1. The shortcomings of the ACA prove
It’s Time for a
Single-payer Healthcare System
Anand Saha
MD Candidate, East TN State Quillen College of Medicine
MPH Candidate, University of Memphis School of Public Health
Board member, Physicians for a National Health Program
2. Physicians for a
National Health Program (PNHP)
• 20,000+ physicians, nurses, public health workers and other
professionals
• We believe access to high-quality health care is a human
right
• We support Single-payer “Improved Medicare for All”
• Medical care should be privately delivered but publicly
funded
• Health care should be provided equitably as a public
service
• Health care should not be bought and sold as a
commodity
3. “Triple Aim” of
Good Healthcare Systems
QUALITY of
patient care
Minimize COST
Better
POPULATION
HEALTH
outcomes
4. The Most Expensive
Health Care System In the World
Data are for 2013 or nearest year
US$ Purchasing Power Parity
OECD data accessed Nov 30 2015
Annual per
capita
dollars
spent on
health care
$0
$2,000
$4,000
$6,000
$8,000
$10,000
UnitedStates
Switzerland
Norway
Netherlands
Sweden
Germany
Denmark
Austria
Luxembourg
Canada
Belgium
France
Australia
Japan
Iceland
Ireland
OECDAVERAGE
Finland
NewZealand
UnitedKingdom
Italy
Spain
Portugal
Slovenia
Israel
Greece
Korea
CzechRepublic
SlovakRepublic
Hungary
Chile
Estonia
Poland
Mexico
Turkey
USA: $8,713
Average: $3,453
5. US Spending per Capita
Data are for 2010
Sources: OECD 2012; Health Affairs 2002 21(4)88
$3,040
$3,430
$3,760
$3,970
$4,340
$4,440
$5,290$2,940
$-
$2,000
$4,000
$6,000
$8,000
$10,000
Total US Public US Private
2010healthcarespendingpercapita
USA’s public spending exceeds
everyone’s total spending!
6. Health Insurance Is
Increasingly Unaffordable
http://www.commonwealthfund.org/interactives-and-data/chart-cart/presidents-column/costs-of-
failure/average-family-premium-as-a-percentage-of-median-family-income
Accessed Feb. 25, 2016
12%
13%
14%
16%
17%
18% 18% 18% 18% 18%
19% 19% 19%
20% 20%
21% 21%
22% 22%
23%
24%
0%
5%
10%
15%
20%
25%
30%
2000 2005 2010 2015 2020
Average Family
Premium as a
Percentage of
Median Family
Income
7. We Have Plenty of Administrators
Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of
CPS
Managers shown as moving average of current year and two previous
years
0%
500%
1000%
1500%
2000%
2500%
3000%
3500%
1970 1975 1980 1985 1990 1995 2000 2005 2010 2015
Managers Physicians
Growth
since
1970
8. $0.31 of healthcare dollar is spent on
non-value added care
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
$300 monthly premium $93 monthly waste
16%
84%
United States
Canada
9. Health Insurance CEO 2014 Pay
Source: SEC filings
Mark Bertolini Joseph Swedish Michael Neidorff
David Cordani Steve Hemsley Bruce Broussard
Aetna
Annual Comp:
$15.0 M
Pay/Weekday:
$57,745
Cigna
Annual Comp:
$27.2 M
Pay/Weekday:
$104,479
United
Annual Comp:
$66.1 M
Pay/Weekday:
$254,328
Humana
Annual Comp:
$13.1 M
Pay/Weekday:
$50,319
Wellpoint
Annual Comp:
$8.1 M
Pay/Weekday:
$31,016
Centene
Annual Comp:
$ 28.1 M
Pay/Weekday:
$107,962
10. 30 Million Will Remain Uninsured
Graphic by the New Republic
CBO May 2013 Update on ACA
CBO Feb 2014 Update on Budget and Economic Outlook
57
57 57 56 56 55 55 56 56 56 56 5755
45
37
31 30 30 30 30 31 31 31 31
0
10
20
30
40
50
60
2013 2015 2017 2019 2021 2023
Without ACA With ACA
Uninsured
(Millions)
