Norbert I. Goldfield, MD Executive Director, Healing Across the Divides

1. Health Insurance – the Solution or the Problem for Quality Care for Citizens of a “Civilized” Country – The Case of the U.S. Norbert I. Goldfield, MD Executive Director, Healing Across the Divides Medical Director, 3M Health Information Systems, Inc Note: this presentation represents my personal opinion. My institutional affiliations are for identification only

2. President Bush – 2006 State of the Union Speech • “Our government has a responsibility to help provide health care for the poor and the elderly, and we are meeting that responsibility.”

3. Budget Bill that Passed Congress 2 Days After the State of the Union Speech • Budget to Hurt Poor People on Medicaid, Report Says – Report Issued by the Non Partisan Congressional Budget Office. • For example, C.B.O. estimates that about 45,000 enrollees would lose coverage in fiscal year 2010 and that 65,000 would lose coverage in fiscal year 2015 because of the imposition of premiums. About 60 percent of those losing coverage would be children."

4. 18,000 die prematurely Actually ill, uninsured children and adults receive lower and less timely services, leading to increased morbidity and worse outcomes 8 Million uninsured people with chronic illnesses receive inferior services and have increase morbidity and worse outcomes 41 millionuninsured adults and children are less likely to receive preventive and screening services. All of them are at risk for the health consequences shown above 60 millionuninsured individuals and members of their families have less financial security and increased life stress due to lack of insurance People living in communities with a higher than average uninsured rate are at risk to reduced availability of health care services and poor public health resources All Americans

5. Health Spring Inc Rises 13% in First Day of Trading – Wall St Journal February 5, 2006 • Medicare may be giving consumers headaches this year, but it made for a trouble free-initial public offering of stock from Health Spring Inc (a new health insurance company serving Medicare enrollees) on the New York Stock Exchange on Friday.

6. Every few weeks at this point in my 30 yr career I steal insulin for a diabetic patient of mine who cannot afford the payment.OrFrom a societal point of view all we need to see is the American government’s response for our poor and vulnerable after Hurricane Katrina.

7. In this presentation I will provide • A slide outlining the health care system in the U.S. • Basic philosophical assumptions inherent in the current U.S. situation • Data points to illustrate the current and evolving challenges for individuals at risk in the U.S. • A very brief summary of what is being done to address these issues in the U.S.

8. Health Insurance In the U.S. comes from: • From your employment – becoming less common (not mandatory) and the premium itself becomes more expensive (e.g. WalMart executive wrote a memo stating that sick people could be dissuaded from working there by making more jobs involve physical activity and switching to high deductible plans – both were done) • Over 65 AND paid into the Medicare system: Federal government pays. There are substantial copayments and deductibles. Pharmaceuticals are covered under a new bill which is complicated and does not cover many bills. • Poor – definition of poor depends on the state (Massachusetts more generous than Texas; ). • Buy insurance individually – virtually impossible if you have a chronic medical problem such as diabetes.

9. Basic philosophical assumptions inherent in the current U.S. situation

10. How can economists disagree? According to the economist Lester Thurow, economic forecasts and projections vary, depending on the assumptions behind them, all of which are very much based on the political perspectives of economists: "There is an ethical value judgment as to whose income ought to go up or down. This ethical value judgment has nothing to do with technical economics, but it is usually at the heart of differences between liberal and conservative economists....no one talks about liberal or conservative chemists. There are only chemists who in the rest of their lives happen to be liberals or conservatives."9

11. Since the Colonial period, Americans have viewed economic success as a sign of virtue and poverty as the result of a misspent life. In complaining about Americans' unwillingness to help the poor, Horace Mann, a 19th Century observer of American culture, complained: "In this country, we seem to learn our rights quicker than our duties."11 The rights Mann refers to are the libertarian principles enshrined in our constitution. As discussed in this article, libertarianism represents the principal philosophy undergirding America’s legislative decisions with respect to health policy in general and coverage for the uninsured.

12. Robert Nozick best summarizes the philosophical underpinnings of the libertarian perspective. The state, according to Nozick, has only two functions: protection of individual rights and a "monopoly" over the use of force.

13. The issue about what to do with the health-care system is sometimes presented as a technical argument about the merits of one kind of coverage over another or as an ideological argument about socialized versus private medicine. It is, instead, about a few very simple questions.

14. Do you think that this kind of redistribution of risk is a good idea? Do you think that people whose genes predispose them to depression or cancer, or whose poverty complicates asthma or diabetes, or who get hit by a drunk driver, or who have to keep their mouths closed because their teeth are rotting ought to bear a greater share of the costs of their health care than those of us who are lucky enough to escape such misfortunes?

