Medicare for All!!Medicare for All!!

Paul Y. Song, MDPaul Y. Song, MD

Physicians for a National Health ProgramPhysicians for a National Health Program

Hippocratic OathHippocratic Oath

““I will follow that system of regimen, which I will follow that system of regimen, which according to my ability and judgment, I according to my ability and judgment, I consider for the benefit of my patients, and consider for the benefit of my patients, and abstain from whatever is deleterious and abstain from whatever is deleterious and mischievous”.mischievous”.

The ProblemThe Problem The US spends $2.5 Trillion a year which is 17.3% of our The US spends $2.5 Trillion a year which is 17.3% of our

GDP on healthcare and more than any other GDP on healthcare and more than any other industrialized country in the world by far. industrialized country in the world by far.

The CBO estimates it will grow to 25% of our GDP by The CBO estimates it will grow to 25% of our GDP by 2025.2025.

The average family premium is $14,000 a year.The average family premium is $14,000 a year.

17% of American income now goes to pay for health 17% of American income now goes to pay for health care.care.

75 million Americans are underinsured.75 million Americans are underinsured.

The number of uninsured in the US now exceeds 50.7 The number of uninsured in the US now exceeds 50.7 million and has actually increased since the passage of million and has actually increased since the passage of the healthcare bill.the healthcare bill.

Broken System??Broken System??

The Commonwealth Fund 6/23/10

51 Million Americans 51 Million Americans Without Insurance TodayWithout Insurance Today

4545

4040

3535

3030

2525

2020

Source: Himmelstein, Woolhandler, Carrasquilo – Tabulation from CPS and NHIS data

Mill

ion

s of

Un

insu

red

Am

eri

can

s

19801980 19851985 19901990 19951995 200020001976 2008

Who are the Uninsured?Who are the Uninsured?

FULL-TIME WORKER 66.5%

PART-TIME WORKER 14%

Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2008 and 2009 Current Population Survey (CPS: Annual Social and Economic Supplements).

NON-WORKER19.5%

Of the 50.7 million, over 20 million are fully employed and Of the 50.7 million, over 20 million are fully employed and 70% of all uninsured are from families with one or more full-time 70% of all uninsured are from families with one or more full-time workers.workers.

Uninsured DeathsUninsured Deaths

50,000 annual deaths are 50,000 annual deaths are attributed simply to a lack of attributed simply to a lack of coverage.coverage.

Medical Related BankruptciesMedical Related Bankruptcies

Number of medical related bankruptcies Number of medical related bankruptcies increased 50% during the last 9 years.increased 50% during the last 9 years.

In 2011, it is estimated that there will be In 2011, it is estimated that there will be over 4 million bankruptcies.over 4 million bankruptcies.

- 2/3 are due to a medical illness.2/3 are due to a medical illness.

Most of the Medically BankruptMost of the Medically BankruptHad Insurance CoverageHad Insurance Coverage

Source: Himmelstein et al. Am J Med, Aug. 2009

Insurance at onset of illness

Hard for Employers Too!Hard for Employers Too!

For every For every $100$100 that US companies spend on that US companies spend on health care, companies in Japan, Germany, health care, companies in Japan, Germany, France, and Canada spend France, and Canada spend 6363 cents which cents which leads to more off-shoring of jobs and less leads to more off-shoring of jobs and less job creation.job creation.

Ford spent $3.2 Billion on health premiums; Ford spent $3.2 Billion on health premiums; Prior to the bailout, GM spent more on Prior to the bailout, GM spent more on health premiums than on steel.health premiums than on steel.

It is estimated that health care costs add It is estimated that health care costs add $1500-2000 to the sticker price of a US $1500-2000 to the sticker price of a US made car.made car.

The For-Profit Insurance Industry The For-Profit Insurance Industry is Not Your Friend!is Not Your Friend!

Take 31 cents out of every dollar away from actual patient Take 31 cents out of every dollar away from actual patient care.care.

