The greatest enemy of the truth is very often not the lie--deliberate, contrived, and dishonest, but the myth -- persistent, persuasive, and unrealistic.Belief in myths allows the comfort of opinion without the discomfort of thought. John F. Kennedy
National Story: Healthcare Spending Crisis• “Health spending will hit $2.5 trillion this year• “devouring 17.6 percent of the economy• “The United States spends more on healthcare than any other country• “but its system is widely considered inefﬁcient and it lags many other nations in key quality measures” Reuters, Feb 24, 2009
Oregon Story: 57 Y F in extremis• ED: lethargy, high pCO2, large pleural effusion• ICU: Stabilized, improved, extubated• able to provide Past History: • Noted breast lump months before • Spouse lost job, waited for insurance • Seen in clinic, mammogram ordered• Dx: Malignant effusion, Metastatic breast cancer
Myth Number 10 We have the best healthcare system in the world.
1 Japan 75 3 Sweden 73.3 4 Switzerland 73.2 7 Italy 72.7 8 Australia 72.6 9 Spain 72.6 11 Canada 72 12 France 72 13 Norway 72Health Adjusted 14 16 Germany Austria 71.8 71.4Life Expectancy 17 19 Israel Netherlands 71.4 71.22002 WHO data 20 Belgium 71.1 22 Greece 71 23 New Zealand 70.8 24 United Kingdom 70.6 26 Denmark 69.8 27 Ireland 69.8 28 Slovenia 69.5 29 United States of America 69.3 32 Cuba 68.3 33 Republic of Korea 67.8
Myth Number 9 It’s their fault -Uninsured are different from you & me.
“They” Are You and Me, Typical Americans• 50 million Americans • 1 in 6 Oregonians • ages 19-30 • ~10 M children• 80% employed • $20,000 - $60,000/yr • self employed, service sector, small business • outsourced middle aged couples
Myth Number 9 b It’s our faultOur lifestyle and diversity are the problem
Not smoking, obesity, homicide, diversity or statistical artifact Exhibit 1Per Capita Health Spending And 15-Year Survival For 45-Year-Old Women, United States And 12 Comparison Countries,1975 And 2005 US Thousands of dollars Switzerland Belgium Canada Austria Netherlands France Sweden Australia UK Japan US Switzerland Canada Australia Sweden Austria France Netherlands UK Belgium JapanSOURCE Authors’ analysis based on data from the sources described in the text. NOTES The dashed line separates 1975 values (bluecircles) and 2005 values (red squares). Values are presented for the percentage of forty-five-year-old women surviving fifteen years.
Myth Number 8 Safety Net CareEqual access to quality care for people without insurance
No Prenatal Care for 11% Why not? 31% No money or insurance47% Unable to get appointment Other reason 22% MMWR 5/12/2000; 49:393
More Deaths Among Uninsured With Trauma• 174,921 kids National Trauma Data Bank• Controlled for injury, severity, age, race, type of hospital• Uninsured kids: 2.97 times higher deaths• Medicaid kids: 1.19 times higher deaths
No Insurance Means Poor Outcomes• up to 1.25x higher mortality overall• up to 3.2 x higher in-hospital mortality• delays in Dx of colon cancer, melanoma• poorer outcomes for breast cancer• avoidable admissions for asthma, bleeding ulcers, diabetes, etc.• up to 3x more likely to have adverse outcomes
Some Major Public Health ProblemsDiabetes 72449Inﬂuenza, pneumonia 56326Colon cancer 50610Second hand smoke ~50000No insurance 44840Breast cancer 40470Trafﬁc deaths 37261Prostate cancer 26328
Myth Number 7Our system is good forpeople with insurance
Already ☠ 1 in 3 with insurance defer needed care now Schoen, Health Aﬀairs 6/10/08 slide: PNHP IN/Rob Stone
SmallBusiness Climate:Unhealthy John Schmitt and Nathan Lane, Center for Economic and Policy Research
Strikes and Layoffs in HeadlinesPay, health care keep strike goingSanta Cruz Sentinel, CA …issues keeping the two sides from reaching adeal, namely health care beneﬁts ...Strike looms, teachers consider pay, health beneﬁtsBurlingtonFreePress.com,VT …Questions about health care costs andcoverage have emerged as a hugeTWU threatens strike over health care $philly.com, PA ...ready to strike because the health planMachinists Union Strike for Pensions and Health ...Emediawire WA Union members voted to strike ... Their votecentered on issues of pensions, health care and job security. ...
Myth Number 5Our system is good for health professionals
Doctors Urged to Turn Away the Very Sickest “[We can] no longer tolerate patients with complex and expensive-to-treat conditions being encouraged to transfer to our group.” -letter to faculty from academic hospital chiefSource: Modern Healthcare, 9/21/95:172.
37 Number of Practicing Physicians per 1,000 Population, 2007 4 3 2 1 0 NETH NOR SWITZ ITA SWE* GER FR OECD MedianAUS* UK US NZ CAN THE COMMONWEALTH* 2006 FUNDSource: OECD Health Data 2009 (June 2009).
38 Average Annual Number of Physician Visits per Capita, 2007864 7.5 7.0 6.3 6.3 6.3 5.8 5.7 5.0 4.72 4.0 3.8 2.80 GER ITA** AUS FR OECD MedianCAN* NETH UK NZ SWITZ US* SWE** 2006 THE COMMONWEALTH** 2005 FUNDSource: OECD Health Data 2009 (June 2009).
