america’s crisis: the uninsured donna e. sweet, md, macp professor of medicine the university of...
TRANSCRIPT
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America’s Crisis: The Uninsured
Donna E. Sweet, MD, MACPProfessor of Medicine
The University of Kansas School of Medicine - Wichita
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U.S. Uninsured 2003 to 2004
• The number of uninsured rose from 45 45 million to million to 45.845.8 million- million-15.6%15.6% of the of the populationpopulation
• The fourth straight year of increases• The number of uninsured has increased
by 66 millionmillion since 2000• Middle-Class losing coverage at fastest
rate
US Census Bureau, US Dept. of Commerce, AUGUST 29, 2006
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U.S. Uninsured2004 to 2005
• The percentage of people without The percentage of people without health insurance coverage rose health insurance coverage rose
from from 15.6 %15.6 % to to 15.9 % 15.9 %
46.646.6 million peoplemillion people
1.US Census Bureau, US Dept. of Commerce, AUGUST 29, 2006
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Over 46 Million Americans are now without Health Insurance
Coverage
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Making preventive medicine and existing treatment therapies available to uninsured will…
•Increase overall access to health care
•Substantially contribute to a reduction in the total burden of illness facing the U.S.
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Uninsured Americans Experience Reduced Access to Health Care
• Are less likely to have a regular source of care.
• Are less likely to have had a recent physician visit.
• Are more likely to delay seeking care.
• Are more likely to report they have not received needed care.
• Are less likely to use preventive services.
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Uninsured Americans Experience Poorer Medical
Outcomes• Experience a generally higher mortality
• specifically higher in-hospital mortality.
• May be up to three times more likely than privately insured individuals to experience adverse health outcomes.
• Have been found to be up to four times as likely as insured patients to require both avoidable hospitalizations and emergency hospital care.
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Infant / Maternal Mortality in the U.S.
• US ranks 25 / 29 of the developed countries in infant mortality:• 6.8 deaths / 1000 live births• (Iceland – 2.7 / 1000 births)
• US ranks 22 / 29 of the developed countries in maternal mortality:• 9.9 deaths / 1000 births• (Switzerland 1.4 deaths/100,000 births)
Source: ACP News 2007
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On an Average Day in the US…
11,266Babies are born
1,393Babies are born preterm
(less than 37 weeks gestation)
1,156Babies are born to teen mothers
(<20 years)
909Babies are born low birth weight
(less than 2500 grams or 5 ½ pounds)
329Babies are born with a birth defect
224Babies are born very preterm
(less than 32 weeks gestation)
166 Babies are born very low birth weight
(less than 1500 grams or 3 ½ pounds)
77Babies die before reaching their first birthday
Source: Perinatal Data Companion 2007 Edition – March of Dimes
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Medical Treatment for the Uninsured is…
•Often more expensive than
preventative, acute,
and chronic care of the insured
•Often is more likely received in the Emergency Department
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The World Health Organization's ranking of the world's health systems
2000 Report
1 France 2 Italy3 San Marino4 Andorra 5 Malta 6 Singapore 7 Spain 8 Oman9 Austria 10 Japan
31 Finland 32 Australia 33 Chile34 Denmark35 Dominica 36 Costa Rica
38 Slovenia39 Cuba40 Brunei
37 United States
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Coverage Clearly Matters
• Uninsured adults have a 25% greater risk of premature death
• The Institute of Medicine estimates that the number of excess deaths each year among uninsured adults, age 25-64, is 18,000
http://covertheuninsured.org/factsheets/display.php?FactSheetID=116
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For Comparison…
• Estimated annual deaths in the under age 65 population in the U.S. due to the following causes:
• Diabetes 17,500• Stroke 19,000• HIV / AIDS 14,100• Homicide 19,700
http://covertheuninsured.org/factsheets/display.php?FactSheetID=116
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Potential Years of Life LostPer 100 People for All Causes
premature death preventable at any age
5.081
3.666 3.536 3.3862.938 2.84
0
1
2
3
4
5
6
U.S. Germany Canada Australia Sweden Japan
OECD, 2005
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Who Are The Uninsured?
Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS
*Students>18, Homemakers,
Disabled, Early retirees
Employed50%
Children25%
Unemployed5%
*Out of labor force20%
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Percentage of Children Without Health Insurance, By Poverty Level, 1997-2005
1997 1998 1999 2000 2001 2002 2003 2004 2005Notes: Survey method change in 2005 affects comparison with earlier years slightly. Children less than 18 years old.Source: L. Ku, “Medicaid: Improving Health, Saving Lives,” Center on Budget and Policy Priorities analysis of National Health Interview Survey data, August 2005.
Children below 200% of poverty
Children above 200% of poverty
23%
14%
6%5%
21%
5%
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Access Problems for Middle Class Families
(Income $25,000-$49,999)
22% 23%
13% 12%
0%
5%
10%
15%
20%
25%
Postponed Needed Care Problem Paying Bills
Didn't Get Needed Drug Collection Agency Call
NPR/Kaiser Survey, June2002
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Current System
Who Profits?
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Drug Companies Profits 1996-2004
% Return on Revenue
5
17.1
3.9
16.1
5.2
18.5
5.1
18.6
5.3
18.6
3.3
18.5
3.1
17
4.6
14.3
5.2
15.8
02468
101214161820
1996 1997 1998 1999 2000 2001 2002 2003 2004
Fortune 500 Median Drug Companies
Fortune 500 rankings for 1995-2004
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Drug Companies’Cost Structure
Taxes7%
R&D13%
Marketing/Adm35%
Manufacturing27%
Profits(after taxes)18%
Health Affairs 2001:20(5):136
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MEDICAL MALPRACTICE INSURANCE
2000-2004
9.6%
134.5%
0%
20%
40%
60%
80%
100%
120%
140%
160%
Payout Increase Premiums Increase Gross Losses Paid Gross Premiums Written
Falling Claims and Rising Premiums in the Medical Malpractice Insurance Industry, July 2005
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Growth of Registered Nurses and Administrators, 1970-2002
Bureau of Labor Statistics & Himmelstein/Woolhandler/Lewontin Analysis of CPS data
0%
500%
1000%
1500%
2000%
2500%
1970 1975 1980 1985 1990 1995 2002
Gro
wth
sin
ce 1
97
0
Administrators RNs
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Growth of Physicians and Administrators, 1970-2002
Source: Bureau of Labor Statistics & NCHS
0%
500%
1000%
1500%
2000%
2500%
1970 1975 1980 1985 1990 1995 2002
Gro
wth
sin
ce 1
970
Administrators Physicians
Bureau of Labor Statistics & Himmelstein/Woolhandler/Lewontin Analysis of CPS data
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Administrative Expenses & Profit
% of premium 1998
33%26% 25% 25%
18%15% 14%
1.30%
0%
10%
20%
30%
Best
Week L
ife/H
ealt
h S
peci
al R
eport
4/1
2/9
9 f
rom
SEC
filli
ngs
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Administrative Expenses & Profit% of premium 2000
3.10%
16.30%19.90%
26.50%
0.00%
5.00%
10.00%
15.00%
20.00%
25.00%
30.00%
Medicare Non Profit Blues
Commerical Carriers Investor Owned Blues
International Journal of Health Services 2005:35(1):64-90
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Administrative Expenses & Profit
% of premium 2005
23.1%21.4%
19.4%17.1% 16.8% 16.1%
0%
10%
20%
30%
com
pan
y 1
0-K
, year-
en
d fi
lings
wit
h t
he S
ecu
riti
es
and E
xch
an
ge C
om
mis
sion
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Current System
Cost
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Nations Health Spending per person 2003
$2,231$2,903 $2,996 $3,003
$5,635
$0.00
$1,000.00
$2,000.00
$3,000.00
$4,000.00
$5,000.00
$6,000.00
per capita
U.K. France Germany Canada U.S.
OECD Health Data 2005, OECD, Paris, 2005.