Increase overall health care costs by discouraging people Increase overall health care costs by discouraging people from receiving preventative care and by driving the sick from receiving preventative care and by driving the sick into more expensive care settingsinto more expensive care settings

1/6 of all policies are actually grossly inadequate to cover a 1/6 of all policies are actually grossly inadequate to cover a serious illness.serious illness.

70% of losses (money paid out in claims) goes to cover 70% of losses (money paid out in claims) goes to cover about 10% of their subscribers creating a powerful about 10% of their subscribers creating a powerful incentive to screen subscribers and harass them to drop incentive to screen subscribers and harass them to drop their coverage and go elsewhere.their coverage and go elsewhere.

They encourage higher deductibles and co-pays by They encourage higher deductibles and co-pays by increasing premiums to insure they cover very little.increasing premiums to insure they cover very little.

The For-Profit Insurance Industry The For-Profit Insurance Industry is Not Your Friend!is Not Your Friend!

Over the past 9 years:Over the past 9 years:

Only recession proof industry that consistently raises Only recession proof industry that consistently raises prices 10-15% every year regardless of the economy. Far prices 10-15% every year regardless of the economy. Far outpacing inflation.outpacing inflation.

Average premiums have increased nearly 120%Average premiums have increased nearly 120%

– Profits at the 10 largest publicly traded insurance Profits at the 10 largest publicly traded insurance companies have rose 428% (reported).companies have rose 428% (reported).

– Average annual CEO salary at these companies was Average annual CEO salary at these companies was $11.9 Million which is 468 times what the average US $11.9 Million which is 468 times what the average US worker makes.worker makes.

– In CA, the six largest insurers denied over 45.7 million In CA, the six largest insurers denied over 45.7 million claims in the last six years.claims in the last six years.

CEO Salaries (2008)CEO Salaries (2008)

Roy Williams – CEO Aetna - Roy Williams – CEO Aetna - $ 24,300,122$ 24,300,122 H. Edward Hanway – Cigna - H. Edward Hanway – Cigna - $ 12,236740$ 12,236740 Angela Bray – Wellpoint - Angela Bray – Wellpoint - $ 9,844,212$ 9,844,212 Dale Wolf – Coventry Healthcare - Dale Wolf – Coventry Healthcare - $ 9,047,469$ 9,047,469 Michael Niedorff –Centene - Michael Niedorff –Centene - $ 8,744, 483$ 8,744, 483 James Carlson – Amerigroup - James Carlson – Amerigroup - $ 5,292,546$ 5,292,546 Michael McAllister – Humana - Michael McAllister – Humana - $ 4,764,309$ 4,764,309 Jay Gellert – Health Net - Jay Gellert – Health Net - $ 4,425,355$ 4,425,355 Steven Helmsley – United Health Group - Steven Helmsley – United Health Group - $ 3,241,042$ 3,241,042

Billy Tauzin – CEO PhRMA - Billy Tauzin – CEO PhRMA - $2,000,000$2,000,000 Karen Ignani – Amer. Health Insurance Plans - Karen Ignani – Amer. Health Insurance Plans - $ $

1,580,0001,580,000

Anthem Blue Cross proposed 39% rate increases in 2010.

Whenever profits are not enough, patients get crucified!!

Blue Shield of California proposed to raise health insurance rates a whopping 59% for individual policyholders in 2011, saying the increase is “absolutely necessary” to deal with rising health care costs and restrictions in the new health care law.

Insurance Industry EffortsInsurance Industry Efforts

4525 lobbyists for the 535 Congressional 4525 lobbyists for the 535 Congressional members (8:1) – 450 lobbyists are former members (8:1) – 450 lobbyists are former congressional staffers and 12 were former congressional staffers and 12 were former Max Baucus Staffers.Max Baucus Staffers.

$1.4 Million was spent each day!!$1.4 Million was spent each day!!

$260+ Million was spent by the health $260+ Million was spent by the health insurance industry and big Pharma – more insurance industry and big Pharma – more than on the 2004 Bush-Kerry presidential than on the 2004 Bush-Kerry presidential campaign.campaign.

Insurance stocks hit a 52 week high once Insurance stocks hit a 52 week high once there was no public option.there was no public option.

