You Bet Your Life: Why We Need a National Health Program

Richard D. Quint, MD, MPHHealth Sciences Clinical Professor of Pediatrics,

Emeritus (UCSF)California Physicians Alliance

Universal Health Care:The International Communist

Conspiracy

US National Health Program Efforts Pre-WWII

• American Association for Labor Legislation, 1915

• Social Security, 1935

The Road to Employment-Based Private Insurance in the US

The Provider - Insurer Pact

• Health insurance plans initially sponsored by hospital and physician organizations

• Hospitals and physicians wrote “cost-based” payment rules

1943-1948: The Murray Wagner Dingell Bill

Keep Politics Out of This Picture

When the life – or health – of a loved one is at stake, hope lies in the devoted service of your Doctor. Would you change this picture? Compulsory health insurance is political medicine. It would bring a third party – a politician – between you and your doctor. It would bind up your family’s health in red tape. It would result in heavy payroll taxes – and inferior medical care for you and your family. Don’t let that happen here!

1965

• Medicare

• Medicaid

1970-19741970-1974

Nixon vs. Kennedy Proposals

The Watery Demise of Health Care Reform

California Activism 1985-89• Anti-patient dumping legislation

• Proposals for Universal Coverage

• Birth of California Physicians’ Alliance and Physicians for a National Health Program

The sincerest form of flattery...

Here Comes the AMA Again...

Proposition Proposition 186186

1994

Number Uninsured

California: 6.6 million

PNHP, 2004; California Healthcare Foundation, 2005

Health Care Options Project (HCOP)

• Convened by California Health and Human Services Agency in 1999

• Examined options for extending health care coverage in California

• Analyzed and compared by consultants from The Lewin Group and AZA Consulting

How do the HCOP Plans Compare?

Incremental Example

Pay or Play Example

Universal Care Example

Reduction in Uninsured

2.6 5.7 6.6

Change in Total Health Spending

+ $1.4 billion + $3.0 billion

-($7.6) billion

2006: Where do we go from here?

First, let’s look at what we’ve got

High quality?Cost efficient?Ready for change?

Overall Health System Performance

The US ranks 37th out of the 191 WHO member states, placing it below

Colombia, Saudi Arabia, and Portugal

WHO 2000 World Health Report

Lack of insurance increases morbidity and mortality

• 18,000 excess deaths per year due to lack of health coverage

• People without health insurance:– Receive less medical care and receive it later– Are sicker when diagnosed– Have 25% higher mortality rates– Earn less because of poorer health– 81% are from working families

“Care Without Coverage”, Institute of Medicine, May 2002“Sicker and Poorer”, Medical Care Research and Review, June 2003

Life Expectancy

78.5 78.479.4 79.7 79.9

81.8

77.2

70

75

80

U.S. U.K. Germany France Canada Italy Japan

Ranking: 21/30; OECD, 2005

Infant Mortality per 1000 Births

5.44.8 4.7

4.2 3.9

3

7

0

1

2

3

4

5

6

7

8

U.S. Canada Australia Italy Germany France Japan

Source: OECD Health Data 2005

MRI Units per Million People

2.7 4.2 5.58.6

10.4

35.3

8.2

0

5

10

15

20

25

30

35

40

France Canada Germany U.S. Denmark Italy Japan

OECD, 2004 (2002 Data, U.S., Canada, and Germany are 2001)

How hard is it to get care?

21

15 15 15

28

0

5

10

15

20

25

30

U.S. Canada New Zealand Australia U.K.

% f

ind

ing

it

dif

ficu

lt t

o g

et c

are

Commonwealth Fund Survey, 1998

Continuity of Care

52%57%

65% 65%

45%

0%

20%

40%

60%

80%

100%

U.S. NewZealand

Canada Australia U.K.

% w

ith

sam

e d

oct

or

> 5

yea

rs

Commonwealth Fund Survey, 1998

Financing healthcare in the U.S.

Individuals / Businesses

Government [payer]

Health Service Providers

Private Insurers [payers]

Direct or Out-of-Pocket Payments

Medicare, Medicaid, etc.

Taxes

Premiums

Public employees’ premiums

Provider Payments

|------Collection of funds-------||---------Reimbursement--------|

Percent of GDP Spent on Health 2003

The Economist, January 27, 2006

Cost Excesses in the US

• Administrative waste

• Over-utilization of non-beneficial high-tech care

• Inadequate, inefficient primary care infrastructure

• Excess pricing of pharmaceuticals

D.McCanne, Quote of the Day, PNHP

Health-care spending per capita, 2005

$3,001

$2,996

$2,903

$2,520

$2,231

$2,139

$5,635U.S.

