The Business of Health Care Reform: What's Here? What's Missing? What's Next
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The document discusses the current state of healthcare in the United States and proposals for reform. It begins by outlining various metrics where the US lags behind other developed nations such as life expectancy, healthcare spending, obesity rates, and access to care. It then summarizes key provisions and impacts of the Affordable Care Act but notes it did not address the root problems with the system. Finally, it outlines the proposal for a single-payer "Medicare for All" system as established in HR 676, including its benefits and projected cost savings compared to the current multi-payer approach.
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The Business of Health Care Reform: What's Here? What's Missing? What's Next
- 1. The Business of Health Care Reform: What’s Here? What’s Missing? What’s Next? Tom Lieb, MD Ed Weisbart, MD
- 2. Projected data for 2013 CIA World Fact Book Accessed Dec 3 2013 74 76 78 80 82 84 86 UnitedStates Guam Portugal Denmark Gibraltar SaintHelena+ PuertoRico WallisandFutuna CaicosIslands Finland Korea,South VirginIslands Taiwan Belgium EuropeanUnion Luxembourg Malta FaroeIslands Austria SaintPierre+ Greece UnitedKingdom Jordan Germany Ireland Norway NewZealand IsleofMan CaymanIslands Bermuda Netherlands Anguilla Iceland Israel Sweden Spain France Canada Jersey Liechtenstein Italy Australia HongKong Switzerland Guernsey Andorra SanMarino Singapore Japan Macau LifeExpectancyatbirth Guernsey Switzerland Hong Kong Australia Italy Liechtenstein Canada Jersey France Spain Sweden Israel Iceland Anguilla Netherlands Bermuda Cayman Islands Isle of Man New Zealand Ireland Norway Germany Jordan United Kingdom Greece Saint Pierre+ Austria Malta We’re Number 51 in Life Expectancy
- 3. We Spend More Than Double Most Other Modern Nations Data are for 2011 Sources: OECD 2013; Health Affairs 2002 21(4)88 $2,940 $3,280 $3,140 $3,970 $4,350 $4,780 $5,749 $3,201 $- $2,000 $4,000 $6,000 $8,000 $10,000 Total US Public US Private 2011healthcarespendingpercapita $8,950Our taxes already more than pay for universal care anywhere else in the world.
- 4. We’re Not Very Old Percent of population over age 64 Note: Data are for 2012 or most recent year available Source: OECD, 2013 0% 5% 10% 15% 20% 25% USA CAN UK FRA SWE GER ITA JAP Japan is much older but spends one third what we spend
- 5. We’re Not Big Smokers 0% 5% 10% 15% 20% 25% 30% 35% Sweden Iceland UnitedStates Australia Canada Luxembourg Norway Finland NewZealand Israel Portugal Slovenia Mexico SlovakRepublic UnitedKingdom Denmark Japan Switzerland Belgium Netherlands Germany Italy Austria Korea France Poland Spain CzechRepublic Turkey Estonia Hungary Ireland Chile Greece Percent of population ages 15+ smoking daily USA: 14.8% Missouri: 25% of adults Note: Data are for 2012 or most recent year available Source: OECD, 2013
- 6. We Are Obese 0% 10% 20% 30% 40% Percent of population with BMI above 30 Self-reported data for 2012 or most recent year available Source: OECD, 2013
- 7. We Have Plenty of Technology 0 20 40 60 80 100 USA GRE TUR GER LUX ICE BEL SPA DEN FRA AUST CAN NET EST UK CZE SLO HUN POR AUSL ISR IRE KOR POL CHIL MRI exams per 1,000 people Note: Data are for 2011 or most recent year available OECD Data Accessed Nov 28 2013