39 Hospital Discharges per 1,000 Population, 2007300225150 75 0 FR GER NOR SWITZ SWEOECD MedianAUS* ITA* NZ US* UK NETH CAN* THE COMMONWEALTH* 2006 FUNDSource: OECD Health Data 2009 (June 2009).
40 Average Length of Hospital Stay for Acute Myocardial Infarction, 2007 Days12 9 6 3 0 GER UK ITA* SWITZ NETH OECD Median CAN* FR AUS* US* SWE NOR THE COMMONWEALTH* 2006 FUNDSource: OECD Health Data 2009 (June 2009).
41 Hospital Spending per Discharge, 2007 Adjusted for Differences in Cost of Living Dollars 18,000 16,000 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0 US* CAN* NETH SWITZ NOR* SWE NZ OECD Median AUS* FR GER THE COMMONWEALTH* 2006 FUNDSource: OECD Health Data 2009 (June 2009).
NIH Clinical Research GrantsFall in High Managed Care Areas Managed Care Penetration Low Medium HighNumber of grants relative to 1986 1.300 1.175 1.050 0.925 0.800 1986 1988 1990 1992 1994 Source: Moy et al. JAMA 1997; 278:217
Innovation: Published Research Leading to Drugs 15% 55% 30% Drug Companies Foreign labs NIH Funded LabsSources: Internal NIH document available from Public Citizen;also Zinner, Health Affairs, Sept-Oct 2001; also Boston Globe 4/5/98 slide: PNHP/Marcia Angell
Managed Care Drives Out Charity CareHMO Penetration in Region Low Medium High 13 Hours of Charity Care/Month 11 9 7 5 3 0% 1-20% 21-40% 41-60% 61-84% >84% % of Practice Revenue from Managed Care
Myth Number 3We can’t afford to cover everyone
Health Care Expenditures Per Capita, Adjusted for Diﬀerences in Cost of Living $7,000 Out-of-Pocket Spending Private Spending $6,000 Out-of-Pocket Spending Public Spending $5,000 $2,572 $4,000 $803 $3,000 $483 $444 $342 $354 $239 $906 $313 $472 $370 $148 $582 $28 $396 $2,000 $238 $389 $113 $359 $2,727 $2,475 $2,350 $2,210 $2,176 $1,000 $1,894 $1,940 $1,917 $1,832 $1,611 $0 United States Canada France Netherlands Germany AustraliaUnited Kingdom OECD Median Japan New ZealandSource: The Commonwealth Fund, calculated from OECD Health Data 2006. slide: PNHP IN/Rob Stone
Myth Number 1 “It’s a Non Starter”There’s No Support for a Single Payer
Public Support – Single Payer ☤ 49% favor coverage from a single govt. plan1 ☤ 59% prefer a system like Medicare for all 2 ☤ 59% say government should provide na?onal health insurance 3Polls from 20091 April, Kaiser Family FoundaJon2 January, Grove Insight Opinion Research3January, New York Times/CBS News slide: PNHP IN/Rob Stone
“In principle, do you support or oppose government legislation to establish national health insurance?” Ann Intern Med 2008;148:566-567
Single-Payer: “Politically Feasible?” Other “Politically Infeasible” Movements Abolition of Human Slavery (1860s) Women’s Suffrage Movement (1840-1920) Civil Rights Act (1964) slide: PNHP Nick Skala
Expensive, Inefﬁcient, Inequitable• No system in the industrialized world is as heavily commercialized, and none is as expensive, inefﬁcient, and inequitable• In short, the U. S. experience has shown that private markets and commercial competition have made things worse, not better, for our health care system. Arnold S. Relman, MD
Goals• Health care for every American no exceptions, cradle to grave.• Free choice of doctors and hospitals like Medicare patients have• Patients and doctors make care decisions not in the backroom or the board room• Health policy is public policy with accountability and transparency.• No one goes bankrupt because of illness not patients, not businesses, not governments
Do we keep rearranging thedeck chairs on the Titanic?
"...the greatest tragedy of this period … was not the strident clamor of the badbut the appalling silence of the good people” Dr. Martin Luther King Jr.
What can we do?Nobody can doeverything,buteverybody cando something Gil Scott-Heron
Primary Care & PPACA• Greater need • Workforce expansion • 32 million new insured • fund residencies (favor track • need for prevention, record primary care) continuity, coordination • loans for 10 y promise• Inadequate supply • Payment reform • 30% of MDs (vs 50-60%) • RBRVS reform (10% increase) • 30-60% lower salaries • Medicaid/Medicare increase • greater workload • New models of care • diminishing resources • Patient centered medical home • Accountable care organization
Current bills like unecessary surgery “We have to do something”• Access? No. Millions still uninsured, thousands will die because of no access• Choice? No. Insurance companies choose who you see, what you can get, how much you pay• Affordability: No. Billing and claims waste unchanged. Prices still set to guarantee big insurance proﬁt. Bankruptcies persist for individuals, businesses, governments
Current Bills Fail to Improve• Portability?No. You still lose insurance when you change jobs, get laid off, etc. Discontinuity -> poor outcomes• Accountability? No. Health policy set by big insurance in private. No accountability, no transparency, no recourse• Quality? No. Continues tweaking system that’s been failing for decades