Canada

Germany

France

Sweden

U.K.

Japan

$ Per Capita

Source: OECD Health Data 2005

Health-care spending per capita, 2005

$3,001

$2,996

$2,903

$2,520

$2,231

$2,139

$5,635U.S.

Canada

Germany

France

Sweden

U.K.

Japan

$ Per Capita

Source: OECD Health Data 2005

Insurance Overhead Spending

$0

$50

$100

$150

$200

$250

$300

$350

U.S. Canada France Australia Germany

$ p

er

cap

ita

OECD, 2003

U.S. Overhead Spending

16.3%

19.9%

26.5%

0%

10%

20%

30%

Medicare Non-Profit Blues CommercialCarriers

Investor-OwnedBlues

International Journal of Health Services 2005; 35(1): 64-90

U.S. Overhead Spending

16.3%

19.9%

26.5%

3.1%

0%

10%

20%

30%

Medicare Non-Profit Blues CommercialCarriers

Investor-OwnedBlues

International Journal of Health Services 2005; 35(1): 64-90

HMO Overhead Spending

14.1%17.3% 17.8% 18.5% 18.9% 19.7% 21.2%

2.4%

0%

10%

20%

30%

Managed Care Magazine July, 2003; Kaiser data: CMA Knox-Keane Report, May 2005

Which administrative costs should we reduce?

Source: Kenneth Thorpe, 1992.

Government Health Insurance for All, Even if Taxes Increase?

Oppose30%

Favor65%

No opinion5%

Slice 40%

Pew Report, May 2005

No opinion 5%

The Institute of Medicine recommends that health-care should…

• Be universal: Everybody in, nobody out• Be comprehensive and continuous• Be affordable to individuals and families• Use an insurance strategy that is affordable and

sustainable for society• Enhance health and well-being by promoting access to

high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable

Institute of Medicine Report, 2004

2006: What are Solutions?

• Market (consumer driven health care)• Incremental Reform • More Major Reform (“national” health care,

“universal” health care, “Medicare for All” or “single payer health care”)– California

• SB 840

– US• HR 676 "Expanded & Improved Medicare For All Bill

(Conyers)"

What does Dobie Gillis have to do with healthcare in California?

State Senator Sheila Kuehl (D, Santa Monica)

California Single Payer SB 840Eligibility

• All state residents eligible.

• Individuals lacking legal immigration status (i.e., “undocumented”) included if they document residence.

California Single Payer SB 840Benefits

• Inpatient and outpatient• ER visits• All physician services• Prescription drugs• Laboratory and diagnostic

tests• Mental health and

substance abuse treatment

• Vision care, incl. glasses• Hearing exams and aids• DME• Home health and adult

daycare• Rehabilitation• Dental care

Single payer financing: simplified

Individuals / Businesses

Government [payer]

Health Service Providers

Direct or Out-of-Pocket Payments

CHIRA

(SB 840)Taxes

|------Collection of funds-------||---------Reimbursement--------|

Projected Savings SB 840: 2006-2015 (in billions)

Year State/local Total2006 0.9 8.02007 1.6 12.32008 2.2 17.02009 2.8 22.42010 3.6 28.42011 4.5 35.02012 5.3 42.22013 6.4 50.22014 7.6 59.22015 8.8 68.9

43.7 331.3

Lewin Report, 2004

Single payer financing: reality

Individuals / Businesses

Government [payer]

Health Service Providers

Direct or Out-of-Pocket Payments

CHIRA

(SB 840)Taxes

|------Collection of funds-------||---------Reimbursement--------|

Private insurers (non-

covered services)

Premiums Provider Payments

California Single Payer SB 840Administration

• Health Care Agency• Elected commissioner• Statewide boards/offices: Health Policy;

Consumer Advocacy; Medical Practice Standards.

• … responsible for financial management of the system; establishing eligibility and benefits; negotiating reimbursement.

California Single Payer SB 840Delivery system

• Private and public, as currently.

• Fee-for-service and capitated (integrated health delivery systems such as Kaiser Permanente). Providers and participants choose one.

• Maintains choice

After SB 840: Anticipated Changes

• Decreased emergency room use• Increased access to care• Improved continuity of care• Increased emphasis on preventative

care and health education• More integrated systems?• Regionalization of high risk services?

Advantages of single payer to…

• Patients:– Improved health

– Free choice of provider

– Portability of coverage

Advantages of single payer to…

• Physicians– Restoration of clinical autonomy

– Lower malpractice premiums

– Improved patient care

– Simplified billing

Advantages of single payer to…

• Businesses– Decreased health care costs

– Level the playing field

– Improved global competitiveness

Potential disadvantages

• Threat of underfunding by hostile government

• Strength of special interests that would seek to undermine the system

• Potential imbalance between quality controls and expenditure growth

Potential disadvantages

• Transition from current system will be difficult

• Important tradeoffs: will America make them?– You can’t give every health care intervention to every person

– Less choice in insurance plan

– More government control for less private control

Sounds Great….How About Political Reality?

