Transcript Document

PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
29 EAST MADISON
SUITE 602
CHICAGO, IL 60602
TEL: (312) 782-6006
WWW.PNHP.ORG
Who Are The Uninsured?
50%
Employed
20%
force
*Out of labor
5%
Unemployed
25%
*Students>18,
Children
Homemakers,
Disabled, Early retirees
Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS
Chronically Ill and Uninsured
Unmet Health Needs of the
Uninsured
18,314 Adult Deaths Annually Due to
Uninsurance
Full Time Jobs Provide Little
Protection for Hispanics
ni ylredle-non fo tnecreP
oh w rekro w e mit-lluf a hti w seili maf
derusninu era
White
0%
10%
20%
30%
Source: Commonwealth Fund, 3/2000
Black
Hispanic
Rising Out-of-Pocket Costs for Seniors
Voucher/Premium Support Proposals Would Worsen
43%
2025 (premium support)
35%
2025 (current law)
25%
2000
23%
1997
21%
1994
1984
1977
14%
12%
Percent of Income
Source: Senate Select Committee on Aging; AARP 4/95 & 3/98; and Commonwealth Fund
May, 1999 projections (adjusted to include nursing home costs)
Who Pays for Nursing Home Care?
Medicaid
44%
Other
5%
Out of pocket
31%
Private
7%
Medicare
14%
Source: Health Affairs 2000; 19(3):44
Illness and Medical Costs,
A Major Cause of Bankruptcy
•
45.6% of all bankruptcies involve a medical reason or large
medical debt
•
326,441 families identified illness/injury as the main reason
for bankruptcy in 1999
•
An additional 269,757 had large medical debts at time of
bankruptcy
•
7 per 1000 single women, and 5 per 1000 men suffered
medical-related bankruptcy in 1999
Source: Norton's Bankruptcy Advisor, May, 2000
Many With Insurance Lack Choice
42% Are Offered Only 1 Plan
eciohC oN hti W tnecreP
Income Group
<$10K
$19,999
$10,000-
$29,999
$20,000-
$49,999
$30,000-
$99,999
$50,000-
65%
53%
49%
39%
35%
0%
20%
40%
60%
Note: Those without choice were 70% more likely to give their plan a low rating
Source: Health Affairs 1998; 17(5):184
Patients Refused Authorization for ER Care
• 8% to 12% of HMO patients presenting to 2 ERs were
denied authorization
• Authorization delayed care by 20 to 150 minutes
• Of those denied:
47% had unstable vital signs or other high risk
indicators
40% of children were not seen in f/u by primary MD
Eventual diagnoses included: meningococcemia (2),
ruptured ectopic (2),shock due to hemorrhage (2), septic
hip, PE, MI (2), ruptured AAA, pancreatitis, peritonsillar
abscess, small bowel obstruction, unstable angina,
pneumothorax, appendicitis, meningitis(3)
Source: J Emerg Med 1997; 15:605; Acad Emerg Med 1997; 4:1129; Ann Emerg med 1990; 19:59
gnitropeR llI yllanimreT fo %
smelborP detaleR-tsoC lacideM
Financial Suffering at the End of Life
Problem
Mod/Severe
Income*
>10% Family
Sold Asset etc.**
0%
12%
21%
10%
20%
39%
30%
40%
Source: Ann Int Med 2000; 132:451 - Study of 988 terminally ill patients
* Out-of-pocket medical costs > 10% of household income
** Patient or family sold assets, took out mortgage, used savings or took extra job
Why Women Delay Prenatal Care
When They Know They Are Pregnant
47%
31%
22%
No money or insurance
Other reason
Unable to get appointment
Note: 11.1% of pregnant women failed to get timely prenatal care despite knowing they were
pregnant
Source: MMWR 5/12/2000; 49:393
Distribution of Wealth, 1976 & 1998
1998
1976
19%
51%
30%
35%
34%
Wealthiest 1%
Next 9%
Bottom 90%
31%
Poverty Rates, 1997
U.S. and Other Industrialized Nations
% of Population Below Poverty Level
0%
5%
US
17%
11%
Germany
UK
11%
Canada
11%
Sweden
9%
France
8%
Netherlands
10%
6%
Source: Luxembourg Income Study Working Papers
Note: U.S. figure for 1997, other nations most recent available year
15%
20%
Americans Lead the World in Hours Worked
Hours/worker-year - 1997
0
250
500
750
U.S. (1997)
1000
1966
U.S. (1980)
1883
Japan
1889
U.K.