- 8. We Have the Best Cancer Outcomes http://www.cancer.org/acs/groups/content/@epidemiologysurveil ance/documents/document/acspc-027766.pdf accessed Nov 28, 2013 5-Year survival, all cancer types 0% 10% 20% 30% 40% 50% 60% 70% USA SWI BELG GMN SPN UK SLOV
- 9. We Have Nearly the Worst Infant Mortality Rates 0 2 4 6 8 10 Turkey Chile UnitedStates NewZealand Canada Hungary SlovakRepublic Poland Luxembourg UnitedKingdom Australia Switzerland Austria Denmark Germany Netherlands France Ireland Israel Greece Italy Belgium Spain Portugal Korea Slovenia CzechRepublic Estonia Finland Norway Japan Sweden Deaths in first year of life per 1,000 live births Note: Data are for 2011 or most recent year available OECD Data Accessed Nov 28 2013
- 10. Note: Data are for 2009 or most recent year available Source: OECD, 2011 We Have the Worst Maternal Mortality Rates 0 2 4 6 8 10 12 14 USA UK CAN FRA GMN Australia Deaths per 100,000 live births
- 11. We Have Rapid Access to Elective Surgery 0% 5% 10% 15% 20% 25% 30% NET FRA SWI USA NZ ASTL NOR UK SWE CA Adults who needed elective surgery and waited at least 4 months http://www.commonwealthfund.org/~/media/Files/Publicatio ns/Fund%20Report/2012/Nov/1645_Squires_intl_profiles_hl t_care_systems_2012.pdf 2010-2012 data, report Dec 2012, accessed Nov 28 2013
- 12. We Don’t Go to the Doctor Much 0 2 4 6 8 10 12 14 MEX NEZ SWE CHI IRE USA GRE SWI POR FIN DEN UK NOR CAN EST LUX ISR ICE SLV ATL NET POL FRA AUS ITA TUR SPN BEL GER CZE SLO HUN KOR JAP Physician visits per capita http://www.commonwealthfund.org/~/media/Files/Publicatio ns/Fund%20Report/2012/Nov/1645_Squires_intl_profiles_hl t_care_systems_2012.pdf 2010-2012 data, report Dec 2012, accessed Nov 28 2013
- 13. We Don’t Have Very Many Doctors 0 1 2 3 4 CHI TUR KOR MEX POL JAP CAN SLO USA NZD UK LUX HUN BEL NET ATRL IRE EST FIN FRA SVK DN ISR CZE ICE ITA GER SPA SWE SWI PTG Practicing physicians per 1,000 people http://www.commonwealthfund.org/~/media/Files/Publicatio ns/Fund%20Report/2012/Nov/1645_Squires_intl_profiles_hl t_care_systems_2012.pdf 2010-2012 data, report Dec 2012, accessed Nov 28 2013
- 14. We Have Plenty of Administrators Data updated through 2013 Source: Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of CPS GrowthSince1970 Physicians Administrators 3000% 2500% 2000% 1500% 1000% 500% 0 1970 1980 1990 2000 2010
- 15. We Waste 31% of Our Healthcare Dollar Medical overhead, administration, and insurance profits Medical care 31% 69% Woolhandler, et al “Costs of Health Administration in the U.S. and Canada,” NEJM 349(8) Sept. 21, 2003
- 16. We’re Insured, But Not Very Well Uninsured 84% have insurance 16% Commonwealth Fund, Sept. 8, 2011 2012 Biennial Health Insurance Survey
- 17. We’re Insured, But Not Very Well Uninsured Adequately insured (Spend under 10% on healthcare) Under-Insured (Spend more than 10% on healthcare) 54% 16% 30% Commonwealth Fund, Sept. 8, 2011 2012 Biennial Health Insurance Survey
- 18. Deductibles Began Rising Long Before the ACA 10% 12% 18% 22% 27% 31% 34% 38% 0% 10% 20% 30% 40% 2006 2007 2008 2009 2010 2011 2012 2013 Kaiser/HRET Survey of Employer-Sponsored Benefits, 2013 Percent of workers with deductibles >$1,000
- 19. Under-Insurance Drives Bankruptcies Source: Himmelstein et al. Am J Med. Aug. 2009 Medical expenses drove 62% of bankruptcies 78% were insured at onset of the bankrupting illness Uninsured at illness onset
- 20. Massachusetts’ Reform Did Not Slow Medical Bankruptcies 7,504 10,093 0 2,000 4,000 6,000 8,000 10,000 12,000 2007 2009 Source: Himmelstein, Thorne, Woolhandler. Am J Med 2011;124:224 Number of medical bankruptcies in Massachusetts