What can you do?

First, remember Pogo:

What can you do?

• Educate yourself and others

• Organize sessions on universal health insurance

• Participate in grass-roots organizing

• Support universal health-care legislation

• Write op-ed pieces, letters to editors

• JOIN PNHP and CaPA

What is CaPA?• The California Physicians Alliance, a chapter of

Physicians for a National Health Program (PNHP)

WWW.PNHP.ORG• CaPA’s goals are to:

– Promote universal health access in California and the US

– Protect the provider-patient relationship– Promote justice in health care

• Basic assumptions are:– Health care is a human right– Equity in health care

CaPA-Medical School Organizing Project

capa@jps.net

richardquint@sbcglobal.net

Thanks to……

Bree Johnston, M.D., MPH (UCSF, CaPA)

Kevin Grumbach, M.D. (UCSF, CaPA)

Kao-Ping Chua (MS IV, Washington U.)

Physicians for a National Health Program

In Summary

• Our health Care System is a Disgrace• Part of our Role as Professionals should be

advocating for a system that serves our patients well

• What Can We Do?– Urge our professional societies to support universal

health insurance– Dispel Myths about “Government Run Health Care”– Join groups working for reform

Results by Specialty

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Anesthesiology

Surgical Subspecialty

Family Practice

Obstetrics/Gynecology

Medical Subspecialty

General Surgery

Emergency Medicine

General Internal Medicine

General Pediatrics

Psychiatry

Pediatric Subspecialty

Percent Supporting

Governmental Legislationto Establish NHI

Federal Government asSole Payer for NHI

Ann Intern Med. 2003 Nov 18;139(10):795-801

What would it look like?

• Everyone gets a US NHI card

• Complete choice of doctor and hospital

• Doctors and hospitals remain independent

• Govt processes and pays bills

Other savings

• No more co-pays

• No more deductibles

• No more premiums

• NO MORE OUT OF POCKET EXPENSES

Summary: Universal health care…

• Leads to better outcomes

• Would cost no more or save money

• Americans want it

• So do MDs, but won’t come out for a single-payer approach

• Can be accomplished in California

California Single Payer SB 840Cost-sharing

• No cost sharing for 2 years.

• After 2 years, cost-sharing option with limits of $250 per person/$500 per family per year.

• Exemption for individuals who meet income rules, and for prevention.

“Would you prefer the current system or Universal Health Insurance…”

NHI, 62%

Current, 32%

Don't Know, 6%

Washington Post/ABC News Poll, 10/20/03

Managed Care:

• Another Socialist Conspiracy:– Prepaid Group Practices

• Nixon-Ellwood Conservative Reinvention:– HMOs

Inpatient Days per Capita

1.0 1.01.1 1.1

1.2

0.7

0.0

0.2

0.4

0.6

0.8

1.0

1.2

1.4

U.S. Canada Australia U.K. France Switzerland

OECD, 2004, (2001 Data)

Impact of SB 840 on State and Local Government Health Spending: 2006-2015

(billions)

Current Spending

Net Transfer to Single-Payer

Net Savings

2006 $18.7 $17.7 ($0.9)

2007 $20.0 $18.4 ($1.6)

2008 $21.4 $19.2 ($2.2)

2009 $22.9 $20.1 ($2.8)

2010 $24.5 $20.9 ($3.6)

2011 $26.3 $21.8 ($4.5)

2012 $28.2 $22.9 ($5.3)

2013 $30.5 $24.1 ($6.4)

2014 $32.8 $25.2 ($7.6)

2015 $35.2 $26.4 ($8.8)

Lewin Report, 2004

2005: Where are we now, and are we ready for universal healthcare?

• Eroding safety net• Market (consumer driven health care)• Reform Proposals

– California• Children’s “100% Campaign”• SB 840

– US• The United States National Health Insurance Act (HR676 - C

onyers) ("Expanded & Improved Medicare For All Bill")

• Physician’s Proposal (PNHP)

Gov’t Insurance for All, Even If Taxes Increase

0 20 40 60 80 100

Total

Enter.

Soc. Con.

Pro-Gov. Con

Upbeats

Disaffect.

Con. Dems

Dis. Dem.

Liberals

Oppose

Favor

Pew Survey, 2005

What About MDs?

1.Support or oppose governmental legislation to establish national health insurance?

