Healthcare for ALL Myths, Frames & pipe dream?

1. Healthcare for ALL Myths, Frames & pipe dream? • Parker Duncan, CaPA Fellow, Capa.fellow@gmail.com • MS4, UC Irvine; MPH, CSULB; PRIME-LC, inaugural class • CaPA Medical Student Fellow for Healthcare Reform (MSF), 2008-2009 • Pisacano Scholar, 2008 Pduncan@uci.edu Thursday, 29 January, 2009 AMSA - Seacouver www.capa.pnhp.org

2. Goals FRAMING UHC/HCA Concepts: Incentives Social INS IOM GP 5 MYTHS

3. Pre-Quiz NUMBER of people in the US without health insurance? (age <65 = 250M) • <50M • 60-70M • All 250M • It just doesn’t matter!

4. Pre-Quiz NUMBER of people in the US without health insurance? (age <65 = 250M) • <50M (US Census Bureau, 2007: 47M, all or part of year) • 60-70M (the UNDERinsured) • All 250M (IOM: predictably affordable, automatic & guaranteed, high quality & comprehensive) No one <65 in the US has “health security” !!

5. IOM GP5 Definition EBM

6. Consequences of UNinsurance, ‘01-04 www.iom.edu/uninsured

7. IOM Guiding Principles (‘04): “U-CASH” • Universal – everyone in, NOBODY out • Continuous – ‘womb-to-tomb’ • Affordable – to individuals & families • Sustainable to society • ALL contribute; all benefit • SIMPLE: -- Eliminate complex billing & underwriting requirements • High-quality care • Effective, efficient, safe, timely, patient-centered and equitable www.iom.edu/uninsured

8. HI  HEALTH & care IOM, “Insuring America’s Health”, p.152

9. Goals FRAMING UHC/HCA Concepts: Incentives Social INS MYTHS

10. Social insurance $$ Financing CARE WALL Healthy - wealthy Sick – “poor”

11. Health Insurance – unique model • Healthcare is Costly • Uneven distribution • Unpredictable – “predictably unpredictable” • When YOU need it, YOU want it to be there!

12. WHY HI: Uneven & Unpredictable 73% Percent of health Care Expenditures 70% of us < 10% of hc spending ~ $1000/person 13% 6% 4% 0% 0% 0% 1% 1% 2% Source:Agency for Healthcare Research and Quality MEPS, 1999

13. WHY HI: uneven & unpredictable 73% 20% of people account for 86% of the hc costs Percent of health Care Expenditures 13% 6% 4% 0% 0% 0% 1% 1% 2% Source:Agency for Healthcare Research and Quality MEPS, 1999

14. Goals FRAMING UHC/HCA Concepts: Incentives Social INS MYTHS

15. Myth(understanding)s of True UHC 6600  1 PHI

16. “Market” bureaucracy • How much of each PHI $ to clinical care?

17. PHI = $1,000,000,000,000 Marketing “Cherry pick” Profit PURPOSE !! Administration 2-sided 62%

19. Government: VA & Medicare? VA = 1-2% Medicare = 2-3% NO Marketing/PR Take ALL applicants NO Profit incentive PURPOSE: Health!! Administration Electronic; integrated ONE-system >95%

21. $350B of excess paperwork PNHP NEJM 349(8) Sept. 21, 2003

22. “Excess Spending” -- $2000/p $600 B ADMIN -- $150B Cost Tech Tort Uwe Reinhardt, http://graphics8.nytimes.com/images/blogs/economix/EconomixGraphUve.jpg

24. Myth(understanding)s of True UHC 6600  1 PHI Jobs!?

25. PHI via EBI: BAD for US business COST of healthcare to company / vehicle $1400 Source: Modern Healthcare 10/24/05: 14

26. PHI: BAD for Business • Job-lock • Stymies workforce • Lost potential economic productivity • > COST to insure ALL ! (http://www.iom.edu/CMS/3809/4660/5404.aspx)

27. Myth(understanding)s of True UHC $1,000,000,000,000 !! 6600  1 PHI Jobs!?

28. “Work with” current “system”