France
Germany
Norway
Source: International Labor Organization, 1999
1731
1656
1560
1399
1250
1500
1750
2000
Causes Of Excess Deaths Among
12%
African Americans 29%
12%
Infant
13%
Cancer
/ Drugs
Trauma/HIV
17%
Other
Cardiovascular
6%
Infant
39%
20%
Cancer
IV/ Drugs
Trauma/H
Cardiovascular
25% 17%
Other
3%
Diabetes
8%
Diabetes
FEMALE
Source: Himmelstein & Woolhandler - Analysis of data from NCHS
MALE
Racial Disparity in Access to Kidney
Transplants
Pharmacies in Minority Neighborhoods
Fail to Stock Opioids
% Minority Residents in Neighborhood
htiw seicamrahP fo %
ylppuS dioipO etauqedA
<21%
21-60%
>60%
0%
25%
25%
50%
53%
75%
72%
100%
Source: N Engl J Med 2000; 242:1023
Minority Physicians Provide
More Care for the Disadvantaged
Ethnicity of Physician
Medicaid
Uninsured
Poor
ecitcarP fo tnecreP
0%
10%
20%
10%
14%
30%
12% 14%
18%
22% 24%
20%
31%
40%
White
Source: AJPH 1997;87:817
Hispanic
Black
Are Emily and Brendan More
Employable than Lakisha and
Jamal?
Growth of Registered Nurses and Administrators
1970-2002
1970
1975
1980
1985
1990
1995
0791 ecnis htworG
0%
500%
1000%
1500%
2000%
2500%
Administrators
RNs
Source: Bureau of Labor Statistics & Himmelstein/Woolhandler/Lewontin Analysis of CPS data
2001
0791 ecnis htworG
Growth of Physicians and Administrators
1970-2002
1970 1975 1980 1985 1990 1995 2000
0%
500%
1000%
1500%
2000%
2500%
Administrators
Source: Bureau of Labor Statistics & NCHS
Physicians
High Risk HMO Patients Fared
Poorly in the Rand Experiment
Relative Risk of Dying
Diastolic Blood Pressure
1.5
90
85
1
80
0.5
1.21
1
87.8
82.9
75
70
0
HMO
FFS
Source: Rand Health Insurance Experiment, Lancet 1986; i:1017
Note: High Risk = 20% of population with lowest income + highest medical risk
HMO
FFS
The Elderly and Sick Poor did Worse in HMOs
Changes in Physical Health at 4 Years
% of Patients Better/Worse
60%
40%
20%
0%
20%
40%
60%
FFS - Sick Poor
HMO - Sick Poor
Better
Worse
FFS - Elderly
HMO - Elderly
Source: Medical Outcomes Study - JAMA 1996;276:1039
Elderly HMO Stroke Patients
Get Less Specialist Neurology Care
eraC tsilaicepS rof oitaR sddO
stneitaP OMH-noN ot evitaleR
All Ages
<55
55-64
65-74
>74
0
0.5
0.4
0.52
0.54
1
1.06
1.5
Source: Medical Care 1999; 37:1186
Note: Patients receiving specialist neurology care had 23% lower 1 year mortality
0.51
HMOs' Stroke Patients:
Fewer Go Home or to Rehab, More to Nursing Homes
Home
Rehab Unit
Nursing Home
segrahcsiD fo tnecreP
0%
10%
20%
16%
23%
30%
28%
40%
50%
42%
42%
49%
Medicare HMO
Source: JAMA 1997; 278:119
Medicare F-F-S
-hgiH gnisU stneitaP *GBAC fo %
slatipsoH ytilatroM
HMOs Push Heart Surgery Patients
to High-Mortality Hospitals
FFS
Private
FFS
Medicare
45%
49%
HMO
Private
HMO
Medicare
59%
64%
0%
20%
40%
60%
Source: JAMA 2000; 283:1976
*CABG = coronary artery bypass graft surgery
Depressed Patients:
Fee-for Service Vs. Managed Care
Fee-For-Service
Managed Care
53.7%
60.7%
41.8%
46.4%
1.3
1.2
1.5
2.0
Primary Care Patients
Depression Detected
