National Health Insurance

1. National Health Insurance Kenneth Brummel-Smith, M.D. Charlotte Edwards Maguire Professor & Chair, Department of Geriatrics Florida State University College of Medicine

2. Current “System” • 1000 insurers (over 4000 different policies) • Rationing happens here • Wait times for elective surgeries • Preventive care for uninsured and some insured • Chronic care for uninsured • Higher dissatisfaction by patients and Drs • Huge profit margins of insurance companies

3. Billing Clerks • We have 900 billing clerks at Duke (900 bed hospital). I’m not sure we have a nurse per bed, but we have a billing clerk per bed. It’s obscene. Dr. Uwe Reinhardt, hearing on healthcare reform, US Senate Finance Committee, November 19, 2008 • This is how we do “market-based” care • 30% of the health care dollar goes to administration • Canadian hospitals average 2 billing clerks

4. Definitions • Universal coverage – everybody has some form of insurance coverage • Socialized medicine – medical care system is owned and managed by the government • Drs are employed by government • Hospitals are owned by the government • Single payer national health insurance – there is one insurance program for all

5. Many Models

7. 18,314 Adult Deaths Annually Due to Uninsurance

11. Half of Americans Live Where Population Is Too Low for Competition A town’s only hospital will not compete with itself Source: NEJM 1993;328:148

14. “Mandate” Model - Problems • Absent cost controls, expanded coverage unaffordable • Computers, care management, prevention not shown to cut costs • Adds administrative complexity and cost; retains wasteful private insurers • Impeccable political logic, economic nonsense

15. We Are Partly There! • We already have single payer • Medicare • We already have socialized medicine • Department of Defense • Veterans Administration • We already have regulated insurance • Federal Employees Health Benefits • We spend more than anyone else

17. Funding For National Health Insurance • Income Source • Medicare $ • Medicaid $ • DOD, VA $ • Personal income tax – top 5% • Payroll tax similar to current health payments • Small tax on stock & bond transactions • Expenditures • Hospitals (operating) • Hospitals (capital) • Fee-for-service providers • Home care agencies • Long term care providers • HMOs • Malpractice subsidy? • Education subsidy?