29. “Work with” current Bureau of Labor Statistics

30. Many proposals; 2 plans “Work with” current IOM-consistent UNIVERSAL Guaranteed & continuous Lower cost Better inflation-control Focus: CARE EQUITABLE • NOT universal • NOT continuous • Higher ADMIN costs • Focus: ‘coverage’ • NOT equitable – tx NOT based on dz TD Boston, MA

32. Myth: NOT Politically Feasible • MOST of us want it • Public – 60-75% • Physicians – 59%, 2008 (Annals, 1 Apr 2008) • US Conference of Mayors – June 2008 • Already paying for but NOT getting • GOOD for economy • 2.6M jobs; $300B stimulus, nationally1 • ONLY method control HC cost increases 1 http://www.calnurses.org/research/pdfs/ihsp_sp_economic_study_2009.pdf

33. Goals FRAMING CA UHC Act Concepts: Incentives Fin v. Care MYTHS

34. Align Incentives for HC financing ? FOR-profit for-HEALTH $$ WHO: Social insurance

35. WHO would YOU insure? 73% Public Programs Percent of health Care Expenditures PHI 13% 6% 4% 0% 0% 0% 1% 1% 2% Source:Agency for Healthcare Research and Quality MEPS, 1999

36. Myth-understandings • One plan = NO choice • CA UHC is REAL, full choice – of healthCARE provider “The CARE we need, when we need it” • “Choice” of coverage is FALSE choice • Past health status no guarantee of future! • Moral Hazard [i.e. buffet table analogy] • WHO spends leisure time at hospital? • We get HALF the care we need (Rand. McGlynn et al., NEJM 2003) • Bootstraps [“Not MY responsibility to pay for anyone else!”] • You already are • Risk pools lower costs: You can’t do this alone! • HI premiums in CA rising 5x faster than wages

37. Myth-understandings • Increase in taxes • A shift in funding mechanism • NO net increase in spending • Socialized Medicine • Clarify: Social insurance (World Health recommends) • Quality, comprehensive health insurance to ALL • “Patriotic medicine”; “Freedom & equality medicine”

38. Goal of HCA: “Hello, neighbor”

39. Framing Don’t Think of an Elephant, George Lakoff; thanks to Kao-Ping Chua, AMSA JRF, 2006 • A conceptual structure • Your THINKING • Psychology: “schema” • A story

40. The “elephant” frame Big Elephant Animal Grey Floppy ears Frame = story. “Elephant” tells story of a big, grey animal with floppy ears.

41. Framing

42. RE-framing • If a new species of pink elephants evolved… Big Elephant Animal Pink Floppy ears

43. RE-framing • Or if term “pink elephants” became popular… Big Pink Elephant Animal Grey Floppy ears

44. FRAME trumps FACTS “If the truth doesn’t fit the existing frame, the frame will stay in place and the truth will dissipate.” -- George Lakoff • The TRUTH only matters if it fits the frame • Not only WHAT you say; but also HOW • “What frames am I activating with the way I’m talking about my issue?”

45. Messaging vs. reframing REFRAMING MESSAGING • Deeper – • changing one’s relationship & thinking about the world • Use message to associate positive values with the frame of your issue

46. Anti-UHC Frames • Government can’t do anything right • “Free” market more efficient • Individual responsibility (ownership society) • Anti-freeloading/anti-welfare • “Just desserts” aka bootstraps • American exceptionalism • Tax affliction

47. Engage these Frames • Economic efficiency • Security • Family Values • Patriotism • ??

48. Framing comparison Healthcare for ALL Cover UNINSURED 46M uninsured 22,000 die prematurely each year Only cost $B more to ‘cover’ them…. • Increasing costs place all at risk • We’re all 1 pink slip away • We all want health security in order to care for our families

49. Framing comparison Cover EVERYONE Cover UNinsured Universal Health care Universal health care Everyone benefits Only benefits uninsured I’m affected Family’s affected Welfare Self-interest Free-loading Enables laziness Family values

50. ReFrame this!