Business case for single payer

The Business of Health Care Reform:

What’s Here?

What’s Missing?

What’s Next?

Tom Lieb, MD

Ed Weisbart, MD

Projected data for 2013

CIA World Fact Book

Accessed Dec 3 2013

74

76

78

80

82

84

86

Unite

d S

tate

s

Gu

am

Po

rtug

al

Den

ma

rk

Gib

ralta

r

Sa

int

He

len

a+

Pu

ert

o R

ico

Wa

llis a

nd

Futu

na

Caic

os I

sla

nds

Fin

land

Ko

rea

, S

outh

Vir

gin

Isla

nd

s

Ta

iwan

Be

lgiu

m

Eu

rop

ea

n U

nio

n

Luxe

mb

ourg

Ma

lta

Fa

roe

Isla

nd

s

Au

str

ia

Sa

int

Pie

rre

+

Gre

ece

Unite

d K

ing

do

m

Jord

an

Ge

rma

ny

Ire

lan

d

Norw

ay

New

Zea

land

Isle

of

Ma

n

Caym

an I

sla

nds

Be

rmu

da

Neth

erl

an

ds

An

gu

illa

Ice

lan

d

Isra

el

Sw

ed

en

Sp

ain

Fra

nce

Ca

nad

a

Jers

ey

Lie

chte

nste

in

Italy

Au

str

alia

Hon

g K

on

g

Sw

itze

rlan

d

Gu

ern

se

y

An

do

rra

Sa

n M

ari

no

Sin

ga

pore

Jap

an

Ma

cau

Life

Exp

ecta

ncy a

t b

irth

AndorraGuernseySwitzerlandHong KongAustralia

ItalyLiechtenstein

CanadaJerseyFranceSpainSwedenIsraelIcelandAnguilla

NetherlandsBermudaCayman IslandsIsle of ManNew Zealand

IrelandNorway

GermanyJordan

United KingdomGreece

Saint Pierre+AustriaMalta

Faroe IslandsLuxembourg

We’re Number 51 in Life Expectancy

We Spend More Than Double

Most Other Modern Nations

Data are for 2011

Sources: OECD 2013; Health Affairs 2002 21(4)88

$2,940 $3,280 $3,140

$3,970 $4,350

$4,780

$5,749

$3,201

$-

$2,000

$4,000

$6,000

$8,000

$10,000

Total US Public US Private

20

11

he

alth

ca

re s

pe

nd

ing

pe

r ca

pita

$8,950Our taxes already more than

pay for universal care

anywhere else in the world.

We’re Not Very Old

Percent of

population

over age

64

Note: Data are for 2012 or most recent year available

Source: OECD, 2013

0%

5%

10%

15%

20%

25%

USA CAN UK FRA SWE GER ITA JAP

Japan is much older but

spends one third what we spend

We’re Not Big Smokers

0%

5%

10%

15%

20%

25%

30%

35%

Sw

ede

n

Icela

nd

Un

ited

Sta

tes

Austr

alia

Cana

da

Luxe

mb

ou

rg

Norw

ay

Fin

land

New

Ze

ala

nd

Isra

el

Port

ug

al

Slo

ven

ia

Me

xic

o

Slo

vak R

epu

blic

United

Kin

gd

om

De

nm

ark

Ja

pa

n

Sw

itze

rla

nd

Belg

ium

Neth

erla

nds

Germ

any

Italy

Austr

ia

Kore

a

Fra

nce

Pola

nd

Spa

in

Czech R

ep

ub

lic

Tu

rkey

Esto

nia

Hu

ng

ary

Ire

land

Chile

Gre

ece

Percent of

population

ages 15+

smoking

daily

USA:

14.8%

Missouri:

25% of adults


Source: OECD, 2013

We Are Obese

0%

10%

20%

30%

40%

Percent of

population

with BMI

above 30

Self-reported data for 2012 or most recent year

available

Source: OECD, 2013

We Have Plenty of Technology

0

20

40

60

80

100U

SA

GR

E

TU

R

GE

R

LU

X

ICE

BE

L

SP

A

DE

N

FR

A

AU

ST

CA

N

NE

T

ES

T

UK

CZ

E

SLO

HU

N

PO

R

AU

SL

ISR

IRE

KO

R

PO

L

CH

IL

MRI

exams

per

1,000

people


OECD Data

Accessed Nov 28 2013

We Have the

Best Cancer Outcomes

http://www.cancer.org/acs/groups/content/@epidemiologysurveil

ance/documents/document/acspc-027766.pdf accessed Nov 28,

2013

5-Year

survival,

all

cancer

types

0%

10%

20%

30%

40%

50%

60%

70%

USA SWI BELG GMN SPN UK SLOV

We Have Nearly the

Worst Infant Mortality Rates

0

2

4

6

8

10

Tu

rkey

Ch

ile

United

Sta

tes

New

Ze

ala

nd

Cana

da

Hu

ng

ary

Slo

vak R

epu

blic

Pola

nd

Luxe

mb

ou

rg

United

Kin

gd

om

Austr

alia

Sw

itze

rla

nd

Austr

ia

Denm

ark

Germ

any

Neth

erla

nds

Fra

nce

Ire

land

Isra

el

Gre

ece

Italy

Belg

ium

Spa

in

Port

ug

al

Kore

a

Slo

ven

ia

Cze

ch R

ep

ub

lic

Esto

nia

Fin

land

Norw

ay

Ja

pa

n

Sw

ede

n

Deaths in

first year of

life per 1,000

live births


OECD Data

Accessed Nov 28 2013


Source: OECD, 2011

We Have the

Worst Maternal Mortality Rates

0

2

4

6

8

10

12

14

USA UK CAN FRA GMN Australia

Deaths per

100,000 live

births

We Have Rapid Access to

Elective Surgery

0%

5%

10%

15%

20%

25%

30%

NET FRA SWI USA NZ ASTL NOR UK SWE CA

Adults who

needed

elective

surgery and

waited at

least 4

months

http://www.commonwealthfund.org/~/media/Files/Publicatio

ns/Fund%20Report/2012/Nov/1645_Squires_intl_profiles_hl

t_care_systems_2012.pdf

2010-2012 data, report Dec 2012, accessed Nov 28 2013

We Don’t Go to the Doctor Much

0

2

4

6

8

10

12

14M

EX

NE

Z

SW

E

CH

I

IRE

US

A

GR

E

SW

I

PO

R

FIN

DE

N

UK

NO

R

CA

N

ES

T

LU

X

ISR

ICE

SLV

AT

L

NE

T

PO

L

FR

A

AU

S

ITA

TU

R

SP

N

BE

L

GE

R

CZ

E

SLO

HU

N

KO

R

JA

P

Physician

visits per

capita





We Don’t Have Very Many Doctors

0

1

2

3

4C

HI

TU

R

KO

R

ME

X

PO

L

JA

P

CA

N

SLO

US

A

NZ

D

UK

LU

X

HU

N

BE

L

NE

T

AT

RL

IRE

ES

T

FIN

FR

A

SV

K

DN

ISR

CZ

E

ICE

ITA

GE

R

SP

A

SW

E

SW

I

PT

G

Practicing

physicians

per 1,000

people





We Have Plenty of Administrators

Data updated through 2013

Source: Bureau of Labor Statistics; NCHS;

Himmelstein/Woolhandler analysis of CPS

Gro

wth

Sin

ce

19

70

Physicians Administrators

3000%

2500%

2000%

1500%

1000%

500%

0

1970 1980 1990 2000 2010

We Waste 31% of

Our Healthcare Dollar

Medical overhead,

administration, and

insurance profits

Medical care

31%

69%

Woolhandler, et al “Costs of Health Administration

in the U.S. and Canada,” NEJM 349(8) Sept. 21,

2003

We’re Insured, But Not Very Well

Uninsured

84% have insurance

16%

Commonwealth Fund, Sept. 8, 20112012 Biennial Health Insurance Survey

We’re Insured, But Not Very Well

Uninsured

Adequately

insured(Spend under

10% on

healthcare)

Under-Insured(Spend more than

10% on healthcare)

54%

16%

30%

Commonwealth Fund, Sept. 8, 20112012 Biennial Health Insurance Survey

Deductibles Began Rising

Long Before the ACA

10%12%

18%

22%

27%

31%34%

38%

0%

10%

20%

30%

40%

2006 2007 2008 2009 2010 2011 2012 2013

Kaiser/HRET Survey of Employer-Sponsored Benefits, 2013

Percent of

workers with

deductibles

>$1,000

Under-Insurance Drives Bankruptcies

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

Medical expenses

drove 62% of

bankruptcies

78% were insured at

onset of the bankrupting illness

Uninsured at illness

onset

Massachusetts’ Reform

Did Not Slow Medical Bankruptcies

7,504

10,093

0

2,000

4,000

6,000

8,000

10,000

12,000

2007 2009

Source: Himmelstein, Thorne, Woolhandler.