- 21. Uninsured and Under-Insured Delay Seeking Care for Heart Attacks Source: JAMA April 15, 2010. 303:1392 *Adjusted for age, sex, race, clin. charact., hlth status, social/psych fx, urban/rural. Under-insured=had coverage but patient concerned about cost 1.00 1.21 1.38 0.0 0.2 0.4 0.6 0.8 1.0 1.2 1.4 1.6 Insured Under-insured Uninsured Odds ratio for delayed care*
- 22. Note: Data are for 2011 or most recent year available Figures adjusted for Purchasing Power Parity Source: OECD, 2013 We Have the Most “Skin in the Game” $968 $733 $640 $571 $315 $298 $267 $0 $200 $400 $600 $800 $1,000 $1,200 USA AUSL CAN GER UK FRA HOL Out-of- pocket dollars per capita
- 23. Source: Health Affairs 2011;30:2437 Cost Barriers Are the Worst in the US Percent Reporting Problems (Among Sicker Adults) 50% 40% 30% 20% 10% 0 UK FR A CA N AUL NZ E US UK FR A CA N NZ E AUL US Sick Americans say cost drove their access problems Sick Americans find it uniquely hard to pay their medical bills
- 24. This really is a “Patient Bill of Rights” Affordable Care Act: Millions of More Insured Americans New Insurance Regulations • Dependents covered to age 26 • No one is “uninsurable” • No cancellations for being too sick • No lifetime/annual maximums New Insurance Marketplaces • Single door • “Ten Essential Benefits” • Priced only by age, smoking and location • 60-90% value • Navigation assistance Stronger Public Programs • Medicare stabilized and strengthened • Medicaid expansion option Many many more things
- 25. How Many People Are Involved in Medical Bankruptcies Each Year? CanadaUSA 2 Million62% of Americans file cases 866,000 total cases affecting 2 million Americans Excludes those too poor to declare bankruptcy Source: Himmelstein et al. Am J Med: August, 2009
- 26. How Many People Don’t Have Health Insurance? CanadaUSA with the ACA US Census Bureau, 2012 30 Million
- 27. How Many People Go Without Some Medical Care Because of Cost? CanadaUSA Commonwealth Fund, Schoen 2007 115 Million
- 28. How Many People Die Each Year From Not Having Insurance? CanadaUSA Wilper, et al “Health Insurance and Mortality in U.S. Adults,” American Journal of Public Health; Vol. 99, Issue 12, Dec 2009 45,000
- 29. The ACA’s Biggest Flaw Preserves the insurance industry • Limited lists of doctors and hospitals • Large gaps in covered benefits • Financial barriers to care • Needless complexity • Millions remain uninsured
- 31. National Health Programs 101 National Health “Insurance” • Public funding, private delivery • Medicare • Canada National Health “Service” • Public funding, public delivery • VA • Great Britain “All Payer” • Highly regulated insurance model Multi-Payer • Insurance industry- centric • Uniquely American “Single Payer”
- 32. National Health Programs 101 National Health “Insurance” • Public funding, private delivery • Medicare • Canada National Health “Service” • Public funding, public delivery • VA • Great Britain “All Payer” • Highly regulated insurance model Multi-Payer • Insurance industry- centric • Uniquely American HR 676The Improved and Expanded Medicare for All Act”
- 33. HR 676 “Medicare for All” Builds on Medicare Fix Medicare • Comprehensive benefits • No financial barriers • No need for “Medicare supplemental” or “wrap” • Preserve private delivery Expand Medicare • All Americans, including Congress • Roll up most other programs • “Everybody in, nobody out.”