June 17, 2009 – As 22 Senators began hearings and work on healthcare reform, the room was full of registered healthcare Lobbyists.

Easy to Blame the GOP, but…Easy to Blame the GOP, but…

The Democrats had a supermajority for most of The Democrats had a supermajority for most of the debate.the debate.

60%60% of all money went to Democrats. of all money went to Democrats.

Max Baucus (Chairman of the Senate Finance Max Baucus (Chairman of the Senate Finance Committee) received over $2 million.Committee) received over $2 million.

Ben Nelson received more money from the health Ben Nelson received more money from the health insurance industry than any other industry.insurance industry than any other industry.

Joe Lieberman received over $1 million and his Joe Lieberman received over $1 million and his wife was employed by several healthcare and wife was employed by several healthcare and Pharma companies.Pharma companies.

Arguments Against ReformArguments Against Reform

““Will explode the deficit!”Will explode the deficit!”

Nixon/Ford: Nixon/Ford: 6.8% per year6.8% per year

Carter: 2.0% per Carter: 2.0% per yearyear

Reagan: -1.3% Reagan: -1.3% per yearper year

Bush 1: 4.0% Bush 1: 4.0% per yearper year

Clinton: 2.5% Clinton: 2.5% per yearper year

Bush Jr: 8.2% Bush Jr: 8.2% per yearper year

Arguments Against ReformArguments Against Reform

““Will explode the deficit!”Will explode the deficit!” ““This is the largest government run This is the largest government run

health care program ever”.health care program ever”.

Originally passed in 2004 at a projected cost of

$400B over 10 years, some estimates suggest it will cost over $900 Billion.

Passed by a GOP controlled house and senate led by then Rep. Billy Tauzin (R-

La) who left immediately after its passage to become the head of PhRMA.

Arguments Against ReformArguments Against Reform

““Will explode the deficit!”Will explode the deficit!”

““This is the largest government run This is the largest government run health care program ever”.health care program ever”.

““Socialized medicine”Socialized medicine”

Socialized Medicine was popularized by a public relations firm working for the American Medical Association in 1947 to disparage President Truman's proposal for a national health care system.

It was a label, at the dawn of the cold war, meant to suggest that anybody advocating universal access to health care must be a communist.

And the phrase has retained its political power for six decades.

“If you don’t stop Medicare and I don’t do it, one of These Days, you and I are going to spend our sunset years telling our children, and our children’s children

what it once was like In America when men were free”

- Ronald Regan 1961

The original meaning of “socialized medicine” was confined to systems in which the government owns and operates health care facilities and employs health care professionals, support staff, and all ancillary workers.

England, Germany, Israel, Sweden, Finland, New Zealand, France, Canada, Taiwan, Japan all have “socialized medicine”.

October 22, 2009 - Veterans Health Care Budget Reform And Transparency Act

More than 1400 hospitals, clinics and nursing homes, 14,800 doctors, 61,000 nurses , and 5 million patients.

Rand Corporation found that 67% of veterans received appropriate care compared to 55% for the general public.

University of Michigan study found 83% satisfaction for Veterans compared to 73% for general public.

Let the Free Market Let the Free Market Rule!Rule!

There currently is no free market! Only two There currently is no free market! Only two industries in the US have antitrust exemptions – industries in the US have antitrust exemptions – Major League Baseball and The Health Insurance Major League Baseball and The Health Insurance Industry.Industry.

There has been heavy consolidation and near There has been heavy consolidation and near monopolies established in the past 10 years.monopolies established in the past 10 years.

One or two insurers generally control the top 94 One or two insurers generally control the top 94 metropolitan areas in the US.metropolitan areas in the US.

In some states like Alabama, 90% have Blue Cross.In some states like Alabama, 90% have Blue Cross.

By allowing insurers to sell across state lines, By allowing insurers to sell across state lines, patient protections will be reduced due to variations patient protections will be reduced due to variations between states.between states.

So What Did We End Up With?So What Did We End Up With?

The Patient Protection and Affordable Care The Patient Protection and Affordable Care Act, not Obamacare.Act, not Obamacare.

It is not socialized medicine or a It is not socialized medicine or a government takeover of medicine.government takeover of medicine.