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U.S. Health Spending
0
200
400600
800
1000
1200
1400
16001800
2000
1980 1990 2000 2002 2003 2004
Billion
$255
$717
$1359$1608
$1741$1878
California HealthCare Foundation
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U.S. Health Spending % of Gross Domestic Product
9.1%
12.4%13.8%
15.4% 15.9% 16.0%
0.00%
2.00%
4.00%
6.00%
8.00%
10.00%
12.00%
14.00%
16.00%
1980 1990 2000 2002 2003 2004California HealthCare Foundation
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U.S. Health Spending per person
$3,910$4,267
$4,726$5,485
$6,280
$0
$1,000
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
1996 1998 2000 2002 2004California HealthCare Foundation
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Employer Health BenefitsCumulative Changes
2000-2006
0%11%
25%43%
59%73%
87%
7%4%
10%12% 15% 20%
3% 5% 7% 10% 14%18%
0%10%20%30%40%50%60%70%80%90%
100%
2000 2001 2002 2003 2004 2005 2006
Health Ins Premium Overall Inflation Workers' Earnings
Employer Health Benefits 2006 Survey, KFF
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% of Workers CoveredOffering & Not Offering
Employers
63%
65%
63%62%
61%60%
59%
56%
57%58%
59%60%
61%
62%63%
64%65%
2000 2001 2002 2003 2004 2005 2006
Covered Workers
Employer Health Benefits 2006 Survey, KFF
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Average Annual Premium Contribution 2006
$3,615
$2,973
$627
$8,508
$0 $2,000 $4,000 $6,000 $8,000 $10,000 $12,000 $14,000
Worker Employer
$11,480 Family
$4,242 Single
Employer Health Benefits 2006 Survey, KFF
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Employers’ Health Benefits Cost U.S. Vs. Canada
% of Salaries and Wages8.0%
0.6% 0.7%0.5%
0.7%0.4% 0.1%
0%
1%
2%
3%
4%
5%
6%
7%
8%
Medical Disability Dental Vision Care etc
US Canada
KPMG:WWW.GOV.MB.CA
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Hospital Billing & Administration U.S. Vs. Canada
$487
$85
$0
$100
$200
$300
$400
$500
$ per Capita
U.S. Canada
Woolhandler/Himmelstein/Campbell NEJM 2003:349:768 UPDATED
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A Major Cause of Bankruptcy
Over 50% of personal bankruptcies caused by illness and medical costs
75% of those bankrupted by medical bills had insurance at the time they got sick
Nortons Bankruptcy Adviser, May 2000Health Affairs/online/February,2005
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Health Coverage
Single Risk Pool
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Current System• 1/3 of Americans are uninsured or
underinsured• Denies care to millions with illnesses• Premature death rate higher than other
wealthy countries• Cost double Canada’s, Germany’s, or
Sweden’s and rising faster• Executives and investors making billions• Destruction of the doctor/patient
relationship
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Current System• Hospitals with empty beds• Enough well trained
professionals but rural areas inadequately served
• Excellent research• Current spending could cover
everyone
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Advantages of Single Risk Pool Health Care
• Comprehensive Health Coverage for everyone -all needed care,no co-pays or deductible
• Greater choice of provider
• Health decisions made by patient and provider
• Public accountability for quality and cost, but minimal bureaucracy
• Eliminates the high overhead cost of multiple private, for-profit insurances. Reduces administrative costs from up to 33% to 1-5%.
• Fee for service with simplified negotiated fee schedule- simplified reimbursement
• Improved Health Planning
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Funding For a Single Risk Pool
Revenue• Federal funds
designated for Medicare & Medicaid
• State & local government funds
• Employer / Employee taxes
Reimbursements• Hospitals,
operating & capital• Healthcare
Providers• Home care
agencies• Long term care
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2005 Poll Preference Financed by Taxpayers
Single Risk Pool
30% Current
65% Single Pool
5% Don’t Know
Pew Report, May 2005
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Employee Advantages
• Choice of employer not based on health care coverage
• Employer concerned with job performance not your health condition
• Health coverage not based on location
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Employer Advantages
• Employer would not be responsible for employee health coverage
• No bargaining with labor unions over health benefits
• No competing on health benefit costs
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U.S. Business Competitiveness
• In 1994, Jack Smith, former CEO of General Motors, said he "personally favored the Canadian system" of health coverage.
• Auto manufacturers and other companies are voting for single-risk pool health care by moving plants to Canada (e.g., Toyota, Ford, General Motors & Microsoft Support).
• In 2005, it was reported that the cost of employee health care to manufacturers adds $1,500 to the cost of a U.S.-made car.
