Presentation Transcript

1. The Right to Medical TreatmentAVAILABILITY OF HEALTH CAREIN THE UNITED STATES Janice F. Mulligan, Esq. Law Offices of Mulligan & Banham San Diego, California, U.S.A. jfm@janmulligan.com 001-619-238-8700
2. Famous American Civil Rights Activist Martin Luther King once said :“[o]f all forms of inequality, injustice in health care is the most shocking and inhumane.” Yet to date, the United States is the only industrialized nation that still does not have health care guaranteed to all its citizens.
3. All of This May be About to Change The Patient Protection and Affordable Care Act (ACA), called “Obamacare”,is a U.S. federal statute signed into law by President Barack Obama in 2010.
4. ACA is most significant overhaul of American healthcare system in over fifty years.   Only a few of its rules have gone into effect already: Allows children to stay on their parents’ plans until age 26 Outlaws lifetime $ limits Lowers cost of seniors’ drugs Refunds total + $1.1 billion to 12 million people Expands free preventive care The majority of the ACA will not become law until 2014.
5. Many Americans are Opposed to Obamacare.

6. What is the fundamental dispute?

7. Is Healthcare a right…or a privilege? Most of the world treats access to health care as a basic right, but U.S. historically treated health care as a privilege, available only to those who could afford it Currently, over forty-nine million Americans are without health insurance

8. Before we talk about where health care in America may be going in the future…

   Let’s talk about the current status.
9. What Does the American Government Currently Fund? Medicare for elderly and disabled with a prior work record; Medicaid for some, but not all poor; State Children's Health Insurance Program for children of low-income families; Veterans Health Administration for U.S. military veterans through a network of government hospitals; TRICARE for service members and their families. Source: HEALTH CARE COSTSA Primer,KEY INFORMATION ON HEALTH CARE COSTS AND THEIR IMPACT (May 2012), Kaiser Foundation http://www.kff.org/insurance/upload/7670-03.pdf Together, tax-financed programs cover 27.8% of the population and make government the largest health insurer in the nation.
10. Who are the Americans Without Health Insurance? Majority are from working families with low to moderate incomes. 70% of the uninsured are in families with one or more full-time workers, butinsurance is either not offered by their employer or is not affordable.* Source:* “The Uninsured: A Primer,” Kaiser Commission on Medicaid and the Uninsured. November, 2004.
11. Uninsured Americans are less likely to receive preventive health care and routine screenings. As many as one-third of uninsured Americans report that they are unable to fill a prescription drug because of cost.
12. This group has less access to health care than ever before… Working age adults with less than a high school diploma who do not have health insurance rose to 43% from 35% in 1993. However, just 10% of Americans with a college degree were uninsured last year.* *Source:U.S. Census Bureau.
13. Why Are There So Many Americans Without Health Care? One main reason is that America has the most expensive health care in the world and many Americans cannot afford it.
14. How Does the Cost of Health Care in America Compare to the Rest of the World? In 2010, the U.S. spent $8,650 per person. The closest contenders were Switzerland ($5,144 per person) and Netherlands ($4,914)
15. Is the trend is for costs to continue to rise in U.S? * A majority of Americans have insurance through private employer health plans. 55.9 % of adult Americans under 64 receive employer-provided health insurance ** The cost of these plans increased from 2003 to 2010,with an average increase of 50% Ifpremium trends continue at the same rate, average annual premium for family coverage will rise 72% by 2020, to nearly $24,000… Sources: *State Trends in Premiums and Deductibles, 2003–2010: The Need for Action to Address Rising Costs, Cathy Schoen et al, Commonwealth Fund, November 2011 ** Gallup poll , www.gallup.com, Poll taken July, 2012.
16. Or will it???? …. “Snail’s Pace” Source: * National Health Expenditure Projections 2011-2021 www.cms.gov/Research-Statistics-
17. Is it Because of the Recession ?* Source: * National Health Expenditure Projections 2011-2021 www.cms.gov/Research-Statistics- As unemployment rose, Americans lost jobs and often health insurance. Even those with insurance used fewer health care goods and services because of financial uncertainty. If so, is there only a temporary slowing of cost increases?