There are no death panels.There are no death panels.

CBO estimates it will cost $940 Billion over CBO estimates it will cost $940 Billion over the first 10 years.the first 10 years.

Majority of the provisions will not begin Majority of the provisions will not begin until 2014.until 2014.

Impact of Health Reform Impact of Health Reform On the UninsuredOn the Uninsured

Problems With the Reform BillProblems With the Reform Bill $475 Billion subsidy to the insurance $475 Billion subsidy to the insurance

industry that forces 30 Million Americans to industry that forces 30 Million Americans to buy coverage from these companies that do buy coverage from these companies that do not care about patients!not care about patients!

23 Million people will still be uninsured nine 23 Million people will still be uninsured nine years from now.years from now.

Millions of middle income people will be Millions of middle income people will be forced to buy commercial policies costing up forced to buy commercial policies costing up to 9.5% of their income, but covering only to 9.5% of their income, but covering only 70% of their medical expenses, leaving them 70% of their medical expenses, leaving them still very vulnerable to medical related still very vulnerable to medical related bankruptcies due to high deductibles and co-bankruptcies due to high deductibles and co-pays which will still be permitted.pays which will still be permitted.

Fee-For-ServiceFee-For-Service

Problems With the Reform BillProblems With the Reform Bill While Insurers will no longer be able to deny While Insurers will no longer be able to deny

coverage or set maximum caps, they will still be able coverage or set maximum caps, they will still be able to increase co-pays, deductibles, and premiums to increase co-pays, deductibles, and premiums which will only serve to preclude access to which will only serve to preclude access to healthcare.healthcare.

Enforcement of new regulations such as ending Enforcement of new regulations such as ending denials on the basis of pre-existing conditions are denials on the basis of pre-existing conditions are riddled with loopholes and waivers, and there is riddled with loopholes and waivers, and there is nothing to prevent older people or women from nothing to prevent older people or women from being charged more based on age or gender until being charged more based on age or gender until 2017.2017.

– HHS has already scaled back rules on health insurance HHS has already scaled back rules on health insurance appeal denials making the process even more difficult appeal denials making the process even more difficult for patients!for patients!

People with employer based coverage will remain People with employer based coverage will remain locked in their plans and have no choice of providers locked in their plans and have no choice of providers or hospitals. No competition for most of us!or hospitals. No competition for most of us!

Medicare – A Single Payer Medicare – A Single Payer System!!System!!

Established in 1965 when only 56% of adults over 65 Established in 1965 when only 56% of adults over 65 years of age were insured.years of age were insured.

Prior to Medicare, 1/3 of all seniors were living in poverty.Prior to Medicare, 1/3 of all seniors were living in poverty.

Commonwealth Fund Study (5/09) – Medicare patients had Commonwealth Fund Study (5/09) – Medicare patients had much greater satisfaction, better access to care, and much greater satisfaction, better access to care, and fewer billing problems than those with employer fewer billing problems than those with employer sponsored plans.sponsored plans.

Kaiser Family foundation study showed greater overall Kaiser Family foundation study showed greater overall satisfaction and much more cost efficiency than private satisfaction and much more cost efficiency than private insurance companies.insurance companies.

Medicare spends approximately 3.6% on administrative Medicare spends approximately 3.6% on administrative costs and 96.4% on actual patient care!costs and 96.4% on actual patient care!

Patients have greater choice and do not need pre-Patients have greater choice and do not need pre-authorizations.authorizations.

Medicare – A Single Payer Medicare – A Single Payer System!!System!!

The government does not tell doctors how to The government does not tell doctors how to practice, what tests to order, which hospitals to go practice, what tests to order, which hospitals to go to, or what medications to prescribe.to, or what medications to prescribe.

It is the private insurance companies that tell It is the private insurance companies that tell patients who to see, where to go, and what doctors patients who to see, where to go, and what doctors can do.can do.

Since 2008, more providers are dropping more Since 2008, more providers are dropping more patients with private non capitated insurance than patients with private non capitated insurance than patients with Medicare.patients with Medicare.

