units / Million Population, 2004

U.S.U.S.

U.S.U.S.

U.S.U.S.

U.S.U.S.

Health Affairs, 14 May 2009

INCREASING HEALTH INCREASING HEALTH DISPARTIESDISPARTIES

For most core quality measures, Blacks (73%), Hispanics (77%), and poor people (71%) received worse quality care than their reference groups.

For most measures for poor people (67%) disparities were increasing.

Increasing disparities were especially prevalent in chronic disease management.

Agency for Healthcare Research and Quality: National Healthcare Disparities Report, 2006.

HIGHEST NUMBER OF PREVENTABLE DEATHS

Measuring The Health Of Nations: Updating An Earlier Analysis: Ellen Nolte and C. Martin McKee Health Affairs, 27, no. 1 (2008): 58-71

LOSING PRIMARY CARELOSING PRIMARY CARE

Shortages in pediatrics, internal Shortages in pediatrics, internal medicine and family medicine.medicine and family medicine.

Decreased access Decreased access to geriatricians and gynecologists.

Low interest by medical students Low interest by medical students because of:

high student loan debtmalpractice insurancelow starting salaries

Administrators Are Growing Faster Than Physicians

Source: Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of CPS

3,000%

2,000%

1,000%

01970 1980 1990 2000 2009

Physicians

Physicians

Administrators

Administrators

HMO CEO’S PAY, 2009HMO CEO’S PAY, 2009Executive Firm Pay

Steve Hemsley United $102.0 Million*

Ronald Williams Aetna $24.3 Million

Edward Hanaway** Cigna $18.8 Million

Angela Braly WellPoint $9.8 Million

Michael McCallister Humana $6.5 Million

Dale Wolf Coventry $9.0 Million

Source: AFL/CIO CEO Pay Database & StarTribune 4/15/2010 * Includes exercised stock options** Retired with $73 million bonus

HMO OVERHEAD, 2009HMO OVERHEAD, 2009

Source: SEC filings to shareholders. Calculated as (100 – Medical Loss Ratio)

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 Quality MEPS, 1999

Percentof health CareExpenditures

1% 1% 2% 4% 6%

13%

73%

0% 0% 0%

80% uses less than $1000 of care per year

WHO WOULD YOU WHO WOULD YOU INSURE?INSURE?

EXPENSES ARE RISING EXPENSES ARE RISING FOR THE PRIVATELY FOR THE PRIVATELY

INSUREDINSURED

Source: Bernstein D. Office of Economic Policy, US Treasury

Full-year, privately-insured households with out-of-pocket expenses >$5,000 (2006 dollars)

Underinsurance: Consumer-Directed Health

Plans• Plans with very high deductibles ($2,000 to

$15,000 per family) and often high co-insurance rates thereafter (25 to 35%).

• Tax-free savings accounts (HSA and MSA) from which deductible and co-insurance can be paid.

• Employer contribution generally covers half or less of deductible.

• Only “covered services” count toward deductible.

Rising Trend of Underinsured

% of those under age 65 with Private Health Insurance

Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, 2009 By Robin A. Cohen, Ph.D., Michael E. Martinez, M.P.H., M.H.S.A., and Brian W. Ward, Ph.D.Centers for Disease Control and Prevention (CDC) National Center for Health StatisticsJune 16, 2010

INCREASING MEDICARE HMO INCREASING MEDICARE HMO COPAYS DRIVE PEOPLE INTO COPAYS DRIVE PEOPLE INTO

HOSPITALHOSPITAL

Differences between plans that did and did not raise copayments

Source: NEJM 2010 362:320

UNINSURED AND UNINSURED AND UNDERINSURED UNDERINSURED

DELAY CARE FOR HEART DELAY CARE FOR HEART ATTACKSATTACKS

*Adjusted for age, sex, race, clinical, health status, social/psych factors, urban/rural

** Under-insured = had coverage but patient concerned about cost

Od

ds

rati

o f

or

dela

yed

care

*

Source: JAMA April 15, 2010:303:1392

UNSUSTAINABLE CYCLE!UNSUSTAINABLE CYCLE!

UNINSUREDUNINSURED

MOST OF THE MEDICALLY MOST OF THE MEDICALLY BANKRUPTBANKRUPT

HAD INSURANCE COVERAGEHAD INSURANCE COVERAGE

Source: Himmelstein et al. Am J Med, Aug. 2009

Insurance at onset of

illness

WHO ARE THE WHO ARE THE UNINSURED?UNINSURED?

FULL-TIME WORKER 66.5%

PART-TIME WORKER 14%

Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2008 and 2009 Current Population Survey (CPS: Annual Social and Economic Supplements).

NON-WORKER19.5%

UNINSURED CHILDREN UNINSURED CHILDREN HAVEHAVE

HIGHER INPATIENT HIGHER INPATIENT MORTALITY MORTALITY

Source: Jnl of Public Health, October 29, 2009

*Adjusted for gender, race, age, location, hospital type, and admission source

Ad

just

ed

* m

ort

alit

y r

ate

(%

)

SOLUTIONS?SOLUTIONS?

Ø Mandate Model

Ø Tort Reform

Single Payer

TEXAS’ 2003 TORT TEXAS’ 2003 TORT REFORM REFORM

FAILED TO CURB MEDICAL FAILED TO CURB MEDICAL COSTSCOSTS

$10,000

$5,000

01992 1997 2002 2007

Tort reform implementedTort reform

implementedTexas

US

Medicare reimbursement per enrollee, adjusted for medical service inflation

Source: Public Citizen, December 2009

Note: Total malpractice payments decreased 67% between 2003 and

2008

DO YOU HAVE YOUR FIRE INSURANCE CARD?

A HEALTH SYSTEM THAT A HEALTH SYSTEM THAT WE CAN BE PROUD OF:WE CAN BE PROUD OF:

NATIONALNATIONALIMPROVEDIMPROVEDMEDICAREMEDICAREFOR ALL!FOR ALL!