18. Or…is a Slowed Increase in Costs Because of Changes in Cost Sharing? Changes in deductibles and other insurance benefits increased the cost sharing paid by patients If this is the cause, it may be a more permanent slowing of costs?
19. Even at a slower rate of increase,American Health Care is StillToo Expensive
20. United States Total Spent Annually on Health Per Capita:(Expenditure as % of GDP: 17.4%) Netherlands (12% of GDP) France (11.8%) Germany (11.6%) Denmark (11.5%) Canada (11.4%) Only 47.7% total spent is from the government — third-smallest percentage among developed countries. However, the actual amount of public spending, $3,795, is among the highest.
21. Unequal distribution: What are U.S. healthcare dollars spent on? In 2009, half of all health care spending was used to treat just 5% of the population. Adults aged 65 and older have the highest health care spending, averaging $9,744.
22. Why is Health Care So Expensive in the U.S.?
23. Is it the lawyers and their frivolous lawsuits? NO! Like many states, in 2003, Texas put a cap on non-economic damages. Non-economic damages are for “pain and suffering” and do not include medical bills or lost wages. States hoped that tort reform would cause health insurance premiums to drop.
24. Limits on Lawsuits Did Not Lower Cost Between 2003 and 2010 average price of a Texan’s health insurance premium went up 46%.* Texas has one of the highest rates of uninsured people in the country
25. Don’t blame lawsuits for expensive U.S. Healthcare. Texas’ experience is not uncommon and is typical for the states that have put limits on medical malpractice lawsuits. *State Trends in Premiums and Deductibles, 2003–2010: The Need for Action to Address Rising Costs, Cathy Schoen et al, Commonwealth Fund, November 2011
26. Is Health Care Expensive Because Americans Are less healthy? No, but… U.S. has smaller elderly population and fewer smokers, but higher obesity rates than most nations Higher rates of obesity inflate health spending U.S. Medical costs due to obesity reached @10% of all medical spending in 2008 However, younger population and lower rates of smoking may be offset *Source: D. Squires, Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality, The Commonwealth Fund, May 2012.
27. Does U.S. Have Too Many Doctors ? No There were 2.4 physicians per 1,000 population in the U.S.- fewer than all other study countries except Japan. Source: "The(Paper)Work of Medicine: Understanding International Medical Costs,“ , Cutler. David et al., (Spring 2011) Journal of Economic Perspectives.
28. Are American Doctors Paid Too Much ? Maybe? But it is only “tip of the iceberg” Average earnings of U.S. primary care doctors is $186,582 Average U.S. specialist physician earns $230,000 annually—78 % above the average in other countries But …. American doctors live in an economy with a more unequal distribution of wages If all U.S. physician incomes were reduced to match international ratio of physicians’ incomes per capita GDP, it would only lower costs by only @ 2% * David M. Cutler and Dan P. Ly, "The (Paper)Work of Medicine: Understanding International Medical Costs," Spring 2011.Journal of Economic Perspectives
29. Is it the cost of drugs? Only a little *David M. Cutler and Dan P. Ly, "The (Paper)Work of Medicine: Understanding International Medical Costs," Spring 2011.Journal of Economic Perspectives Prices for 30 most commonly prescribed drugs 1/3 higher in U.S. than Canada and Germany, + double the prices in Australia, France, Netherlands, New Zealand, U.K. Prices for generic drugs are less in U.S. Drugs are only @ 10 % of U.S. healthcare spending * Overall amount saved if the U.S. government purchased drugs is only 2-3 % of total medical costs.* Cost savings also would have to be weighed against reduced incentives for investment and innovation in pharmaceutical industry.