Am J Med 2011;124:224

Number of

medical

bankruptcies in

Massachusetts

Uninsured and Under-Insured

Delay Seeking Care for Heart Attacks

Source: JAMA April 15, 2010. 303:1392

*Adjusted for age, sex, race, clin. charact., hlth status, social/psych fx,

urban/rural. Under-insured=had coverage but patient concerned about cost

1.00

1.21

1.38

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

1.6

Insured Under-insured Uninsured

Odds ratio

for delayed

care*


Figures adjusted for Purchasing Power Parity

Source: OECD, 2013

We Have the Most “Skin in the Game”

$968

$733

$640$571

$315 $298 $267

$0

$200

$400

$600

$800

$1,000

$1,200

USA AUSL CAN GER UK FRA HOL

Out-of-

pocket

dollars per

capita

Source: Health Affairs 2011;30:2437

Cost Barriers Are the Worst in the US

Percent

Reporting

Problems

(Among

Sicker

Adults)

50%

40%

30%

20%

10%

0UK FR

A

CA

N

AUL NZ

E

US UK FR

A

CA

N

NZ

E

AUL US

Sick Americans say

cost drove their

access problems

Sick Americans find

it uniquely hard to

pay their medical

bills

This really is a

“Patient Bill of Rights”

Affordable Care Act:

Millions of More Insured Americans

New Insurance Regulations

• Dependents covered to age 26

• No one is “uninsurable”

• No cancellations for being too sick

• No lifetime/annual maximums

New Insurance Marketplaces

• Single door

• “Ten Essential Benefits”

• Priced only by age, smoking and location

• 60-90% value

• Navigation assistance

Stronger Public Programs

• Medicare stabilized and strengthened

• Medicaid expansion option

Many many

more things

How Many People Are Involved in

Medical Bankruptcies Each Year?

CanadaUSA

2 Million62% of Americans file cases

866,000 total cases affecting 2 million Americans

Excludes those too poor to declare bankruptcy

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

How Many People

Don’t Have Health Insurance?

CanadaUSA with the ACA

US Census Bureau, 2012

30 Million

How Many People Go Without

Some Medical Care Because of Cost?

CanadaUSA

Commonwealth Fund, Schoen 2007

115 Million

How Many People Die Each Year

From Not Having Insurance?

CanadaUSA

Wilper, et al “Health Insurance and Mortality in U.S.

Adults,” American Journal of Public Health;

Vol. 99, Issue 12, Dec 2009

45,000

The ACA’s Biggest Flaw

Preserves the insurance industry

• Limited lists of doctors and hospitals

• Large gaps in covered benefits

• Financial barriers to care

• Needless complexity

• Millions remain uninsured

A National Health

Program for the

USA

National Health Programs 101

National Health

“Insurance”

• Public funding, private delivery

• Medicare

• Canada

National Health

“Service”

• Public funding, public delivery

• VA

• Great Britain

“All Payer”

• Highly regulated insurance model

• Maryland

Multi-Payer

• Insurance industry-centric

• Uniquely American

“Single Payer”

National Health Programs 101

National Health

“Insurance”

• Public funding, private delivery

• Medicare

• Canada

National Health

“Service”

• Public funding, public delivery

• VA

• Great Britain

“All Payer”

• Highly regulated insurance model

• Maryland

Multi-Payer

• Insurance industry-centric

• Uniquely American

HR 676The Improved and Expanded

Medicare for All Act”

HR 676 “Medicare for All”

Builds on Medicare

Fix Medicare

• Comprehensive benefits

• No financial barriers

• No need for “Medicare supplemental” or “wrap”

• Preserve private delivery

Expand Medicare

• All Americans, including Congress

• Roll up most other programs

• “Everybody in, nobody out.”