Appropriately Treated
Patients Seeing Psychiatrist
# Functional Limitations - Baseline
# Functional Limitations - 2 Years
SOURCE: Medical Outcomes Study - JAMA 1989;262:3298 & Arch Gen Psych 1993; 50:517
Managed Mental Health: Audit Report
•
•
Plans overstated utilization by 45%
•
•
Plans rarely site-visited or interviewed providers
•
•
Quality problem in 30-58% of charts reviewed
•
Overhead + profit NEVER consumed < 45% of premiums
Delay from initial call to starting care > contractor's
written standard by 97%-347%
No providers in 15% of counties "covered"; no child
provider in 25% of counties
Criteria for inpatient care dangerously restrictive (eg.
requiring DTs prior to detox admit)
Source: J. Wrich - Audit findings submitted to CBO, 3/98
Primary Care Physicians: Patients Can't Get
Quality Mental Health Services
How often can you obtain high quality mental health
services for your patients?
Always/Almost
always
32%
Frequently
19%
Sometimes
29%
Never/rarely
20%
Source: Center for Studying Health System Change, 1997 - survey of 5,160 primary care physicians
Note - Data shown are for inpatient care; responses regarding outpatient care were similar
States that Limit New Heart Surgery
Programs: Higher Volumes, Lower
Mortality
Unnecessary Procedures
Seniors Without Drug Coverage
Forego Cardiac Medications
Out-of-Pocket Costs for Medicare
HMO Enrollees, 1999-2002
Can Seniors Make Informed HMO Choices?
Proportion with Knowledge of How HMOs Work
Inadequate
knowledge
59%
No
knowledge
30%
Source: AARP Survey - Health Affairs 1998; 17(6):181
Adequate
knowledge
11%
eracideM SFF fo % sa stsoc tneitapnI
Medicare HMOs:
The Healthy Go In, The Sick Go Out
FFS Medicare
Joining HMO*
Before
Leaving HMO**
After
0%
66%
50%
100%
100%
150%
200%
* Data are for 12 month period before joining HMO
** Data are for 3 month period after leaving HMO
Source: N Engl J Med 1997; 337:169
180%
For-Profit HMOs’
Increasing Dominance, 1985-2000
1985
1987
1989
1991
1993
1995
tnemllornE OMH fo %
0%
25%
50%
75%
100%
Non-profit
Source: Interstudy
For-profit
1997
1999
)tnecrep( etar egarevA
S
tia
fs
For-Profit
a
tc
i
no
IM
E
ax
sm
P
o
ts
E
y
e
re
S
em
a
sr
Not-For-Profit
vO
e
r
lla
iD
a
b
tie
c
lB
o
kc
P
pa
pa
h
y
el
r
s
oT
d
d
m
o
rg
aM
m
nu
i
z
de
m
I
m
eB
t
a
Investor-Owned HMOs
Provide Lower Quality Care
0
25
35
50
75
48
64
72
69
75
69
59
77
71
100
Source: Himmelstein, Woolhandler, Hellander & Wolfe - JAMA 1999; 282:159
54
62
“Productive” Physicians, Worse Care
"Fast"
:oitaR doohilekiL
stneitaP citebaiD rof gniredrO
Testing
HDL
"Slow"
Testing
Proteinuria
Referral
Ophthalmology
0
0.25
0.25
0.5
0.75
1
0.53
0.6
1
1
Physician Practice Style
Note: Fast physicians = those seeing more pts./hour than average
Slow Physicians = those seeing fewer pts./hour than average
Source: Arch Int Med 1999; 159:294
1
Doctors Urged to Shun the Sick
“[We can] no longer tolerate patients
with complex and expensive-to-treat
conditions being encouraged to
transfer to our group.”
