Is It “Rest in Peace” for a National Health Program?

2. Is It “Rest in Peace” for a National Health Program? Richard Quint, MD, MPH California Physicians Alliance Health Sciences Clinical Professor of Pediatrics (Emeritus), UCSF

3. The Health Care Crisis • Description • Causes • Solution

4. Illustrative Case: Ms. Jones 52 yo divorced woman , twin 18 yo sons, has family health insurance through her job as a store clerk. Bored. Becomes a real estate agent (no job benefits). Uses COBRA to buy an interim policy. Income $60,000 per year. Develops breast cancer while on COBRA. Receives potentially curative surgery, radiation, and chemotherapy. COBRA expires. Shops for individual policy. Insurers either refuse to sell her a policy or offer an outrageously expensive one ($ 2,300 per month with a $5,000 per year deductible). She becomes uninsured. Unable to afford daily drug to prevent breast cancer recurrence and so takes it only every 3rd day.

5. Ms. Jones just went from here….. 73% 80% uses less than $1000 of care per year Percent of health Care Expenditures 13% 6% 4% 0% 0% 0% 1% 1% 2% Source:Agency for Healthcare Research and Quality MEPS, 1999

6. …..To here: 73% 20% use 86% of the care Percent of health Care Expenditures 13% 6% 4% 0% 0% 0% 1% 1% 2% Source:Agency for Healthcare Research and Quality MEPS, 1999

7. U.S. Health Expenditures 2008: $2.2 trillion 70% spent on services & infrastructure Source: Centers for Medicare&Medicaid Services 30%

13. The Health Care Crisis in USA • High Cost • ~$7000 spent per capita is double that of other industrialized nations: >16% of our GDP • Costs are rising rapidly and 2-3X faster than CPI • Decreased Access • 47 million uninsured • > 60 million underinsured • Impaired Quality • Chaotic “system” • Poor health outcomes

14. Major Causes of Rising Costs • Aging population, burden of chronic disease • Rising cost of health insurance premiums • Expensive new technology • Administrative waste • Pharmaceuticals • Unnecessary care • Delayed care sicker patients

15. Changes in Health Insurance Premiums vs. Workers’ Earnings & Inflation Bureau of Labor Statistics

16. % with employment based coverage 19 % uninsured 18 17 16 15 14 Decreased Access: Falling Job-Based Insurance & Rising Uninsurance Custer WS 1999

17. Impact of the Economic Collapse • 1% increase in unemployment 1.1 million more uninsured • Since January, 2008: 4 million uninsured/under-insured • Increased out-of-pocket expenses, medical debt: increased personal bankruptcy Kaiser Family Foundation Report October, 2008

18. 47 Million Uninsured = Combined Population of 24 States Alaska Oregon Idaho Nevada New Mexico Arizona Utah Hawaii N Dakota S Dakota Montana Oklahoma Iowa Kansas Arkansas Mississippi Maine Vermont New Hampshire Delaware Connecticut Rhode Island W Virginia Missouri In addition, 1/5 of those with insurance are really underinsured (drug costs, deductibles, out of pocket expenses, etc.)

19. Quality of Care • Too little care • Uninsured or underinsured can’t access care • Hurried office visits • Crowded ER’s , closed trauma centers • Too much care • Unnecessary care • Duplicated care • Uncoordinated care • Many specialists, few primary care doctors • Changing insurance carriers • Poor outcomes • 45,000 deaths per year due to lack of health coverage • USA ranked 37th in overall quality by WHO

20. Covers only workers Employer’s discretion Excludes or penalizes sickest Complex administration Costly Uninusurance Open ended expenses Answers to investors • I. Dysfunctional health insurance Private insurance • Job-based • For-profit • Multiple plans, pools • Fee for service (FFS) • FFS rewards procedures Public insurance • Limited eligibility • Tied to state budgets II. No real health care system based on population needs. Most adults 21-65 excluded Eligibility/means testing Capricious, low funding Low reimbursement Few providers accept it Cost shifting No way to rationally allocate resources, plan or budget Root Causes of Health Care Crisis

21. 2009: Where do we go from here?

22. Status of Current Health Reforms • Oregon • Tennessee • Vermont • Minnesota • Washington • Maine • Massachusetts

23. Principles for Reforming Health Care • Universal coverage • Comprehensive scope of coverage: all necessary care • Equitably distributed and portable • High quality with improvement in health • Choice • Affordable • Shared responsibility for funding: individuals, employers, government • Sustainable funding mechanism • Accountable, transparent Institute of Medicine, 2004

24. Real vs. Phony Universal + Mainly the healthy Comprehensive + Exclusions, high deductibles Permanent + High loss potential Affordable + High contributions relative to income, stripped-down benefits Choice + Restricted lists of providers Quality fostered Poorer pay less, get less Efficiency promoted Administrative waste SB 810 HR 676 HR 3200, Sen. Finance

25. The Only Rational Solution for Health Care Reform: “Medicare For All” How it works: • Everyone in single insurance pool • All private insurance replaced by a single public insurer • Funding: • Fold in existing public programs for poor, disabled, elderly, gov’t workers, (veterans) • Replace all premiums and out-of-pocket expenses with an equitable tax on employers, workers, and individuals • Delivery of Care: remains private (not socialized) • Governance: public agency with representation of various stakeholders

27. Challenge for Current Legislation: How to Balance... Paying for healthcare with accessibility and quality of care www.washingtonpost.com/wp-dyn/content/article/that2009/11/02/AR2009110201285.html

28. Health insurance will be mandated • Can people afford it (i.e., how high will deductibles and copayments be)? • Will government subsidies be high enough? • Will coverage be adequate? Real impact will be on the middle class Is the Public Option a diversion from the issue of affordability?