A Few Sick People Drive Most CostsA Few Sick People Drive Most Costs

Decile of privately insured

Percentage of total health spending in 2001

Source: MEPS data, from Thorpe and Reinhart

Top two deciles account for 78.3%

of spending

Top two deciles account for 78.3%

of spending

Current Medicare Has LimitationsCurrent Medicare Has Limitations Medicare doesn’t cover everything – 45% of outpatient mental Medicare doesn’t cover everything – 45% of outpatient mental

health services, no dental coverage.health services, no dental coverage.

Medicare Part B which covers doctors’ services generally pays Medicare Part B which covers doctors’ services generally pays for 80% of all reasonable charges, leaving seniors responsible for 80% of all reasonable charges, leaving seniors responsible for the remaining 20% which can be very expensive when for the remaining 20% which can be very expensive when dealing with a life threatening or serious illness.dealing with a life threatening or serious illness.

Medicare is fully privatized and there is no price negotiations Medicare is fully privatized and there is no price negotiations for bulk purchasing.for bulk purchasing.

Without PPACA, Medicare is forecast to be bankrupt by 2016.Without PPACA, Medicare is forecast to be bankrupt by 2016.

Due to the anticipated savings due to PPACA of more than Due to the anticipated savings due to PPACA of more than $120 Billion, Medicare should now be insolvent in 2024.$120 Billion, Medicare should now be insolvent in 2024.

In 1999, the Bipartisan Commission on the Future of Medicare In 1999, the Bipartisan Commission on the Future of Medicare predicted that Medicare would be bankrupt by 2008. predicted that Medicare would be bankrupt by 2008.

                                                                

“I think very likely what the president intends is that Medicare will go broke and ultimately that answer will be Obamacare for senior citizens”

- Michele Bachmann 8/25/09

Private insurers waste Private insurers waste 3131 cents of every dollar on cents of every dollar on overhead, sales and overhead, sales and marketing, lobbying, billing, marketing, lobbying, billing, underwriting, and exorbitant underwriting, and exorbitant executive compensation.executive compensation.

This waste is now estimated to This waste is now estimated to be over $400 Billion a year!!be over $400 Billion a year!!

Administrators Are Growing Administrators Are Growing Faster Than PhysiciansFaster Than Physicians

Source: Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of CPS

3,0003,000%%

2,0002,000%%

1,0001,000%%

001970 1980 1990 2000 2009

Physicians

Physicians

Administrators

Administrators

Single Payer SystemSingle Payer System Single payer financing is the only way to recapture this Single payer financing is the only way to recapture this

wasted money and provide comprehensive coverage to wasted money and provide comprehensive coverage to everyone without paying more than we already do.everyone without paying more than we already do.

Would be financed by eliminating private insurance and Would be financed by eliminating private insurance and recapturing their administrative waste. recapturing their administrative waste.

Modest new taxes would replace premiums and costs Modest new taxes would replace premiums and costs would be controlled through negotiated fees, global would be controlled through negotiated fees, global budgeting, and bulk purchasing.budgeting, and bulk purchasing.

Unified risk pool – everybody in, nobody out, continuous Unified risk pool – everybody in, nobody out, continuous which would provide a new financial solvency to Medicare!!which would provide a new financial solvency to Medicare!!

Everybody contributes to fund health care based on ability Everybody contributes to fund health care based on ability to pay.to pay.

Transparency and Accountability to the publicTransparency and Accountability to the public

We can save over $4 Trillion in the next 10 years with a We can save over $4 Trillion in the next 10 years with a Medicare for All program.Medicare for All program.