-Letter to faculty from University of
California Irvine Hospital Chief
Source: Modern Healthcare, 9/21/95:172.
Corporate Social Responsibility?
“Few trends could so thoroughly undermine
the very foundations of our free society as
the acceptance by corporate officials of a
social responsibility other than to make as
much money for their shareholders as
possible.”
Milton Friedman, 1962
Source: Milton Friedman - Capitalism & Freedom, 1962.
Health Insurers' Tobacco Habit
Stock Holdings in 1999 - $ Millions
Prudential
MetLife/
Travelers
Cigna
RJ Reynolds
$137.2
-
-
Philip Morris
$435.2
$55.3
$38.6
Loews
(Kent etc.)
$319.6
$6.8
$4.1
Source: Boyd, Himmelstein & Woolhandler - JAMA 8/9/2000
Milliman & Robertson
Pediatric Length of Stay Guidelines
•
•
•
1 Day for Diabetic Coma
2 Days for Osteomyelitis
3 Days for Bacterial Meningitis
“They're outrageous. They’re dangerous. Kids
could die because of these guidelines.”
Thomas Cleary, M.D. Prof. of Pediatrics, U. Texas, Houston
Listed as "Contributing Author" in M&R manual
Source: Modern Healthcare May 8, 2000:34
Milliman & Robertson
“We do not base our guidelines on any
randomized clinical trials or other
controlled studies, nor do we study
outcomes before sharing the evidence
of most efficient practices with
colleagues.”
Wall Street Journal 7/1/98
Medicare Costs Rose Faster in
Communities with For-Profit Hospitals
atipac rep tsoc eracideM
1989
Non-profit
1989
For-profit
1995
Non-profit
$0
$5,148
$4,427
$1,000
$2,000
1995
For-profit
$3,990
$3,556
$3,000
$4,000
$5,000
$6,000
Hospital
Physician
Home Health
Note: For-profit=HSA with only for-profit hospitals (n=208)
Non-profit=HSA with only non-profit hospitals (n=2860)
Source: Silverman, Fisher & Skinner - NEJM 1999;341:420
Other Svcs
Why Are For-Profit Hospitals Costlier?
Higher Administrative and Non-Personnel Costs
yats latipsoh rep tsoC
$0
For-Profit
Profit
Not-For-
$8,115
$2,954
$7,490
$3,296
$2,872
$2,385
$2,500
$5,000
Public
$2,909
$6,507
$2,166
$1,432
$7,500
$10,000
$2,289
Clinical Personnel
$1,809
All Other Costs
Administration
Source: Woolhandler & Himmelstein - NEJM 3/13/97 - Analysis of data from 5201 acute care hospitals
Note: Costs are for FY 1994, adjusted for hospital case mix and local wages
fo tnecreP sA etaR htaeD detsujdA
slatipsoH tiforP-roF ta etaR
Death Rates are Higher
at For-Profit Hospitals
No Teaching
For-Profit
No Teaching
Non-Profit
Teaching*
Major
50%
75%
75%
93%
100%
100%
* 85.5% Non-Profit, 14.3% Government, 0.2% For-Profit
Source: NEJM 1999; 340:293
Death Rates Were Higher
at For-Profit Hospitals in 1989
tnecreP sA etaR htaeD detsujdA
slatipsoH tiforP-roF ta etaR fo
For-Profit
All Non-Profits
Teaching*
Non-Profit
50%
75%
89%
94%
100%
100%
*Member of Council of Teaching Hospitals
Source: NEJM 1989; 321:1720
VA Quality of Care for MI Patients:
Better than Other Hospitals
More Nurses, Fewer Complications
A Study of 589 Hospitals in 10 States
•
A 1 hour increase in RN hours/patient day was
associated with:
8.4% decrease in post-op pneumonia
5.2% decrease in post-op thrombosis
3.6% decrease in post-op pulmonary compromise
8.9% decrease in post-op UTIs
•