30. So... Why Does the U.S. Spend 50% More on Health Care Than The Next Highest Countries ? There is no one answer, but some of the theories are…
31. $ $ $ Unnecessary spending in US health care system $ $ $ Some estimate that + 20% of total health care expenseis due to waste, including overtreatment, failures of care coordination, fraud and abuse. . Role of provider profit motive may contribute (for example, encouraging the use of profitable equipment.) Lack of integrated, efficient systems to electronically store and transmit health data also contributes to higher costs (and limits the data available to study treatment effectiveness) National Healthcare Expenditure Projections 2011-2012 www.cms.gov/Research-Statistics-
32. Also Contributing to U.S.’ High Health Care Costs : 1. High use of medical devices and imaging. 2. Poor management of chronic conditions 3. Expensive hospital stays 4. Excessive administration and paperwork. Source: *D. Squires, Explaining High Health Care Spending in the United States: An International Comparison of Supply, Utilization, Prices, and Quality, The Commonwealth Fund, May 2012.
33. Some Medical Devices Are Used More and Cost More in U.S. Some medical devices are more widely used in the U.S: In 2009, the U.S. and Germany, performed the most knee replacements (213 per 100,00) among the OECD countries, and 75 percent more knee replacements than the median (122 per 100,000). U. S. has an above-average number scanners per population: Magnetic resonance imaging (MRI) machines (25.9 per million), computed tomography (CT) scanners (34.3 per million), positron emission tomography (PET) scanners (3.1 per million), and mammograms (40.2 per million). U.S. average diagnostic imaging fees far higher than almost all other countries . $1,080 for an MRI and $510 for a CT exam * Source: The Organisation for Economic Co-operation and Development (OECD see http://www.oecd.org/statistics/
34. Chronic Diseases Are Not Well Managed Many chronic diseases are capable of being well-managed, reducing enormously costly episodes of hospitalization. However, as the Center for Disease Control and Prevention concludes: "Chronicdiseases—such as heart disease, cancer, and diabetes—are the leading causes of death and disability in the UnitedStatesaccounting for 70% of all deaths in the U.S., which is 1.7 million each year. These diseases also cause major limitations in daily living for almost 1 out of 10 Americans ...."
35. Hospital Stays are More Expensive U.S. hospital stays in U.S. exceed $18,000 per discharge (Compared with less than $10,000 in Sweden, Australia, New Zealand, France, and Germany) Yet U.S. has fewer hospital beds (2.7 per 1,000 ), shorter lengths of stay for acute care (5.4 days), and fewer discharges (131 per 1,000) than the median....
36. Hospital Stays Involve More Surgeries Population-adjusted admission rates are about the same in U.S. and Canada, but more surgeries are given for same diagnosis in the U.S. . Aheart attack in U.S. is twice as likely to be treated with bypass surgery or angioplasty than in Canada. While no difference in outcome in favor of the U.S. over Canada, the number of surgery centers is very different: California is 3times larger in population but has 10 times more heart surgery centersthan Ontario. Given this difference in the number of facilities, it is impossible for physicians in Ontario to perform as many open heart surgery operations as those in California. *David M. Cutler and Dan P. Ly, "The (Paper)Work of Medicine: Understanding International Medical Costs," Spring 2011.Journal of Economic Perspectives *Citation
37. Administrative Costs Are Higher U.S. has 2.2 administrative workers for every 1 physician. Canada, by contrast, has only half as many administrative workers per physician. The U.S. has 25 % more administrators than the U.K., 165 % more than the Netherlands, and 215 %more than Germany. Health insurance administration is 12 % of premiums in the U.S. and less than half that in Canada. ** “ Source: The (Paper)Work of Medicine: Understanding International Medical Costs,“ Cutler. David et al., (Spring 2011) Journal of Economic Perspectives.
38. What are all these U.S. administrators doing? Credentialing(receiving permission to practice medicine in hospital or for a health plan) Average U.S. physician submits 18 credentialing applications annually—each insurer, hospital, ambulatory surgery center, requires a different one—taking @ 70 minutes of staff time and 11 minutes of physician time per application. Verifying Insurance Information Aver. 20 to 30 patients daily People change insurance plans frequently and the cost-sharing (“deductibles”) charged varies so charges to each patient are variable. Billing and payment collection about 3 claims are denied per physician per week and need to be rebilled. 3/4 of denied bills are paid, but the administrative time involved is high. Theadministrative burden is rising over time as insurance policies have become more complex.
