Healthcare Reform: Is It Necessary? Subroto Kundu, M.D. Consultant Neurologist SF Bay Area
Public Opinion is often a mish-mash of misconceptions and myths.. (…and then there is Fox News)
Tally of Assets
Let us look at what are our strengths and weaknesses…
What is Right with our System?
Excellent hospitals, equipment, and health care facilities
Enough well trained professionals
What is Wrong with our System ? We spend far more money than any other country on health care... … but get far fewer benefits, far worse health outcomes, and far less patient satisfaction.
The Healthcare Americans Want
Free choice of doctor
Trust and respect
The Healthcare Americans Get
1/3 are uninsured or underinsured
HMOs deny care to millions
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
Approaching these myths with appropriate scientific validation is not hard to do….
Myth #1: We Have The Best Health Care System In The World
Just the facts, please
45 Million Uninsured
Who Are The Uninsured? Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS *Students>18, Homemakers, Disabled, Early retirees
*Out of labor
Maternal Mortality 1999
Infant Mortality, 1999 Deaths In First Year Of Life/1000 Live Births Source: OECD, 2002 5.7 5.3 5.1 4.5 4.3 3.4 7.1 0 1 2 3 4 5 6 7 8 U.S. AUSTRALIA CANADA ITALY GERMANY FRANCE SWEDEN
Life Expectancy For Women, 1999 Source: OECD, 2002 - Data on Italy are for 1998 82 80.7 82.5 79.8 81.6 81.7 79.4 77 78 79 80 81 82 83 U.S . U.K. GERMANY I TALY CANADA SWEDEN FRANCE YEARS
Life Expectancy For Men, 1999 Source: OECD, 2002 - Data for Italy are for 1998 74.7 75 75 75.3 76.3 76.7 73.9 70 71 72 73 74 75 76 77 78 U.S. GERMANY FRANCE UK ITALY CANADA SWEDEN YEARS
Hospital Inpatient Days Per Capita, 2000 Source: OECD, 2002 1.1 1.2 2.4 2.6 2.7 4 0.8 0 1 2 3 4 U.S. Canada U.K. France Australia Germany Japan Days/person
Consider Associated Statistics…..
Poverty Rates, 1997 U.S. and Other Industrialized Nations Source: Luxembourg Income Study Working Papers Note: U.S. figure for 1997, other nations most recent available year 6% 8% 9% 11% 11% 11% 17% 0% 5% 10% 15% 20% Netherlands France Sweden Canada UK Germany US % of Population Below Poverty Level
Americans Lead the World in Hours Worked Source: International Labor Organization, 1999 1399 1560 1656 1731 1889 1883 1966 0 250 500 750 1000 1250 1500 1750 2000 Norway Germany France U.K. Japan U.S. (1980) U.S. (1997) Hours/worker-year - 1997
Incarceration Rates, 2000
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
Myth #1: We Have The Best Health Care System In The World
Certainly does not seem like the best, does it?
Myth #2: We Don’t Have the Money to Cover Everyone
Health Care Spending
2009 value: $2.5 trillion !! (17.6% of GDP)
2018 projection: $4.4 trillion
Source: National Coalition on Health Care www.nchc.org
HEALTH COSTS AS % OF GNP: U.S. & CANADA, 1960-2001 CANADA'S NHP ENACTED NHP FULLY IMPLEMENTED Source: Statistics Canada, Canadian Inst. for Health Info., & NCHS/Commerce Dept 5 6 7 8 9 10 11 12 13 14 15 1960 1965 1970 1975 1980 1985 1990 1995 2000 % of GNP CANADA U.S.
Myth # 3: Government Is Less Efficient Than the Private Sector
Overhead & Profit As Percent of Premium
Private insurers’ High Overhead
Medicare Coverage is Better than Private
Healthcare Cradle to Grave… Productive years 90% of healthcare expenditure done in last 10% of life Medicare: government spending Healthiest portion of life least healthcare spending HMO/PPO Spending Only earning period of life Highest contribution to healthcare 25 65
services Patients Medical Providers Pvt Health Insurance payment payment Auto Insurance Workmens Compensation Home Owners Insurance Misc Health Insurance payment payment payment payment MediCare MediCaid
So, what would you say to a plan that reduced the multiple payments with a single coverage…
services Patients Medical Providers payment payment Single Insurance Payer Specially one with 3.1% overhead And no profit
56% of Medical Students & Faculty Favor Single Payer, Med School Deans Source: NEJM 1999; 340:928 “ What is the best health care system for the most people?”