For-profit hospitals had higher rates of post-op
pneumonia, pulmonary compromise & UTI, even after
control for their lower RN staffing
Source: Kovner & Gergen - Image: J Nurs Schol 1998;30:315
Fewer Nurses, Worse Hospital
Outcomes
Nursing Home Staffing
Low Standards, Poor Working Conditions
•
Required: 1 RN - 8 hrs/day, 1 LPN - 24
hrs/day
•
RNs + LPNs = only 30% of nursing staff
•
Pay = 15-20% below hospitals
•
Turnover rates = 80-100%/year
Source: C. Harrington, UCSF - 1997
For-Profit Dialysis:
More Deaths, Fewer Transplants
Death Rate
Referred to Transplant
0%
5%
5%
7%
10%
15%
17%
20%
25%
21%
For-Profit
Non-Profit
Note: Figures are adjusted for demographic factors and co-morbidities
Source: NEJM 1999; 341:1653
For Profit Dialysis For Children:
Less Use of Peritoneal Dialysis
.sv tiforP-roF ,esU DP rof oitaR sddO
tiforP-noN
Unadjusted
Adjusted
0
1
2
2.2
3
4
Source: Pediatrics 104:519
2.9
End Stage Renal Disease Care
85% of U.S. Providers are For-Profit,
Outcomes are Worse than Canada's
•
U.S. death rates for dialysis patients are 47%
higher after control for age, sex, race & comorbidities
•
Canadians get more transplants (35% vs. 17%)
•
57% of U.S. patients were treated with reprocessed
dialyzers, 0% in Canada
•
Costs lower in Canada by $503/patient/month
•
Fresenius (a German firm) controls 24% of U.S.
market; profit = $225/patient/month
Source: Med Care 1997; 35:686 & Fresenius SEC filings, 2000
Investor-Owned Care
Summary of Evidence
•
•
•
•
•
Hospitals: Costs 3%-11% higher, fewer nurses,
higher overhead, death rates 6%-7% higher,
fraud
HMOs: Higher overhead, worse quality,
collaboration with tobacco industry
Dialysis: Death rates 20% higher, less use of
transplants & peritoneal dialysis, fraud
Nursing Homes: More citations for poor quality,
fraud
Rehab Hospitals: Costs 19% higher
Crime Pays: CEOs Who Cook the
Books Earn More
U.S. Seniors Paying More for Ten
Top Selling Drugs*
Vermont
Canada
Mexico
$129.33
$75.54
$69.35
Source: U.S. GAO – www.house.gov/bernie/legislation/pharmbill/international.html
*Zocor, Ticlid, Prilosec, Relafen, Procardia XL, Zoloft, Vasotec, Norvasc, Fosamax, Cardizem CD
Millions Can’t Afford Prescriptions
Drug Firms Avoid Taxes
U.S. Taxes as a Percent of Total Income
yrtsudnI
Utilities
Transport/
33%
Services
28%
Construction
28%
23%
Manufacturing
All Industries
Drug Firms
27%
16%
Source: Congressional Research Service, 12/13/1999
Note: Figures are industry-wide averages for 1993-1996
Drug Company Marketing, 19962001
Drug Company Sponsored Miseducation
•
•
•
•
•
Spending for drug promotion (>$10 billion/yr.)
exceeds total medical student teaching costs
The average MD meets with one of the 56,000
drug reps once a week
Attending drug company-sponsored CME
predicts worse prescribing
11% of drug reps’ factual claims are false (all
favorable) - 26% of MDs recognize even one
falsehood
30% of journal drug ads falsely claim "drug of
choice", 40% omit key side effect info
Source: JAMA 283:373 & 273:1296, Ann Int Med 116:919, and www.nofreelunch.org
Percent of Population with
Government-Assured Insurance
U.S.
Germany France
Canada Australia
Japan
U.K.