39. Side Effects of Expensive American Health Care :Earlier Death and Bankruptcy
40. The U.S. poor and uneducated die young…. Least educated Americans life expectancy has fallen by an average of four years since 1990.* Life expectancy for women without high school degree 73.5 years, compared with 83.9years for women with college degree. For men gap is bigger:67.5 years for least educated men compared to 80.4 years with college degree. *Source:Life Spans Shrink for Least-Educated Whites in the U.S., Sabrina Tavernise, New York Times, September 20,2012
41. There is a strong connection between bankruptcy and high medical bills for uninsured Americans * Source: Himmelstein,David U., et al. MarketWatch: Illness And Injury As Contributors To Bankruptcy Health Affairs,: Published online February 2005, doi: 10.1377/hlthaff.w5.63
42. What is The Future of Health Care in America?
43. In a landmark decision*, U.S. Supreme Court upheld most of the ACA (“Obamacare”) , including a requirement for most Americans to have health insurance . *National Federation of Independent Business v. Sebelius,567 U.S. __ (2012)
44. This U.S. Supreme Court decision was grounded in abstract legal theories of federalism (the rights of the states versus the federal government) and the American government’s right to tax its citizens.
45. The Court accepted the argument that the mandate to buy health insurance is allowed under Congress’ power to “lay and collect taxes”.
46. The ACS is not due for full implementation until 2014 What will American health care look like ? .
47. Promises, Promises The promise is that Obamacare will: Give most Americans health insurance Generate money Improve quality of care Expand some coverage
48. When New System Begins in 2014… Health Plans must sell coverage to everyone regardless of pre-existing condition. Can’t charge more for ill-health or gender. Most people will still get health insurance through their work or federal program.
49. Obamacare Will Expand Federal $ for Health Care Medicaid = state operated,federally funded program covering lower income people and disabled. States required to expand Medicaid coverage to include more preventive care. Medicaid to cover @ 16 million more Americans (incomes up to $14,856 per person or $30,657 per family of four)
50. Does Obamacare Make Federal Government too Strong? Supreme Court decision* allows Medicaid expansion to go forward but forbids government from punishing states that don’t comply. Some fear that Court opinion strengthens the power of the federal government and weakens states’ rights. * National Federation of Independent Business v. Sebelius, 567 U.S. __ (2012)
51. Federal Government will Also Subsidize Some People… If income is between 100-400% of poverty level, government will pay part of insurance cost. Example: Family of four with income 200% of poverty (about $46,000) will pay no more than $235 month for health insurance.
52. Penalty if No Health Insurance In 2014, penalty of $95 per person or 1% of income, which ever is greater. Penalty increases to $695 person or 2.5% income in 2016.
53. New Taxes For Some(really taxes not “penalties”) …. Extra payroll tax for earnings + $200,000 year (or married couple with +$250,000) will pay extra 0.9 % tax for all income above this level. (Not including retirement income) Net Investment Income tax of 3.8 % upon sale of stocks , interest (“unearned income”) if income above $200,000 person/$250,000 couple Special taxes for house sale if high income.
54. Some Americans Think the ACA Will Make Health Care Worse
55. Some ACA Coverage is Controversial. Example: Universal birth control coverage . Only limited exceptions for employers that are churches, mosques, synagogues, etc.. Coverage includes organizations owned/ controlled by religious institutions opposing contraception (such as Catholic hospitals and universities.) Coverage based on Institute of Medicine, finding access to contraception medically necessary "to ensure women's health and well-being."
56. Even Proponents of the ACA are Critical of the Legislation…
57. Some Believe Obamacare Won’t Due Enough… No Universal Coverage No Single Payer Option -Single-payer would be funded from single source run by government. - Single-payer systems contract with private companies (Canada) or government owned/operated healthcare organizations (UK). - Instead, ACA has for-profit insurance companies. True universal coverage not guaranteed. No coverage for undocumented immigrant adults. Not all treatment all drugs available to all.
58. Even if not Perfect, It is a Giant Step Forward U.S. is finally about to take a giant step forward in providing basic health care to most of its citizens. If the presidential election allows for it….
59. “The issue of universal health coverage is not a matter of economics. Little more than 1 percent of the gross domestic product assigned to health care could cover all. It is a matter of the soul.” * * Dr. Uwe Reinheart, Princeton University health economist