11. Why Are So Many Uninsured?
KCMU Analysis of 2013 NHIS
No Offer,
11.2%
Aged Out /
Left School
8.8%
No Need
1.5%
Lost Job
29.4%
Insurance Not
Affordable
31.6%
Other
17.4%
12. Note: Data are for 2013 or most recent year available
Source: OECD, 2015
Infant Mortality
Deaths in First Year of Life Per 1,000 Live Births
6.0
4.8
3.6 3.6
3.3
2.9 2.7
0
1
2
3
4
5
6
7
USA CAN FRA AUSTRL GER ITA SWE
13. Note: Data are for 2013 or most recent year available
Source: OECD, 2015
Physician Visits per Capita
4.0
4.5
5.0
6.4
7.3 7.7
12.9
0
2
4
6
8
10
12
14
USA DEN UK FRA AUSTRL CAN JAP
15. Ultimate cost:
45,000 Annual Deaths
State Percent Uninsured Excess Deaths
California 23.9% 5,302
Texas 29.7% 4,675
Florida 26.0% 3,925
New York 17.5% 2,254
Georgia 23.6% 1,841
USA 15.3% 44,798
Source: Wilper et al. Am J Public Health 2009.
State tabulations by author
16. Ultimate Cost:
Personal Bankruptcy
Himmelstein, et.al. Am J Med, August, 2009
of all bankruptcies in 2007 were medical
62%
had medical debts over $5,000
or 10% of pretax family income92%
had health insurance75%
17. Source: Himmelstein et al. Am J Med: August, 2009
VA / Military
2%
Medicare
10%
Medicaid
5%
Uninsure
d
22%
Private
Insurance
60%
And Most Had Insurance!
20. Two Options for Reform
Double down on
current system with
for-profit insurance
companies and the
free market.
Establish
single-payer
“Improved and
Expanded
Medicare for All.”
–or–
21. The ACA: Cost
Pros
• Accountable Care Organizations
(ACOs)
Cons
• No increased bargaining
power of Medicare for drugs
• No decrease in the
complexity responsible for
administrative waste
22. The ACA: Access
Pros
• Can’t discriminate against women
or against citizens with pre-
existing conditions
• Stay on parents’ plan until 26
years old
• Approximately 19 million newly
insured
Cons
• Supreme Court ruled Medicaid
expansion on a state-by-state
basis
Who knows…
• Established insurance exchange @ healthcare.gov
• Individual mandate (penalty if no coverage)
23. The ACA: Quality
Pros
• FREE yearly check-up & flu shot
• Insurance companies must
spend at least 80-85% on patient
care
• No lifetime limit on insurance
payouts
Cons
• Plans with high deductibles and
co-pays
Who knows…
• ”What does this mean for the patient?” – still
very elusive question
24. Tennessee Is Not Yet
Expanding Medicaid
Anticipated health impact of Medicaid expansion into current non-expansion states.
Dickman S, Himmelstein D, McCormick D, and Woolhandler S. Opting out of Medicaid Expansion: The
Health and Financial Impacts. Health Affairs Blog. January 30, 2014, accessed Dec. 14 2015.
Economic impact from Commonwealth Fund
Better women’s health
• 9,744 more mammograms
• 18,942 more Pap smears
Better treatment of chronic diseases
• 16,843 more diabetics receiving medications
• 28,381 fewer adults with depression
Many fewer preventable deaths
• Between 284 and 759 fewer deaths
• One or two each and every day.
TN is walking away from
$2,111,000,000
in federal funds.
25. Uninformed consumer:
Rhetoric of “Choice”
Name Of Plan*
BlueCross
Bronze B02S
BlueCross Silver
S07S
BlueCross
Platinum P02S
Plan Type Bronze Silver Platinum
Monthly Premium $152 $224 $360
Deductible $4,000 $1,500 $0
Annual Cap $6,350 $6,350 $1,500
Minimum $1,819 $2,684 $4,320
Maximum $8,169 $9,034 $5,820
*Actual health plans from TN Health exchange
Anand’s ACL surgery: $20,000 + Rehab 3x/week: $2,000
27. Our patchwork of models
Beveridge
Model
Bismarck
Model
National
Health
Insurance
Out-of-
pocket
Financing
(Insurance)
Public Private Public None
Delivery
(Providers)
Public Private Private Private
Examples of
countries
Britain, Italy,
Scandinavia
Germany,
Japan, France
Canada,
Taiwan
African
countries,
India, S
America
T.R. Reid's book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care
28. Single Payer, “Improved
Medicare for All” overview
• Public funding
• 1 single pool to pay providers
• Individuals pay into pool via taxes; no additional costs
• Private delivery:
• Majority of healthcare providers remain private
• Healthcare is birth right; everybody in, nobody
out
• Reduce administrative costs
• What will administrators do all day if just 1 insurance company??
