The PNHP Vision for National Health Insurance in the United States Oliver Fein, M.D., Chair Physicians for a National Health Program Metro NY.

The PNHP Visionfor

National Health Insurancein the United States

Oliver Fein, M.D., Chair

Physicians for a National Health Program Metro NY

The PNHP Program for NHI

What will the delivery system look like?• Most physicians are in private or group

practice and paid fee-for-service, although salary and capitation payment possible

• Hospitals are non-profit governed by local Boards of Trustees

• Complete free choice of physician and hospital.

The PNHP Program for NHI

What will the insurance system look like?

• Everybody has insurance: citizens, legal

immigrants, and the undocumented

• Eligibility is defined by length of residency

• Everybody receives an NHI card

• There is universal coverage

“Everybody in, nobody out”

The PNHP Program for NHI

Universal coverage means more than who iscovered, it means the same coverage foreverybody • Coverage does not depend on your employment

status, your age or your income • Coverage must be adequate for everybody,

including the poor • This means no co-payments or deductibles, no

need for a Medicaid-like program

The PNHP Program for NHI

Universal coverage means no more tiering

in health care

• No private insurance will duplicate the public coverage.

• Private insurance would be allowed to cover what is not covered by the NHI – such as cosmetic procedures.

The PNHP Program for NHI

Benefits will cover “All medically necessary services” including:• Hospital care• Physician services• Mental health services• Medication expenses• Home care• Nursing home care• Dental care• Vision care

The PNHP Program for NHI

Will there be any exclusions? • Determined by your local health board• Private rooms, unless medically necessary • Private duty nurses, unless medically necessary• Botox for wrinkles?• Elective Facial cosmetic surgery?? • ? Viagra – good sex is good for health – covered!!

The PNHP Program for NHI

How will the inclusions/exclusions be

decided?

• Evidence-based medicine

• Patient preference

• Coverage board, including health professionals, patients, the public, health care advocates

The PNHP Program for NHI

Why is the Program called “single payer” NHI?  • Because there is a single insurer paying hospitals,

doctors, pharmacies, nursing homes• Because there is no other way to avoid “cherry-

picking” by private, for-profit insurance companies • Because it results in the lowest administrative

costs: Medicare=2-3% vs private insurance=16-30%• Because it returns the largest amount of money to

the care of patients: 97% for Medicare; 70-84% for private insurance.

Private insurers’ High Overhead

The PNHP Program for NHI

How do we pay for single payer NHI? • Not with premiums: they are regressive• With a payroll tax: Medicare Part A (presently

equals 1.45% from employee + 1.45% from the

employer)  • With income taxes: improved Medicare Part B –

no beneficiary contribution

The PHNP Program for NHI

Can we afford single payer NHI? • The gap between Canadian (single payer) and US

(1500 private insurers) amounts to $298 billion/year. (NEJM August 21, 2003)

• If we move from our multi-payer to a single-payer we will save $298 billion/year

• With these administrative savings, all the uninsured and underinsured could be covered, without increasing costs to the overall system

$407

$1,389

$0

$250

$500

$750

$1,000

$1,250

$1,500

U.S. Canada

Bureaucracy: U.S. vs. Canada, 2003

Money Spent Per Capita on Administrative Costs

(includes insurance, hospital and physician administrative costs)

Source: “Administrative Waste in the U.S. Health Care System,” Woolhandler, Himmelstein & Wolfe

0%

500%

1000%

1500%

2000%

2500%

1970 1975 1980 1985 1990 1995 2000

Administrators Physicians

Who Delivers Health Care?

Growth in Physicians and Administrators since 1970

Source: BLS & Himmelstein/Woolhandler/Lewontin Analysis of CPS Data

Is single payer NHI politically feasible?

• Employers face international competition.• Health insurance is not the insurance industry’s

most lucrative product – no long term investment benefit

• With the growth of underinsurance - increased out-of-pocket expenses (premium shifts from employer to employee, increased co-pays, growth of health savings accounts) all Americans are affected!