Harris Poll: “Government Should Provide Quality Medical Coverage to All Adults . . .” Source: USA Today/Harris Poll - 11/23/98 77% 53% 52% 47% 0% 20% 40% 60% 80% General Public Employers State Legislators Congressional Aides Percent agreeing
Since everyone is covered in this system, there are no: --“Pre-existing conditions” --“loss of coverage” e.g., by change of job, moving --and multiple other ills of the present system
Myth #4: Single Payer Means Single Delivery System
Myth #5: We Will Have Rationing “Like They Have in Canada”
We do have “rationing” already. We only recognize them differently, such as by limited access to healthcare, denials by insurance companies, high cost
Access is already restricted!
1 of 5 Americans postponed getting needed health care last year
1 of 7 Americans had a problem paying for medical bills last year
1 of 10 did not get a prescription drug they needed due to cost Kaiser Commission on Medicaid and the Uninsured, July 2002
U.S. Public Spending Per Capita for Health is Greater than Total Spending in Other Nations Note: Public includes benefit costs for govt. employees & tax subsidy for private insurance Source: NEJM 1999; 340:109; Health Aff 2000; 19(3):150 $1,670 $1,750 $1,850 $2,230 $2,430 $2,620 $1,760 $2,600 $0 $1,000 $2,000 $3,000 $4,000 $5,000 U.K. Sweden Japan France Canada Germany U.S. $ Per Capita Total Spending U.S. Public U.S. Private
Out-of-Pocket Payments, 2000
Myth # 6: It is Bad for Business
Employers’ Health Benefit Costs US vs. Canada
Healthcare cost to US businesses…
Myth # 7: Our population is older than the rest of the world
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. Australia Canada France U.K. Germany Japan Percent of Population Older Than 65
Infant Deaths by Income, Canada 1996 Even the Poor Do Better than U.S. Average
MYTH # 8: Doctors will leave “ DOCTORS ARE LEAVING CANADA IN DROVES FOR THE PROMISED LAND OF THE USA”
Few Canadian Physicians Emigrate
Applicants per Medical School Place Source: JAMA; 282:892; Canadian Medical Education Statistics, 1999:150
Myth # 9: We Don’t Want All That Government Intrusion Instead, We Now Have Private Sector Intrusion
The Administrative Nightmare $384 Billion Spent on Administrative Costs Last Year. Saving Half of This Would Easily Cover the Uninsured
Physicians' Billing & Office Expenses United States & Canada, 2000 Source:Woolhandler/Himmelstein NEJM 1991;324:1253 (updated) $430 $102 $0 $100 $200 $300 $400 $500 U.S. CANADA $ PER CAPITA
Hospital Billing & Administration United States & Canada, 2000 Source: Woolhandler/Himmelstein NEJM 1991; 324:1253 & 1993; 329:400 (updated) $372 $68 $0 $100 $200 $300 $400 $500 U.S. CANADA $ PER CAPITA
Growth of Physicians, RNs & Administrators 1970-1998 Bureau of Labor Statistics, NCHS Percentage Growth
Do you want your health care dollars spent Here or Here?
What are the options?
No intervention … maintain status quo
Reform health care market.
Expand public programs.
Improve the employer approach (pay or play).
The Single Payer System
What do we get from Single-Payer?
Administrative efficiency via simplified reimbursement.
Patient freedom to choose/change health care providers, without paying more.
Provider freedom to choose mode of practice (fee-for-service, capitation, or salary).
Fairer financing (lower cost to sick, poor/middle-income).
Explicitness in priorities (e.g., prevention) and financing (e.g., risk adjustment)
Shared dedication to success , via universal participation.
How Does Single-Payer Do It?
Global Budgeting controls costs while leaving clinical decision-making in the hands of the patient’s chosen health care professional.
Just collects money and pays bills without needing to intrude into individual doctor-patient relationships to make a profit.
That is, review the flow of healthcare dollars, but leave HEALTHCARE alone!
Eliminates hidden sources of waste and profiteering
NO NEED TO REINVENT THE WHEEL
THAT IS HOW ALL THE INDUSTRIALIZED NATIONS OF THE WORLD DO IT !!
Who Benefits from the Single Payer System? You do!! And do all providers who are not paid for their services, but look towards their “HMO” kickbacks
Who Loses from the Single Payer System? The Insurance Company and its brokers!! Money Managers