2.Support or oppose a national health insurance plan where all health care is paid for by the federal government?

Ann. Intern. Med. 2003

Government Legislation to Establish NHI

Generally

Strongly

Generally

StronglyOppose

40%

Support

49%

Neutral

11% Ann Intern Med. 2003 Nov 18;139(10):795-801

Government as Single Payer

Generally

StronglyGenerally

Strongly

Oppose

60%

Support

25%

Neutral

14%

Ann Intern Med. 2003 Nov 18;139(10):795-801

Percent of Children Immunized (MMR)

84.5% 85.9%94.5% 99.0% 100.0%91.6%

0.0%

20.0%

40.0%

60.0%

80.0%

100.0%

U.K. France U.S. Canada Denmark Japan

OECD, 2004, (2002 Data)

Infant Deaths by Income

3.94.7

5.1 5.2

6.5 6.8

0

1

2

3

4

5

6

7

8

Wealthiest20%

Middle 20% Poorest20%

U.S.Average

EDUCATE & ADVOCATE

WORK FOR INCREMENTAL REFORMS

When a Political Opening Comes,

MOVE FAST!!

Myth: Canadians don’t get mental health services

6.311.3

26.3

37.1

3.4

10.4

27.7

52.3

0

10

20

30

40

50

60

Nodisorder

MildDisorder

ModerateDisorder

SevereDisorder

Per

cen

t re

ceiv

ing

car

e

U.S.

Canada

Health Affairs 2003; 22(3): 128

By What Criteria Should We Judge Reform Proposals? Institute of Medicine Report: 2004

• Health care coverage should be universal. • Health care coverage should be continuous. • Health care coverage should be affordable to

individuals and families. • The health insurance strategy should be

affordable and sustainable for society. • Health insurance should enhance health and

well-being by promoting access to high-quality care that is effective, efficient, safe, timely, patient-centered, and equitable.

Universal healthcare should…

• Cover everybody

• Be comprehensive and continuous

• Be simpler – one payer, one plan

• Be accountable – transparent and public

• Maintain choice

Institute of Medicine Report, 2004

How would such a system contain costs?

• Set Budget• Health planning• Negotiate

reimbursement• Formulary• Prevention• Simplify

Administration

profile of the uninsured

• 45.5 million non-elderly Americans in 2004• 64% from low-income families• 81% from working families• 80% are adults• 52% are ethnic minorities• 79% are American citizens• More likely to be employed in small businesses,

service industries, and blue-collar jobs

You Bet Your Life: A Marxist

Approach to Health Care in the U.S.? (Or Why We Really Need a National

Health Plan)

Richard Quint, M.D., M.P.H.California Physicians Alliance

0

5

10

15

20

25

30

35

40

19

75

19

80

19

85

19

90

Number of Uninsured in the US

Source: US Census Bureau, Current Population Surveys

National Health Programs

• Germany: 1883

• UK: 1912, 1948

• Canada: 1947, 1971

• Japan: 1922, 1961

1992

Health Care Reform:

“An Aura of Inevitability”

-George Lundberg, JAMA

A NATIONAL HEALTH PROGRAM FOR THE UNITED STATES: A Physicians' Proposal

DAVID U. HIMMELSTEIN, M.D., STEFFIE WOOLHANDLER, M.D., M.P.H., AND THE WRITING COMMITTEE OF THE WORKING GROUP ON PROGRAM DESIGN

New England Journal of Medicine 320:102-108 (January 12), 1989

The Human Cost: Personal Bankruptcies*

Medical

Other

54%46%

*N=1771 bankruptcy filersHealth Affairs, February 2, 2005

Myths About US Health-care

• It’s the best

• A national health program would be more expensive

• Americans don’t want change

Myths about US health-care

• Better outcomes under national health programs

• A national health program would be more expensive

• Americans don’t want change

Four scenarios: Spending reductions 2006-2015 (billion)

0

200

400

600

800

1000

1200

Mandates Expansion FEHB Single-payer

National Coalition on Health Care, May 2005

Myths about US health-care

• Universal healthcare leads to better outcomes

• Universal health care would save money

• Americans don’t want change

Summary: Universal health care…

• Leads to better outcomes

• Saves money

• Americans want it

• What are the prospects for changes?

FINANCING UNIVERSAL HEALTHCARE

MEDICARE

MEDICAID

EMPLOYERPAYROLL

TAX

EMPLOYEEPAYROLL

TAX

SINGLE PAYER HEALTHCARE

FUND

$$$$$$$$$$

Rx

EYE CARE

DOCTOR

Lewin 2004

Objectives: Understand…

History of universal healthcare movement

Current state of US health-care system

Universal health insurance legislation in California