15. In the rest of the industrialized world, it is assumed that the more equally and widely the burdens of illness are shared, the better off the population as a whole is likely to be.

16. The reason the United States has forty-five million people without coverage is that its health-care policy is in the hands of people who disagree, and who regard health insurance not as the solution but as the problem.

17. As Amartya Sen has argued, virtually everybody (outside the United States and China) in the industrialized world today believes in equal rights before the law, equal civil liberties, equality of opportunity. Similarly, most people would accept that not all inequalities are unjust. Inequality in income is an inevitable product of any functioning market economy, though there are questions about the justifiable extent of income inequality. • The idea that people should be consigned to an early death, illiteracy or second-class citizenship because of inherited attributes beyond their control violates most peoples’ (outside the U.S.) sense of what is fair

18. Some libertarians deny the existence of social justice. The free market theorist F.A. Hayek famously argued that it was nonsense to talk about resources being fairly or unfairly distributed. On his account it was up to free markets, not human agency, to determine the appropriate allocation of wealth and assets.

19. , The most important philosophical tension exists between the libertarian foundations of America, characterized by "frontier spirit" and "self-reliance," and the egalitarian spirit, exemplified by "equal opportunity for all." Yet tensions exist even within libertarianism or egalitarianism.

20. Libertarians include not only groups espousing limited or no government involvement in the life of an individual, but also members of organizations that use the language of libertarianism to advocate policies serving their group’s interests.

21. Within American health policy, utilitarianism occupies the political center. In attempting to provide health services for the largest number of people, proponents of utilitarianism attempt to strike a balance between libertarianism and egalitarianism. Evidence based medicine (EBM) is part of utilitarianism. Where does back surgery (poor evidence to support its use), for example, fit in – the politics of utilitarianism.

22. Within egalitarianism there are challenges of a different sort. It is difficult to precisely define from both a policy and a philosophical perspective what is meant by "equal access" for all Americans to health services. Is it “simply” (so simple that it has never happened in the United States):·  An insistence on an equal health care outcome.· Access to an insurance card with the same “floor” of benefits for all or· The right, as is possibly more politically acceptable today in the U.S., to purchase one’s own individual health insurance policy (or a supplemental insurance policy – a key issue in Europe) or…

23. Data points to illustrate the current and evolving challenges for individuals at risk in the U.S.- All Data Points come from Institute of Medicine/ National Academy of Sciences Reports Published in the last 2-4 years

24. Health-Related Outcomes for Children, Pregnant Women, and Newborns • Uninsured children have less access to health care, are less likely to have a regular source of primary care, and use medical and dental care less often compared with children who have insurance. Children with gaps in health insurance coverage have worse access than do those with continuous coverage. As a consequence have higher rates of hospitalization for conditions amenable to good outpatient care

25. Uninsured women and their newborns receive, on average, less prenatal care and fewer expensive perinatal services. Uninsured newborns are more likely to have low birth weight and to die than are insured newborn. Uninsured women are more likely to have poor outcomes during pregnancy and delivery than are women with insurance. Studies have not demonstrated an improvement in maternal outcomes related to health insurance alone.

26. Cancer • Uninsured cancer patients generally are in poorer health and are more likely to die prematurely than persons with insurance, largely because of delayed diagnosis. This finding is supported by population based studies of persons with breast, cervical, colorectal, and prostate cancer and melanoma

27. Chronic Illness • Uninsured adults with hypertension or high blood cholesterol have diminished access to care, are less likely to be screened, are less likely to take prescription medication if diagnoses, and experience worse health outcomes. • Uninsured patients with end stage renal disease begin dialysis with more severe disease than do those who had insurance before beginning dialysis. • Uninsured adults with HIV infection are less likely to receive highly effective medications that have been shown to improve survival and die sooner than those with coverage • Adults with heath insurance that covers any mental health treatment are more likely to receive mental health services and care consistent with clinical practice guidelines than are those without any health insurance or with insurance that does not cover mental health conditions.