100%
100%
0%
20%
40%
45%
60%
80%
100%
92%
100%
100%
100%
Note: Germany does not require coverage for high-income persons, but virtually all buy coverage
Source: OECD, 2002 - Data are for 2000 or most recent year available
Federal Tax Subsidies for
Private Health Spending, 1998
ylimaF reP ydisbuS xaT
emocnI yB
$0
$500
$1000
$1500
$2000
$2500
$3000
$71
$296
K0
$>
1
0
K0
57
01
75
K
K
$
5
0
$
04
05
40
K
K
$535
Note: Total federal tax subsidy = $111.2 billion
Source: Health Affairs 1999; 18(2):176
$
3
0
$
02
03
K
51
02
K5
1$
<
$
$
Family Income
$847
$1195
$1684
$1971
$2357
ynamreG
15.9%
16.0%
16.4%
napaJ
.K.U
12.1%
ecnarF
12.5%
adanaC
ailartsuA
0%
.S.U
56 nahT redlO noitalupoP fo tnecreP
Elderly as Percent of Total Population, 2000
5%
10%
15%
20%
Source: Health Affairs 2000; 19(3):192
12.8%
17.1%
tahwemos ro yrev ,ylemertxe ti gnidnif %
dedeen nehw erac teg ot tluciffid
Difficulties Getting Needed Care
N
ew
U
.S
.
C
an
ad
a
Ze
al
an
d
Au
s
tra
lia
U
.K
.
0
5
10
15
15
20
18
21
25
30
28
35
Source: Commonwealth Fund Survey, 1998
15
rotcod emas htiw tnecreP
sraey 5 naht erom
.U
K
.
uA
s
rt
a
l
ai
C
a
an
d
a
eZ
a
l
a
dn
.U
S
.
eN
w
Continuity of Care
0%
20%
40%
45%
52%
60%
Source: Commonwealth Fund Survey, 1998
57%
59%
59%
Medical Journal Articles per Capita
Minimum Standards For Canada's
Provincial Programs
1. Universal coverage that does not impede, either
directly or indirectly, whether by charges or
otherwise, reasonable access.
2. Portability of benefits from province to province
3. Coverage for all medically necessary services
4. Publicly administered, non-profit program
% Of People With Serious Sx Seeing A Doctor
Before And After Passage Of NHP In Quebec
TISIV ROTCOD HTIW %
BEFORE NHP
Source: NEJM 1973; 289:1174
1 YEAR AFTER NHP
62%
73%
Infant Mortality
Infant Deaths by Income, Canada 1996
Even the Poor Do Better than U.S. Average
9
8
7
6
5
4
3
2
1
0
7.8
6.5
4.7
5.1
5.2
3.9
Wealthiest
20%
Middle
20%
Poorest U.S.
20% Average
Depression Management: Better in Canada
Saw Professional
Appropriate Care*
0%
7%
15%
20%
31%
40%
55%
60%
U.S.
* Antidepressant prescribed + 4 or more visits
Source: JGIM 1998; 13:77
Canada
Waits for Publicly-Paid Cataract Surgery, Manitoba
Longer When Public
Surgeon
Also Operates
Privately
Both Public & Private
Sector Only
1992
1993
1994
noitatlusnoc tsrif morf skeeW
yregrus ot
0
10
20
Surgeon Operates in:
Source: Medical Care 1999; 37(6-supplement):JS187
1995
1996
Physician Services For The Elderly:
Canadians Get More of Most Kinds of Care
All Services
Management
Evaluation/
Procedures
Tests
etaR .S.U/etaR naidanaC
0
0.5
0.75
1
1.17
1.5
2
Source: JAMA 1996; 275:1410
1.18
1.44
Applicants per Medical School Place
6.0
5.5
5.0
4.0
3.0
2.0
2.4
1.0
0.0
United States
: JAMA; 282:892; Canadian Medical Education Statistics, 1999:150
Canada
Few Canadian Physicians Emigrate
What's OK in Canada? Compared to the U.S….
•
Life expectancy 2 years longer
•
Infant deaths 25% lower
•
Universal comprehensive coverage
•
More MD visits, hospital care; less bureaucracy
•
Quality of care equivalent to insured Americans’
•
Free choice of doctor/hospital
•
Health spending half U.S. level
Who Pays For Canada's NHP?
