1. HEALTH CARE FOR ALL Myths and Reality Rob Stone MD FACEP
Introduction and opening stories
Rob Stone MD FACEP

2. THE PROBLEM OF THE UNINSURED
46 Million is 16% of the population.
Indiana has 800,000 uninsured
To get 46 million take all of Indiana, plus Texas, Florida, and Connecticut.
Indiana has a population a little over 6 million

3. Uninsured Americans CPS and NHIS Data
This is the picture of an epidemic.
CPS and NHIS Data

4. Who are the uninsured?
Most of the uninsured have jobs. Some have 2 or even 3 jobs.
This is one of the myths. They aren’t losers, they are workers and children.
*Students>18, Homemakers,
Disabled, Early retirees
Source: Himmelstein & Woolhandler - Tabulation from CPS

5. Lack of Insurance Increases Mortality
18,000 excess deaths per year due to lack of health coverage
People without insurance: Receive less care and receive it later - Have 25% higher mortality rates - Receive poorer care when they are in hospitals
This is the fifth leading cause of death in the US
The safety net is full of holes
On 9/11 a little over 3000 died at one time.
The reason they call it a safety “net” is because of the holes.
Care Without Coverage, Institute of Medicine, May 2002

6. This slide is to demonstrate that I’m not afraid to pander to base emotionality!
And it makes a point that the uninsured really miss out on preventative care.
Also note the sponsors: COC, Business Roundtable

7. Medical Bankruptcy in Indiana
2004 estimate: 55,000 bankruptcies
Almost 28,000 related to medical costs
Affecting 77,000 family members
75% had coverage at start of illness
Average out of pocket medical expenses leading to bankruptcy - almost $12,000.
Examples of a broken ankle leaving tonight, or appendicitis.
Himmelstein et al, Health Affairs 2/2/05

8. A Brief History Wage and price controls in WW II
Truman pushes for National Health Insurance AMA opposes.
A new story that has a sort of happy ending, at least for one man.

9. Red Baiting
“Would socialized medicine lead to socialization of other phases of life? Lenin thought so. He declared socialized medicine is the keystone to the arch of the socialist state.”
AMA Pamphlet 1949

10. A Brief History (continued)
The birth of the Blues
The Great Society: Medicare and Medicaid 1965
The Clinton Health Plan 1993
The death of the not-for-profit Blues
And here’s the happy ending: Larry Glassock

11. Anthem (formerly Blue Cross) Now Wellpoint
CEO Larry Glassock is in Indianapolis
The highest paid executive in Indiana
Bonus announced in 2003 was $42.5 Million
Indianapolis Star 4/7/04

12. Where Does the Money Come From?
And Where Does It Go?

14. US Versus Other Countries
The red line is the amount of our spending that comes from tax dollars, already more than the others spend. The green line is
out of pocket.
2004 data published 1/06: total health spending $1.9 trillion, $6,280 per capita, 16% GDP.
OECD, 2004 & Health Affairs 2002; 21(4): 99
2004 data Health Affairs 1/06: $1.9 trillion or $6,280 per capita

15. And Where Does It Go? The money is going to: - Overhead - Inefficiency
- Waste
- Profit
- And graft

16. Growth of Physicians, RNs & Administrators 1970-1998
Percentage Growth
Bureau of Labor Statistics, NCHS

17. What Do Administrators Do? Cost Shifting.
The $5 aspirin pill
The $500 ER bill
“Skimming the cream off the top”: Avoiding the costly, the very sick, and the uninsured
It’s called “GAMING THE SYSTEM” or “SURVIVOR”

18. What Are We Paying for? A Very Complex System
7000+ private health plans
An army of people to deny health insurance coverage and payments
And an army of people to try to maximize and receive health insurance payments
An army of people to determine who is eligible for what program

19. U.S. Overhead Spending
Now this is usually when you start hearing people complain that the LAST people to run the healthcare system is the government.
After all, the government is obviously inefficient, right? Right? Well, this may surprise you…
International Journal of Health Services 2005; 35(1): 64-90

20. U.S. Overhead Spending
Medicare is a lean, mean, billing machine.
Look at the investor-owned Blues, that’s why they are Wall Street darlings
International Journal of Health Services 2005; 35(1): 64-90