• Collectively bargain lower drug prices
29. “Triple Aim” of Single Payer,
Improved Medicare for All
QUALITY of
patient care
Minimize COST
Better
POPULATION
HEALTH
outcomes
30. PNHP Proposal: HR 676
“Improved Medicare for All”
• Sponsored by Rep John Conyers (D-MI); 54 co-sponsors.
Who?
• ‘Triple Aim’: Improves quality, reduces cost, expands access
What?
• Improves quality of insurance (no deductibles, copays, etc)
• Reduces costs saving $592B total annually
• Cuts administrative costs by $476B annually
• Cuts pharmaceutical costs by collective bargaining $116B
annually
• Insures all 30 million uninsured Americans as a birth right
How?
31. PNHP Proposal: HR 676
“Improved Medicare for All”
• Stop administrative waste (save ~$476B annually)
Streamline
payment
• Stop profit of suffering
Create a single
risk pool
• Stop marketing waste
Offer only
one plan
• Stop pharmaceutical profits (save ~$116B
annually)
Collective
bargaining
• Stop expensive diseases from starting
Increase
prevention
• Stop rationing of health care professional choice
Free choice
of providers
Credit: PNHP California chapter
32. Can we afford Medicare for All?
Data are for 2010
Sources: OECD 2012; Health Affairs 2002 21(4)88
$3,040
$3,430
$3,760
$3,970
$4,340
$4,440
$5,290$2,940
$-
$2,000
$4,000
$6,000
$8,000
$10,000
Total US Public US Private
2010healthcarespendingpercapita
We are paying for single payer but
not getting it!
33. Our taxes already cover
Improved Medicare for All…
3 major public HC expenditures:
• Direct government payouts
• Medicare, Medicaid, VA, NIH, public
health departments
• 47.8% or $1.395 trillion
• Federal, state, and local tax
subsidies for healthcare
• 10% or $296 billion
• Public employees’ health
insurance/benefits
• 6.4% or $188 billion
Himmelstein, David U., and Steffie Woolhandler. "The Current and
Projected Taxpayer Shares of US Health Costs." American Journal of
Public Health 0 (2015): e1-e4.
64.3%
34. Improved Medicare for All
Makes Economic Sense
Friedman, G. Dollars & Sense. March/April 2012
$74
$110
$153
$142
$215
$178
$ Billions
New Costs New Savings
Medicaid Rate Adjustment
Covering the uninsured
Increased utilization
(especially home health
and dental)
Gov. admin ($23B)
Health insurance admin
Increased market power
(better pricing on
drugs and devices)
Admin costs
to providers
35. A Fork in the Road
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
Canada
USA
2014
USA 1971:
HMO Act
Canadian
Single Payer
Fully
Implemented
36. Most Physicians Support a
National Health Program.
2007 detail of surveys of random samples of US physicians.
Carroll and Ackerman. Ann Int Med 2008;148:566
Psychiatry
Peds Specialties
Emergency Med
General Peds
General Int.
Med
Med Specialties
Family Med
OB-Gyn
General Surgery
Surg Specialties
Radiology 0 25% 50% 75% 100%
Percent supporting National Health Insurance
of physicians support
single payer
59%
37. We Can Win the Trifecta
“You can have
universal coverage and
good quality healthcare
while still managing to
control costs…
but you need
Single-Payer to do it.”
Dr. William Hsiao
Harvard Health Economist
39. 170 students from 50+ schools…
in Tennessee!
5th annual SNaHP Summit
Vanderbilt University in Nashville, TN
March 5, 2016
40. For more information…
AnandGSaha@gmail.com
Health policy websites:
• The Commonwealth Fund:
www.commonwealthfund.org
• Kaiser Family Foundation: www.kff.org
• Health Affairs Blog: http://healthaffairs.org/blog/
• Physicians for a National Health Program:
www.PNHP.org