"Critical Condition," James Steele
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National Coalition on Health Care Report
Impacts of Health Care ReformProjections Of Costs And Savings (2006 to 2015) 4 Alternative Solutions
• Employer & individual mandate: total savings= $320.5B
• Expansion of existing public programs for the uninsured: total savings= $320.5B
• Creation of new programs for the uninsured: total savings= $369.6B• Establishment of a universal publicly financed
program: total savings= $1,136Btotal savings= $1,136BKenneth E. Thorpe , Ph.D., Department of Health Policy and ManagementRollins School of Public Health, Emory University
A report prepared for the National Coalition on Health Care,2005
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Massachusetts' New Healthcare Law
• Requires the uninsured to buy their own private coverage
• Assumes that private insurers will offer affordable, comprehensive policies
• Costlier than promised• Out of reach for most of the uninsured• Increases the cost of state subsidies to the
poor• Cost will force more employers to drop
coverage• The program is simply not sustainable
David U. Himmelstein, M.D.Steffie Woolhandler, M.D.
Cambridge, Mass., April 6, 2006
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CanadianHealthcare System
• Canadian doctors are in private practice. Doctors are guaranteed payment by the provincial government according to the standard fees.
• Services not covered or only partially covered such as prescription drugs, dentistry and optometry are paid by the private sector . Many Canadians have private health insurance, often through their employers, that cover these expenses.
• Private clinics offer some of the same services as the public system such as hip replacements and MRI scans. Selling private health insurance that could cover these procedures is legal in several provinces.
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Health Savings Account
vs
Comprehensive
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Health Savings Account (HSA)
• Plans with very high deductibles-$2000 to $15,000/family per year
• High coinsurance rate-25% to 35% after deductible
• Tax free HSA to pay deductible and coinsurance
• Only covered services count toward deductible
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Early Experience withHealth Savings Account
HSAHSA Health Plan with deductible Individual $1000+ Family $2000+
Comprehensive Comprehensive Health Plan with no deductible or less than Individual $1000Family $2000
December 2005 EBRI Issue Brief No. 288
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Satisfaction WithHealth Plan
63%
42%
8% 26% 11%33%
0%
10%
20%
30%
40%
50%
60%
70%
Extremely or VerySatisfied
Not Satisfied Not Likely to Stay
Comprehensive Health Savings Acct.
Dece
mber
2005 E
BR
I Is
sue B
rief
No. 288
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HSA Health Plans Worse Access
% Foregoing Needed Care
17%
24%
10%
20%
11%
23%27%
38%
0%5%
10%15%20%25%30%35%40%
RxFilled Test or treament MD vist Any 4 ProblemsLess than $500Deductible More than $499 Deductible
Commonwealth Fund Bienneal Ins Survey, 2003
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Problems with HSA Health Plans
• Must have a health plan before qualifying for a health saving account
• Decreases necessary care• Discourages preventive care/early intervention• Very high administrative cost• Many unable to pay ruinous medical bills• Makes the current health care crisis worse• Enriches a few people• 2005-Only 1% of health plans have HSA
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The American College of Physicians Plan
• that ACP believes the final authorizing legislation should include:
• Expanded eligibility and funding to cover all • currently eligible children • and to provide coverage to more children from lower
income families.
• The College said that the current funding levels in the bill are insufficient and noted that they are substantially lower than the budget resolution approved by Congress on May 7.
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The American College of Physicians Plan
• A federal grant program to support states that redesign their Medicaid and SCHIP programs around the Patient-Centered Medical Home (PCMH). • The PCMH provides patients with care coordinated
by a primary care physician. • The potential of this model to improve care and lower
costs is supported by the experience of states, like North Carolina, that already are implementing it, and by numerous studies on the beneficial impact of care coordinated by primary care physicians.
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The American College of Physicians Plan
• Higher taxes on tobacco, such as proposed by Senators Baucus and Grassley. • Given the fact that smoking is the number one
cause of preventable deaths in the United States and a huge contributor to the growing numbers of patients with chronic diseases covered by federal government, funds from higher tobacco taxes should be applied to the SCHIP reauthorization and to avert Medicare physician payment cuts.
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Martin Luther King, Jr.
"Of all the forms of inequality, injustice in health care is the most
shocking and inhumane."