HR 676 “Medicare for All” Provides for

All Medically Necessary Services

Primary care Prescription drugs Substance abuse

Prevention DME Chiropractor

Nutritional therapies Long-term care Basic vision

Inpatient care Palliative care Hearing / hearing aids

Outpatient care Mental health services Podiatry

Emergency care Full dentalFree choice of

providers

No copays, no deductibles, no lifetime/annual maximums

HR 676 “Medicare for All” Provides for

All Medically Necessary Services

Primary care Prescription drugs Substance abuse

Prevention DME Chiropractor

Nutritional therapies Long-term care Basic vision

Inpatient care Palliative care Hearing / hearing aids

Outpatient care Mental health services Podiatry

Emergency care Full dentalFree choice of

providers

No copays, no deductibles, no lifetime/annual maximums


Protects Displaced Healthcare Workers

• “Medicare for All Employment Transition Fund”

Fully funded support

• Two years of guaranteed salary (up to $100,000 per year)

• Eligible for unemployment after protected salary period

Two year transition

First priority for retraining and job placement


Builds on the Progressive Income Tax

• Roll-up existing federal and state programs

Consolidate current spending

• Modest increase in progressive taxes

• For 95% of people, the increase in taxes is less than the reductions in premiums, copays, and deductibles.

Eliminate premiums, copays, etc

Friedman, G. Dollars & Sense. March/April 2012

$ Billions

Medicaid Rate Adjustment

Covering the uninsured

Increased utilization (especially home health and dental)

Government administration ($23B)

Health insurance administration

Increased market power (pharma and devices)

Admin costs to providers

New Costs Savings

$74

$110

$142

$153

$178

$215

$200

0

-$200

-$400

-$600


Covers Everyone and Spends Less

Friedman, G. Dollars & Sense. March/April 2012

New

Costs:

$326 B Net savings:

$243 BillionCover everyone

with better benefits

and spend less.

New

Savings

:

$569 B


Covers Everyone and Spends Less

Canada Figured This Out Already

Source: Statistics Canada, Canadian Institute

for Health Info, and NCHS/Commerce Dept.

Health

costs %

of GDP

19%

17%

15%

13%

11%

9%

7%

5%1960 1970 1980 1990 2000

USA

2014

Single Payer

Implemented

Canada

“Uniquely

American”

Source: World Bank.

Accessed Nov. 29, 2013

Life Expectancy

Gap (CA minus US)

(years)

0

1

2

3

1975 1980 1985 1990 1995 2000 2005 2010

Canadians Spend Less and Live Longer

They spend half as much as we do,

and now live 2.5 years longer.

The Investment Community Gets This

Smith, R. “How Much Could Medicare for All

Save You?” The Motley Fool, July 21, 2013

“Single-payer would shave

$400 Billion per year off the national health care bill.”

Universal Health Care

Is Not a Partisan Issue

“Every developed country,

they have universal health

care.

“Whether it’s Obamacare, or

son of Obamacare, I don’t

care. As long as we get it

done.”

Bauman, V. Puget Sound Business Journal. Dec. 5,

2013http://www.bizjournals.com/seattle/blog/health-care-

inc/2013/12/colin-powell-calls-for-universal.html?page=all

Colin Powell

Four Star General, Ret.

Former Secretary of State

We Have Universal Coverage Today:

EMTALA (1986 Law)

IT’S THE LAWIf you have a medical emergency or are in active labor,

you have the right to receive, within the capabilities of

this hospital’s staff and facilities:

An appropriate medical screening

examination and necessary

stabilizing treatment,

even if you cannot pay or

do not have medical insurance.

Care for uninsured adds

$1,000 per family per year

We Have Built the World’s

Least Prudent Health Care StrategyUntreated hypertension

• Dialysis: $46,332 per year

• Strokes: $47,800 per event

Treated Hypertension

• Most medications for hypertension: $4/month

http://www.ncbi.nlm.nih.gov/pubmed/22237223

http://www.cdc.gov/stroke/facts.htm

Who pays

for all this?

What Do You Spend on

Health Care Benefits?

Single Payer ModelUSA Employers Today

7 - 12% of wages

3.3% tax on wages

Bureau of Labor Statistics

Business Health Coalition for Single Payer

7 Ways that Single Payer

Strengthens American Businesses

Reductions inDirect Costs

• Cost of health care benefit

• Health care benefit management costs

• Worker Comp, auto and liability insurance

Reduced Employer Risk

• More predictable future costs

• Eliminate risk of employees with high medical costs

• One less item in labor negotiations

Level the global playing field

for business

Americans Are Not as Divided

As You Might Think

Source: CBS News / New York Times Poll, April 14,

2010

76%

62%

19%

33%

5% 6%

0%

20%

40%

60%

80%

National Sample Tea Party Sample

Worth It Not Worth It Don't Know

“Are the benefits from

government programs

such as Social

Security

and Medicare

worth the costs?”

Business case for single payer

Healthcare

pd data

recent year availablesource

year of life

mdprojected data

year survival

selfreported data

universal care

business of health care