HEALTH CARE FOR ALL Myths and Reality Rob Stone MD FACEP
Mar 26, 2015
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.