- 34. HR 676 “Medicare for All” Provides for All Medically Necessary Services Primary care Prescription drugs Substance abuse Prevention DME Chiropractor Nutritional therapies Long-term care Basic vision Inpatient care Palliative care Hearing / hearing aids Outpatient care Mental health services Podiatry Emergency care Full dental Free choice of providers No copays, no deductibles, no lifetime/annual maximums
- 35. HR 676 “Medicare for All” Provides for All Medically Necessary Services Primary care Prescription drugs Substance abuse Prevention DME Chiropractor Nutritional therapies Long-term care Basic vision Inpatient care Palliative care Hearing / hearing aids Outpatient care Mental health services Podiatry Emergency care Full dental Free choice of providers No copays, no deductibles, no lifetime/annual maximums
- 36. HR 676 “Medicare for All” Protects Displaced Healthcare Workers • “Medicare for All Employment Transition Fund” Fully funded support • Two years of guaranteed salary (up to $100,000 per year) • Eligible for unemployment after protected salary period Two year transition First priority for retraining and job placement
- 37. HR 676 “Medicare for All” Builds on the Progressive Income Tax • Roll-up existing federal and state programs Consolidate current spending • Modest increase in progressive taxes • For 95% of people, the increase in taxes is less than the reductions in premiums, copays, and deductibles. Eliminate premiums, copays, etc
- 38. Friedman, G. Dollars & Sense. March/April 2012 $ Billions Medicaid Rate Adjustment Covering the uninsured Increased utilization (especially home health and dental) Government administration ($23B) Health insurance administration Increased market power (pharma and devices) Admin costs to providers New Costs Savings $74 $110 $142 $153 $178 $215 $200 0 -$200 -$400 -$600 HR 676 “Medicare for All” Covers Everyone and Spends Less
- 39. Friedman, G. Dollars & Sense. March/April 2012 New Costs: $326 B Net savings: $243 Billion Cover everyone with better benefits and spend less. New Savings : $569 B HR 676 “Medicare for All” Covers Everyone and Spends Less
- 40. Canada Figured This Out Already Source: Statistics Canada, Canadian Institute for Health Info, and NCHS/Commerce Dept. Health costs % of GDP 19% 17% 15% 13% 11% 9% 7% 5% 1960 1970 1980 1990 2000 USA 2014 Single Payer Implemented Canada “Uniquely American”
- 41. Source: World Bank. Accessed Nov. 29, 2013 Life Expectancy Gap (CA minus US) (years) 0 1 2 3 1975 1980 1985 1990 1995 2000 2005 2010 Canadians Spend Less and Live Longer They spend half as much as we do, and now live 2.5 years longer.
- 42. The Investment Community Gets This Smith, R. “How Much Could Medicare for All Save You?” The Motley Fool, July 21, 2013 “Single-payer would shave $400 Billion per year off the national health care bill.”
- 43. Universal Health Care Is Not a Partisan Issue “Every developed country, they have universal health care. “Whether it’s Obamacare, or son of Obamacare, I don’t care. As long as we get it done.” Bauman, V. Puget Sound Business Journal. Dec. 5, 2013 http://www.bizjournals.com/seattle/blog/health-care- Colin Powell Four Star General, Ret. Former Secretary of State
- 44. We Have Universal Coverage Today: EMTALA (1986 Law) IT’S THE LAW If you have a medical emergency or are in active labor, you have the right to receive, within the capabilities of this hospital’s staff and facilities: An appropriate medical screening examination and necessary stabilizing treatment, even if you cannot pay or do not have medical insurance. Care for uninsured adds $1,000 per family per year
- 45. We Have Built the World’s Least Prudent Health Care Strategy Untreated hypertension • Dialysis: $46,332 per year • Strokes: $47,800 per event Treated Hypertension • Most medications for hypertension: $4/month http://www.ncbi.nlm.nih.gov/pubmed/22237223 http://www.cdc.gov/stroke/facts.htm Who pays for all this?
- 46. What Do You Spend on Health Care Benefits? Single Payer ModelUSA Employers Today 7 - 12% of wages 3.3% tax on wages Bureau of Labor Statistics Business Health Coalition for Single Payer
- 47. 7 Ways that Single Payer Strengthens American Businesses Reductions in Direct Costs • Cost of health care benefit • Health care benefit management costs • Worker Comp, auto and liability insurance Reduced Employer Risk • More predictable future costs • Eliminate risk of employees with high medical costs • One less item in labor negotiations Level the global playing field for business
- 48. Americans Are Not as Divided As You Might Think Source: CBS News / New York Times Poll, April 14, 2010 76% 62% 19% 33% 5% 6% 0% 20% 40% 60% 80% National Sample Tea Party Sample Worth It Not Worth It Don't Know “Are the benefits from government programs such as Social Security and Medicare worth the costs?”
Editor's Notes
- Our systems devotes nearly a third of its resources to overhead, administration, and profits, a ten-fold increase over Medicare and single payer countries. Americans value personal choice, something that is profoundly restricted in our Multi-payer model. Employers pick one or two insurers to offer their employees; insurers build their own networks of physicians, hospitals, and drug formularies. Patients must get their healthcare within these circumscribed lists, losing access to some hospitals, physicians, and prescription drugs.
- Our systems devotes nearly a third of its resources to overhead, administration, and profits, a ten-fold increase over Medicare and single payer countries. Americans value personal choice, something that is profoundly restricted in our Multi-payer model. Employers pick one or two insurers to offer their employees; insurers build their own networks of physicians, hospitals, and drug formularies. Patients must get their healthcare within these circumscribed lists, losing access to some hospitals, physicians, and prescription drugs.