HARRIS POLL: “Government Should Provide

Quality Medical Coverage to All Adults . . .”77%

53% 52%47%

0%

20%

40%

60%

80%

GeneralPublic

Employers StateLegislators

Congressional Aides

Per

cent

agr

eein

g

Source: USA Today/Harris Poll - 11/23/98

SUPPORT ACROSS POLITICAL PARTIES TO EXPAND MEDICARE BENEFITS

Percent who favor each proposal when arguments for and against are presented…

Having Medicare cover long-term

Nursing home care “even if it means

higher premiums or taxes”

Having Medicare cover prescription

Drugs “even if it means higher premiums

or taxes”

Expansion of Medicare so that people

Aged 62-64 are able to buy into the

program before they turn 65

63%

74%

70%

58%

72%

73%

59%

61%

62%

0 50 100

Republicans

Democrats

Independents

Source: Kaiser Family Foundation/Harvard School of Public Health National Survey on Medicare, 10/20/98 (conducted Aug-Sept 1998)

Americans Pay World’s Highest Taxes For Healthcare

$0

$1,000

$2,000

$3,000

$4,000

$5,000

$6,000

UK Sweden Germany Canada Norway U.S.

Public Expenditures Private Expenditures

Per Capita Health Spending, 2002

OECD and “Paying for National Health Insurance—And Not Getting It”

Health Affairs: July / August 2003

The PNHP Program for NHI(The Physicians’ Proposal)

JAMA 2003: August 13

Single-payer National Health Insurance

• Universal coverage

• Comprehensive coverage

• Progressive financing

• Low administrative costs

• Non-profit delivery system

What can you do about health reform?

1. Pro-active efforts on the federal level • John Conyers: HR 676: National Health

Insurance Act• Barbara Lee: US National Health Service Act• Jesse Jackson, Jr.: Constitutional amendment

– health as a human right• Wellstone/Baldwin: Federalist approach –

incentives for State reform• Bush: Community Health Centers Act

What can you do about health reform?

2. Pro-active efforts on the state level • California: Options Commission - Kuehl

state single-payer bill• Massachusetts: Constitutional amendment –

health as a human right• Maine: Dirigo – Subsidized private insurance• Maryland: Pay or play• New York: Gottfried – Commission for

Healthcare Options

What can you do about health reform?

3. Incremental Reforms• Medicare expansions: down to age 60 or 55 or

50; children up to age 18; unemployed • Employer-mandate laws • NYC: Health Security Act – Quinn • Market-based reforms: Healthy-NY • Community Health Centers Act

What can you do about health reform?

4. Defensive Fights • Stopping the privatization of Social Security • Repealing portions of the MMA: donut-hole

Rx coverage, prohibiting Medicare from negotiating prices with Pharma, subsidies to HMOs (Medicare-Advantage), HSAs

• Fighting Medicaid cutbacks: block grants and waivers

What can you do about health care reform?

5. Reactive Fights• Stop Health Savings Accounts (HSAs)• Expose Consumer Driven Health Care

(CDHC)• Evaluate Tax Credits• Support alternatives to caps on non-economic

damages in malpractice reform• Oppose trade agreements: result in higher

drug prices abroad

The Institute of Medicine says:

• Between the health care we have and could have, lies not just a gap but a chasm

• The American health care delivery system in need of a fundamental change

• The challenge is the enormity of the change required

Common Sense: “You cannot cross a chasm in two jumps”

PHYSICIANS FOR A NATIONAL HEALTH PROGRAM (PNHP) says:

• We’ve tried and failed with incremental reforms for 100 years

• The time has come for single-payer National Health Insurance-an improved Medicare-for-All.

REFERENCES AND CONTACTS• Bodenheimer TS, Grumbach K. Understanding Health

Policy: A Clinical Approach. Appleton & Lange. 2005.

• California Health Options Project: 9 different plans ranging from Medical Savings Accounts to Single Payer Plans are compared. www.healthcare.options.ca.gov

• Commonwealth Fund, One East 75th Street, New York, NY 10021. www.cmwf.org

• Himmelstein D, Woolhandler S, Hellander I. Bleeding the Patient: The Consequences of Corporate Healthcare. Common Courage Press, 2001.

• Physicians for a National Health Program (PNHP), 29 East Madison St., Rm. 602, Chicago, Ill 60602. www.pnhp.org. PNHP-NY, 2753 Broadway #198, New York, NY 10025. www.pnhpnyc.org.