Health Care in the U.S. and the World

1. Health Care in the U.S. and the World Martin Donohoe

2. Determinants of Health Era Socioeconomic status Sex Race Location Environment Genetics Health Habits Access to Care

3. The State of U.S. Health Care • 52 million uninsured • 45,000 deaths/year • 30 million more underinsured • Remain in dead-end jobs • Go without needed care and/or prescriptions • Marry

5. Reasons for No Health Insurance Coverage (2009)

8. The State of U.S. Health Care US ranks near the bottom among westernized nations in overall population health (#24), life expectancy (#42), infant and maternal mortality, etc. 15% of Americans live in poverty 22% of US children live in poverty

13. Health Care Expenditures per Capita • U.S. = $7,960 • Canada, Australia, Japan, Europe: $3,000 to $6,000 • Average for low income developing nations = $22-25

14. Who Pays for Health Care? • Government (federal, state, and local) • Medicare, Medicaid, VA, IHS, jails and prisons • Private insurance • Primarily employer-based • Out-of-pocket • Health care costs = 17.6% of GDP (1/2 of worldwide health care costs)

21. Health Insurance Industry • Delisting • Cherry picking • Pre-existing conditions

22. Health Insurance Industry • High administrative costs • 15-30% (vs. 2-3% for Medicare and Medicaid) • Average full-time physician spends over $85,000/yr on billing and insurance functions • 17,849 different billing codes (in 2012 increases to 141,058)

23. Health Insurance Industry • Amount actually spent on patient care referred to as “medical loss ratio” • Large profit margins • Median pay of health care CEOs = $10.6 million (2010) • Loyalty: shareholders (not patients) • Corruption

26. Distribution of National Health Expenditures

27. Some Reasons for Rising Health Care Costs • Aging population • Chronic diseases • Technological advances • Exploding drug costs • Increasing specialist referrals

28. Some Reasons for Rising Health Care Costs Procedural variability Overuse of diagnostic tests, medications, and therapeutic procedures Administrative costs

31. Drug Companies’ Cost Structure

32. Innovation:Published Research Leading to Drugs

33. Premature Deaths in the U.S. 10% due to inadequate medical care 60% due to behaviors, social circumstances, and environmental exposures

34. Address Social Factors Responsible for Illness and Death • Deaths in 2000 attributable to: • Low education: 245,000 • Racial segregation: 176,000 • Low social support: 162,000 • Individual-level poverty: 133,000 • AJPH 2011;101:1456-1465

35. Address Social Factors Responsible for Illness and Death • Deaths in 2000 attributable to: • Income inequality: 119,000 (population-attributable mortality – 5.1%) • Area-level poverty: 39,000 (population-attributable mortality – 1.7%) • AJPH 2011;101:1456-1465

36. Address Social Factors Responsible for Illness and Death • Deaths in 2000 attributable to: • AMI – 193,000 • CVD – 168,000 • Lung CA – 156,000 • AJPH 2011;101:1456-1465

37. Major Contributors to Illness and Death 40% of US mortality due to tobacco, poor diet, physical inactivity, and misuse of alcohol Every $1 invested in programs covering above items saves $5.60 in health care costs

38. Prevention 2-4% of national health care expenditures Every $1 spent on building biking trails and walking paths would save nearly $3 in medical expenses Every $1 spent on wellness programs, companies would save over $3 in medical costs and almost $3 in absenteeism costs

39. Public Health Spending Public health spending minimal Mortality rates fall 1-7% for every 10% increase in public health spending

40. Compliance 33% of prescriptions go unfilled Only 50-65% of patients take medicines as prescribed Noncompliant patients more likely to be hospitalized and to die Noncompliant patients have twice the annual medical care costs of those who are compliant Cost, health literacy contribute to noncompliance

41. Poverty and Hunger US: 15% of residents and 22% of children live in poverty Rates of poverty in Blacks and Hispanics = 2X Whites Poverty associated with worse physical and mental health

42. Economic Disparities • Women 75 cents/$1 Men • Median income of black U.S. families as a percent of white U.S. families 62% • 60% in 1968 • 63% for Hispanic families

44. Educational Apartheid High levels of de facto school segregation by race and SES Gross discrepancies in per-pupil spending and teacher salaries Achievement and graduation gaps growing

45. Urban/Rural Disparities 25% of the U.S. population lives in rural areas Only 10% of U.S. physicians practice in rural areas

46. Racial Disparities in Health Care Coverage • Percent uninsured: • Whites = 12% • Asians = 17% • African-Americans = 21% • Hispanics = 32% • Undocumented immigrants = 100% (emergency care exception) • CA Proposition 189

47. Racial Disparities in Health Care:African-Americans Higher maternal and infant mortality Higher death rates for most diseases Shorter life expectancies Less health insurance Undergo fewer diagnostic tests / therapeutic procedures

49. Health Disparities Among Latinos • Higher rates of: • Overweight and obesity • Certain cancers • Stroke • Diabetes • Asthma/COPD • Chronic liver disease/cirrhosis • HIV/AIDS • Homicide

50. Racial Disparities in Health Care:African-Americans • Equalizing the mortality rates of whites and African-Americans would have averted 686,202 deaths between 1991 and 2000 • Whereas medical advances averted 176,633 deaths • AJPH 2004;94:2078-2081