28. Black and White Differences in Specialty Procedure Utilization Among Medicare Beneficiaries Age 65 and Older, 1993

29. The Value Lost In Poorer Health – an American argument • Maintaining an uninsured population of 41 million results in a substantial loss of economic value that improved health would provide uninsured individuals • The IOM Committee’s best estimate of the aggregate, annualized cost of the diminished health and shorter life spans of Americans who lack health insurance is between $65 and $130 billion for each year of health insurance forgone. These are the benefits that could be realized if extension of coverage reduced the morbidity and mortality of uninsured Americans to the levels for individuals who are comparable on measured characteristics and who have private health insurance

30. A very brief summary of what is being done to address these issues in the U.S.

31. What to do in the face of the ideology that health insurance is the problem • Local level (town): bringing groups of doctors/hospitals together to provide care for free/minimal cost. • State: Enact state level insurance coverage for all. Mixed results though some movement • National : nothing on universal health insurance. Try to provide better care for the middle class, some poor and hope that will spread to all. Example of post acute care and long term care, Congress just mandated • a demonstration project that might begin to significantly improve post hospital discharge long term care for those with insurance • The identification of preventable complications that occur in hospital; this information could improve care for all hospitalized patients whether insured or not.

32. We must improve the Value of our health care system. Value = Maximum Quality/ Lowest Cost Value can be measured for each type of health care encounter: Ambulatory Visits Hospital Stays Episodes(e.g. year of diabetes care)Long Term Care Quality Cost

33. CRG Severity Index By Group Compared to the Overall Population

34. Number of DM Individuals (numerator) and Admits per 1000 (denominator) By Severity of Illness – Human Centric

35. Coronary Bypass w Cardiac Cath : approximately 10% of all patients with a Cardiac Cath are readmitted within 30days – most are avoidable

36. Rates of Major Heart/LungComplications: e.g. 12.69 % of patients admitted with a stroke develop a major heart problem after hospital admission – today we may extra for these complications many of which are avoidable.

37. Consumer Engagement – A definition • The skills, knowledge, beliefs, and motivations they need to become “activated” or more effectual health care actors • What would it take for consumers to become effective and informed managers of their health and health care? • Much of the preparatory theoretical work has been done by Judith Hibbard • Much of the practical health care system work particularly for complex and/or low-income patients has been done by Bob Master and Lois Simon

38. Domains covered under J. Hibbards Patient Activation Measure • Taking Action I know how to prevent further problems with my health condition

39. Health insurance is THE solution NOT the problem – a life long fight.

40. According to Martin Luther King, “the beauty of nonviolence is that in its own way and in its own time it seeks to break the chain reaction of evil. 10 The increasing number of uninsured represents such an evil.

41. 18,000 die prematurely Actually ill, uninsured children and adults receive lower and less timely services, leading to increased morbidity and worse outcomes 8 Million uninsured people with chronic illnesses receive poorer services and have increase morbidity and worse outcomes 41 millionuninsured adults and children are less likely to receive preventive and screening services. All of them are at risk for the health consequences shown above 60 millionuninsured individuals and members of their families have less financial security and increased life stress due to lack of insurance People living in communities with a higher than average uninsured rate are at risk to reduced availability of health care services and inferior public health resources All Americans

42. Anecdote: A 35 year old single mother of two children came to see me for the first time in early 1998 . Two months prior to her first visit with me, she had suffered a stroke with resultant hemiplegia. She told me that she had gone to the emergency room with headaches. The physician told her that her blood pressure was very high and that she urgently needed medication for control of the blood pressure. She did not have the money to pay for the medication. She did not follow-up with a primary care doctor as she could not afford to pay for the visits. She continued to take Tylenol until she suffered a stroke with the resultant hemiplegia. When she came to me for the first time, she had Medicaid and Medicare (disability) due to her hemiplegia.

43. Italy will have to face globalization as it pertains to health care (etc) – in particular Chinese “Maoist” capitalism • Until the beginning of the reform period in the early 1980's, China's socialized medical system, with ''barefoot doctors'' at its core, worked public health wonders. • From 1952 to 1982 infant mortality fell from 200 per 1,000 live births to 34, and life expectancy increased from about 35 years to 68, according to a recent study published by The New England Journal of Medicine.

44. Italy facing globalization (cont) • Since then, in one of the great policy reversals of modern times, China has dissolved its rural communes, privatized vast swaths of the economy and shifted public health resources away from rural areas and toward the cities. Public hospitals were urged to charge commercial rates for new drugs and most procedures, and today the salaries of health care workers are typically linked to the amount of income they generate for their hospitals.

45. Seeking employment, Mr. Jin set out from his village in Anhui, one of eastern China's poorest provinces, when he was in his early 20's. Living with an uncle in Heilongjiang Province in the far northeast, he collapsed one day while hauling wood. He was taken to a hospital but left without treatment for lack of financial means.

46. I have pessimism of the intellect, optimism of the will – Gramsci, 1920’s I try to be cynical but I can't keep up- Lilly Tomlin