Covering Everyone and Covering Everyone and Saving MoneySaving Money

Additional costsAdditional costsCovering the uninsured and poorly-insured +7.2%Covering the uninsured and poorly-insured +7.2%Elimination of cost-sharing and co-pays +5.1%Elimination of cost-sharing and co-pays +5.1%

SavingsSavingsBulk purchasing of drugs & equipment -2.8%Bulk purchasing of drugs & equipment -2.8%Reduced hospital administrative costs -1.9%Reduced hospital administrative costs -1.9%Reduced physician office costs - 3.6%Reduced physician office costs - 3.6%Reduced insurance administrative costs -5.3%Reduced insurance administrative costs -5.3%Primary care emphasis & reduce fraud -2.2%Primary care emphasis & reduce fraud -2.2%

Net (Savings)Net (Savings) -4.3% -4.3%

Source: Health Care for All Californians Plan, Lewin Group, 2005

Single Payer SystemSingle Payer System Physicians would still be able to practice medicine the way they Physicians would still be able to practice medicine the way they

think is best, but with far less paperwork and administrative think is best, but with far less paperwork and administrative costs!! costs!!

Average private practice currently spend about 25% on Average private practice currently spend about 25% on administrative costs. This would save about $70,000 a year.administrative costs. This would save about $70,000 a year.

All medically necessary care is covered. Patients would have All medically necessary care is covered. Patients would have choice of physician and treatment. choice of physician and treatment.

Strong emphasis on comprehensive, focused, and preventative Strong emphasis on comprehensive, focused, and preventative care in a timely manner.care in a timely manner.

Would lead to higher wages as employers would not have to pay Would lead to higher wages as employers would not have to pay for healthcare premiums.for healthcare premiums.

Would lead to more capital investments by companies.Would lead to more capital investments by companies.

CA Nurses Association study found it would create 2.6 Million new CA Nurses Association study found it would create 2.6 Million new jobs and infuse $317 Billion in new business revenue.jobs and infuse $317 Billion in new business revenue.

Patients would not feel trapped in their current jobs due to the Patients would not feel trapped in their current jobs due to the fear of losing their health care coverage.fear of losing their health care coverage.

Benefits/Portability Benefits/Portability

preventative carepreventative care primary careprimary care inpatient hospital inpatient hospital

care care outpatient careoutpatient care emergency careemergency care prescription drugsprescription drugs

durable medical equipment durable medical equipment long term carelong term care mental health services mental health services dentistry dentistry eye careeye care substance abuse substance abuse

treatmenttreatment

Patients have unlimited choice of physicians, hospitals, and clinics regardless of location

USNHI will cover all medically necessary servicesUSNHI will cover all medically necessary services, , including:including:

Single Payer SystemSingle Payer System

HR 676 – Expanded and Improved HR 676 – Expanded and Improved Medicare Act for All - Conyers (now Medicare Act for All - Conyers (now with 64 co-sponsors)with 64 co-sponsors)

California SB 810 – Mark LenoCalifornia SB 810 – Mark Leno

GOALS OF H.R. 676GOALS OF H.R. 676

To ensure that all people living in the To ensure that all people living in the United State have:United State have:

A single standard of high-quality, A single standard of high-quality, affordable health care guaranteed by affordable health care guaranteed by federal lawfederal law

Access to health care services whenever Access to health care services whenever medical attention is neededmedical attention is needed

Who is Eligible?Who is Eligible?

Every personEvery person living in the United living in the United States is eligible from birth States is eligible from birth throughout lifethroughout life

Every personEvery person living in the United living in the United States and the U.S. Territories would States and the U.S. Territories would receive a United States National receive a United States National Health Insurance Card & ID number Health Insurance Card & ID number once enrolledonce enrolled

Accessing Healthcare Services Accessing Healthcare Services Under H.R. 676Under H.R. 676

All patients are presumed eligible to receive All patients are presumed eligible to receive services, even if not carrying card at time of services, even if not carrying card at time of needneed

Patients will be able to seek treatment from Patients will be able to seek treatment from the physician, clinic or hospital of their choicethe physician, clinic or hospital of their choice

Source: Carroll & Ackerman, Ann Int Med 2008;148:566

Growing Physician Support for NHI

Support NHI, 2007

Generally, 31%

Strongly, 28%

Neutral, 9%

No, 32%

Support NHI, 2002

Generally, 31%

Strongly, 18%

Neutral, 11%

No, 40%

Surveys of Random Samples of U.S. Physicians, 2002 & 2007

We Have What it Takes!

•Excellent hospitals, empty beds

•Well-trained professionals

•Superb research

•Current spending is sufficient