21. Health Care Administration US and Canada
US administrative spending = $399.4 Billion or 31% of total health care costs.
Canada spends 17% on administrative overhead.
Potential savings = $286 Billion, enough to cover the uninsured and then some.
THE problem in the US is the insurance companies.
Woolhandler et al. NEJM 349: /21/2003, CBO, GAO

23. …. And Graft
“Investor ownership has been shown to compromise quality of care in hospitals, nursing homes, dialysis facilities, and HMO’s; for-profit hospitals are particularly costly. A wide array of investor-owned firms have defrauded Medicare and been implicated in other illegal activities.”
References are available.
Journal of the American Medical Association, 8/13/03

24. Columbia/HCA
Fined $1.7 Billion in 2003 for Medicare fraud, the largest fine in Medicare history.
No one went to jail.
CEO Richard Scott left with a $10 million severance package and over $300 million in stock.
Here is just one example.
Woolhandler, Canadian Medical Journal 6/8/04

25. And What Do We Get For All Our Money?
The most expensive health care in the world, no doubt.
The best health care in the world?
How would you measure the best health care in the world? *

26. Life Expectancy
Can’t necessarily ascribe life expectancy figures to availability of universal healthcare, as lifestyle issues also are in factor.
But the US has the 9th lowest life expectancy of the OECD member countries.
US ranked 27th, right after Barbados; OECD, 2004, (2001 Data)

27. Infant Mortality per 1000 Births
The US has the 7th highest infant mortality rate of the 30 OECD member countries.
Countries with a higher IM are Hungary, South Korea, Mexico, Poland, Turkey, and the Slovak Republic.
Ranked 36th, below Cuba and Taiwan OECD, 04

28. WHO Global Health Rankings
Based on outcomes AND fair distribution of care
At the top: #1. France, #2. Italy
US ranks 37th, between Costa Rica and Slovenia
Bartlett and Steele, Critical Condition, 2004

29. Satisfaction with Health Systems in Ten Nations
Harris Poll taken in US, Canada, UK, Germany, Australia, France, Sweden, Japan, Italy, and Holland.
The U.S. had the lowest health care satisfaction rate (11 percent) of the 10 nations.
The people here know they aren’t getting good care, and this was done in ‘90. It would be worse today.
And the other countries are proud of their systems, and overall very satisfied.
Blendon et al. Health Affairs, Summer 1990

30. How Can We Pay So Much and Get So Little?
A lot of data coming up. Pay attention for the test!

31. Inpatient Days per Capita
We make it hard to get into the hospital and kick you out early when you do get admitted.
OECD, 2004, (2001 Data)

32. Some people say it’s hard to find a nurse anymore in the hospital.

33. That big bad government bureaucracy doesn’t look so bad after all.

34. % Finding Difficulty in Receiving Care
The question that goes with this slide is: Which country has health care rationing?
Commonwealth Fund Survey, 1998

35. Elderly as Percent of Total Population, 2000
So is it because we’ve got too many old people in this country and their health care is just too expensive? No.
Source: Health Affairs 2000; 19(3):192

36. Tobacco Smokers OECD, 2004 (2002 Data, U.K is 2001)
Drinking and weight would be the same.
OECD, 2004 (2002 Data, U.K is 2001)

37. MRI Units per Million People
The Japanese are radiation phobic.
OECD, 2004 (2002 Data, U.S., Canada, and Germany are 2001)

38. Renal Transplants OECD, 2004 (2002 Data, Canada and Sweden are 2001)
It’s not because we do so much more hi tech medical care.
OECD, 2004 (2002 Data, Canada and Sweden are 2001)

39. The Health Care System Dinosaur Stumbles Toward the Tar Pit
Rather than call it the “health care system” it’s more accurate to call it our “non-system of illness care.”
Our non-system of illness care

41. Myths Our “system” is fine, it just needs adjustment
There is a safety net
We can’t afford to cover everyone
We have the best health care system in the world

42. And the Myth of “Moral Hazard”
“If you think health care is expensive now, just wait until it’s free.” PJ O’Roarke
The “logic” of Health Savings Accounts
The 80/20 rule
Some things are best not left to the marketplace
Definition: the risk (hazard) that the insurance company takes that the insured may behave badly, dishonestly
or recklessly (moral). As applied to healthcare economics, the fear that if everyone was insured, that people would
Go crazy going to the doctor.
There are a number of problems with moral hazard. The example of auto insurance. In most states it is mandatory.
Did accident rates go up after that because people started driving more recklessly?
Gladwell, The New Yorker, 8/29/05

43. Myth Versus Realty
Every other industrialized country has come to the same conclusion, a national program to insure health care for all.
We can learn from the Canadian experience:
National health insurance (a “single payer”) Fee for service independent doctors just like our Medicare Not-for-profit independent hospitals
Socialized Medicine vs. social insurance: the Canadians call their system Medicare.