29. Can we hold private insurers accountable on costs other than through a government option? No. Why? Because there are no caps or controls on premium costs in the legislative proposals.

30. “Providing health care to all Americans would require a redistribution of wealth.” (Altman) “A single payer system is the simplest, most efficient, and equitable method of redistributing wealth in order to provide truly universal healthcare.” (McCanne) Drew Altman, Washington Post interview, 2 November, 2009 Don McCanne, former president PNHP, 3 November, 2009

31. Another Balancing Act Benefits packages Premiums to be charged Unregulated premium increases Eligibility for insurance exchanges The size of deductibles, copayments, and co-insurance Financial support for out-of-pocket expenses Payment for non-covered out of network services Variable contribution rates for employers Federal and state budget limits on levels of government spending Financing Medicaid programs Financing administrative services Taxes on healthcare products and/or insurance plans……

32. Challenge for Current Legislation Paying for healthcare while assuring accessibility and quality of care… …can be accomplished best with a single payer, or “Medicare for All” system.

34. Is It “Rest in Peace” for a National Health Program?

35. Inpatient and outpatient ER visits All physician services, including pregnancy Prescription drugs Mental health and substance abuse treatment Rehabilitation Vision care, incl. glasses Hearing exams and aids Durable Medical Equipment Home health and adult daycare Dental care Laboratory and diagnostic tests The Return of SB810

36. What can you do? • Educate yourself and others • Organize sessions on changing the healthcare system • Participate in grass-roots organizing • Support “Medicare for All” legislation • Write op-ed pieces, letters to editors • JOIN AMSA (www.amsa.org) and CaPA (www.capa.pnhp.org)

37. FIN

39. What are we getting for our money? From Krugman & Wells, NY Review of Books,March 23, 2006

40. Overall Health System Performance The US ranks 37th out of the 192 WHO member states, placing it below Colombia and Portugal WHO 2000 World Health Report

41. Uninsured Californians • 54% are Latinos • Ages 0-64: 28% Latinos vs. 9% whites uninsured • Employer-based insurance: 43% Latinos vs. 73% whites • Children 0-17: Latinos 21% vs. whites 6% (nationwide) Latino Coalition for a Healthy California, January 2005; Pediatrics 2008

42. Health Disparities: Diabetes Mellitus (DM) • Adults >50 y with DM: 20% Latinos vs. 10% whites • 68% Latinos with DM take their medications vs. 78% whites • Medication use (Latinos): 73% insured vs. 49% uninsured • Glucose monitoring (Latinos): 39% insured vs. 22% uninsured Latino Coalition for a Healthy California, 2005

43. Health Disparities: Latinos and Cancer (CA) • Women have the highest rate of cervical CA in California • Latinas twice as likely as whites to develop cervical CA and die from it • PAP smears: obtained by 92% of Medi-Cal recipients and only 80% of uninsured • 60% Latino males never screened for prostate CA Latino Coalition for a Healthy California, 2005

44. Latino Migrant Workers • 40% female migrant workers and 56% of migrant workers’ children have never seen a dentist • Male migrant workers have never: visited an M.D. or clinic (33%); seen a dentist (50%); had an eye care visit (67%). Latino Coalition for a Healthy California, 2005; California Migrant Worker Health Survey, 1999

45. Cost Excesses in the US • Administrative waste • Excess pricing of pharmaceuticals • Over-utilization of non-beneficial high-tech care • Inadequate, inefficient primary care infrastructure D.McCanne, PNHP 2006

46. Failures of Our Current System • Many uninsured • Benefits not comprehensive • Coverage may be transient • Low affordability • Limited choice • Fragmented, inefficient, and wasteful • Inconsistent quality • Negative impact on business

47. Real vs. Phony Universal + Mainly the healthy Comprehensive + Exclusions, high deductibles Permanent + High loss potential Affordable + High contributions relative to income, stripped-down benefits Choice + Restricted lists of providers Quality fostered Poorer pay less, get less Efficiency promoted Administrative waste SB 840 HR 676 Democrats’ plans………

49. Number Uninsured California: 6.9 million PNHP, 2004; California Healthcare Foundation, 2006

50. Phony Choice of HMO/insurer Coverage = Copays, exclusions etc. Security = Lose it if you can’t work or can’t pay Savings = Less care Real Choice of doctor and hospital Coverage = First $, Comprehensive Security = For everyone, forever Savings >$300 bil on bureaucracy Phony vs. Real Reform