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