45. International Timeline of Universal Health Care
Germany
Switzerland
New Zealand
Belgium
France
United Kingdom 1946
Sweden
USA *
Greece
Japan
Canada
Denmark
Australia
Italy
Portugal
Spain
South Africa
Also Taiwan and Iraq could be added to the list if there were room.

46. The Health Care We Get 1/3 are uninsured or underinsured
HMOs deny care to millions more with expensive illnesses
Death rates higher than other wealthy nations’
Costs double Canada's, Germany's, or Sweden's - and rising faster
Executives and investors making billions
Destruction of the doctor/patient relationship

47. The Health Care We Want Guaranteed access Free choice of doctor
High quality
Affordability
Trust and respect
What would the “best health care system in the world” look like?

48. We Have What it Takes Excellent hospitals, empty beds
Enough well-trained professionals
Superb research
Current spending is sufficient
Polls show the people are ready for change
Large and small business are calling for change

49. Government Health Insurance for All, Even if Taxes Increase?
No opinion 5%
Pew Report, May 2005

50. Please indicate whether you support or oppose this policy: Universal Health Insurance
Unsure 8%
Harris Poll, Wall Street Journal October 20, 2005

51. Remember Columbia/HCA?
Senate Majority Leader Dr. Bill Frist owns $25 million in HCA stock.
HCA is the Frist family business.
Maybe it will be hard to get this legislator to support single payer.

52. Why Health Care for Every Person, Young or Old, Rich or Poor?
I want to tell you one last story, about myself, about a young boy who grew up in Southern Indiana in a family of lawyers, the third of 4 boys. My father was
Harvard trained and a conservative Republican, but he believed that government had some important functions, and he believed in the rule of law. The term
“rule of law” was a bit too abstract for young boys, and so he emphasized fairlness, equality, and responsibility. Brother’s Keeper. Life, Liberty, and the Pursuit
of Happiness. Which is tough if you are sick and can’t get help. It is really from that foundation he gave me that I come to this issue. I don’t see it as a left
wing social justice issue or a right wing economic issue, I just see it as fairness, equality, and freedom, basic American principles. I think our health care is
an essential part of the fabric of our communities, part of the infrastructure, like schools and bridges, like clean air and water. This is the real national security
issue. And this is an issue to unite us, not divide us, to come together around, An idea whose time has come.

53. “The care of human life and happiness, and not their destruction, is the first and only legitimate object of good government.”
Thomas Jefferson
So I claim TJ would support me today if he were alive.

54. There are some tough issues we face. Global warming, world peace
There are some tough issues we face. Global warming, world peace. This one is do-able.
I see this as a long road, but not a long shot.
In fact, I see it as inevitable.

55. “Never doubt that a small group of thoughtful, committed citizens can change the world. Indeed, it is the only thing that ever has. “
Margaret Mead
Please join me in this effort.

57. PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
29 EAST MADISON SUITE 602 CHICAGO, IL TEL: (312)

59. Gallup pole 3/04: More Americans worried “a great deal” about
Gallup pole 3/26/04: More that 60% of Americans say they worry a “great deal” about the affordability and availability of healt care, more than express a “great deal” of concern about crime (46%), illegal drug use (46%), the possibility of a terrorist attack (42%), or the economy (41%).
Gallup pole 3/04: More Americans worried “a great deal” about
affordability and availability of health care than a terrorist attack,
60% vs. 42%.

63. WHAT ABOUT MALPRACTICE?
Democrats propose limiting “frivolous suits” thru something like the panels we have here in Indiana. Good idea.
Republicans favor putting caps on non-medical settlements like we have here in Indiana. Good idea.

64. WHAT ABOUT MALPRACTICE?
Future medical payments themselves are about 25% of total payouts.
Many suits are triggered by anger over bills for care received.
Both of these factors would be taken care of by a single payer system.

65. WHAT ABOUT MALPRACTICE?
Malpractice costs account for ~1% of total health care spending.
The real answer is for doctors and lawyers to come together and face their common enemy: the insurance industry.