Province Of Alberta
erahS/stnemyaP htlaeH fo erahS
emocnI fo
FAMILY INCOME
15,000
25,000
0.74
0.77
35,000
50,000
75,000
100 K
125 K
1.3
1.3
0
0.5
1
0.85
1
1.2
1.5
2
Source: Premier's Common Future Of Health, Excludes Out-of-Pocket Costs
Who Pays For Health Care?
Regressivity Of U.S. Health Financing
INCOME DECILE
fo erahS/stnemyaP htlaeH fo erahS
emocnI
POOREST
0
RICHEST
0.5
0.64
1
1.15
1.31 1.27 1.23
1.5
1.75
2
2.5
3
3
3.5
Source: Oxford Rev Econ Pol 1989;5(1):89
1.1
1.07 0.99
Employers’ Health Benefit Costs US
vs. Canada
Number of Insurance Products
Private insurers’ High Overhead
The Healthcare Americans 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 Healthcare Americans Want
•
Guaranteed access
•
Free choice of doctor
•
High quality
•
Affordability
•
Trust and respect
How Do We Know It Can Be Done?
•
•
•
Every other industrialized nation has a
healthcare system that assures medical care
for all
All spend less than we do; most spend less
than half
Most have lower death rates, more
accountability, and higher satisfaction
We Have What it Takes
•
Excellent hospitals, empty beds
•
Enough well-trained professionals
•
Superb research
•
Current spending is sufficient
Medical Savings Accounts: No Savings
•
•
•
•
•
Sickest 10% of Americans use 72% of care. MSA's
cannot lower these catastrophic costs
The 15% of people who get no care would get
premium “refunds”, removing their cross-subsidy for
the sick but not lowering use or cost
Discourages prevention
Complex to administer - insurers have to keep track
of all out-of-pocket payments
Congressional Budget Office projects that MSAs
would increase Medicare costs by $2 billion.
What's Wrong with
Tax Subsidies and Vouchers?
• Taxes go to wasteful private insurers, overhead
•
•
•
•
•
>13%
Amounts too low for good coverage, especially for
the sick
High costs for little coverage - much of subsidy
replaces employer-paid coverage
Encourages shift from employer-based to individual
policies with overhead of 35% or more
Costs continue to rise (e.g. FEHBP)
Many are unable to purchase wisely - e.g. frail
elders, severely ill, poor literacy
Non-Group Plans, High Overhead
Insurers
Life/Health
Insurers
Hospital/Med
rof smuimerP fo tnecreP
daehrevO
0%
10%
20%
13%
17%
30%
40%
35%
40%
50%
Group
Source: J Health Policy, Pol & Law 2000;25:19
Non-Group
Vouchers by Any Other Name…
Harris Poll: “Government Should Provide
Quality Medical Coverage to All Adults . . .”
Public
General
Employers
Legislators
State
Aides
Congressional
0%
gnieerga tnecreP
20%
40%
53%
60%
80%
77%
Source: USA Today/Harris Poll - 11/23/98
52%
47%
Even Many Small Business Owners
Favor NHI
Wealth Buys Political Power
•
The 107,000 residents of zip code 10021 gave $1.5 million to
1999 presidential campaigns, and $9.3 million to 1996
congressional races
•
The residents of New Hampshire gave $333,000 to
presidential candidates in 1999
•
The 9.5 million people in communities that are > 90%
minority gave $5.5 million in 1996 congressional races
•
In 1996, 91% of Congressional races were won by the
candidate who spent the most
•
Since 1984, the candidate with the most money on
January 1 of the election year always wins his party’s
nomination
Source: www.publicampaign.org;
Who Votes? Voter Turnout by
Income, 2000
56% of Medical Students & Faculty
Favor Single Payer,
Majority of Med School Deans Concur
“What is the best health care system for the most people?”
56%
22%
3%
19%
Managed Care
No Preference
Source: NEJM 1999; 340:928
Single Payer
Fee-for-service