29 East Madison, Suite 602 Chicago, Il 60602 312-782-6006 www.pnhp.org THE EVIDENCE FOR SINGLE PAYER Margaret Flowers, M.D. Congressional Fellow
Dec 26, 2015
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!