1. Martin Donohoe

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

3. The State of U.S. Health Care 52 million uninsured 52 million uninsured 45,000 deaths/year 45,000 deaths/year 30 million more underinsured 30 million more underinsured Remain in dead-end jobs Remain in dead-end jobs Go without needed care and/or prescriptions Go without needed care and/or prescriptions Marry 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. 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 15% of Americans live in poverty 22% of US children live in poverty 22% of US children live in poverty

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

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

14. Health Insurance Industry Delisting Delisting Cherry picking Cherry picking Pre-existing conditions Pre-existing conditions

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

16. Health Insurance Industry Large profit margins Large profit margins Corruption Corruption Loyalty: shareholders (not patients) Loyalty: shareholders (not patients)

20. Drug Companies’ Cost Structure

21. Innovation: Published Research Leading to Drugs

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

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

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

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

27. Major Contributors to Illness and Death 40% of US mortality due to tobacco, poor diet, physical inactivity, and misuse of alcohol 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 Every $1 invested in programs covering above items saves $5.60 in health care costs Prevention: 2-4% of national health care expenditures Prevention: 2-4% of national health care expenditures Noncompliance Noncompliance

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

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

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

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

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

34. 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 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 Whereas medical advances averted 176,633 deaths AJPH 2004;94:2078-2081 AJPH 2004;94:2078-2081

35. Outside the US One billion people lack clean drinking water and 3 billion lack sanitation One billion people lack clean drinking water and 3 billion lack sanitation 13,000-15,000 deaths per day worldwide from water-related diseases 13,000-15,000 deaths per day worldwide from water-related diseases Hunger kills as many individuals in eight days as died during the atomic bombing of Hiroshima Hunger kills as many individuals in eight days as died during the atomic bombing of Hiroshima

36. Water Amount of money needed each year (in addition to current expenditures) to provide water and sanitation for all people in developing nations = $9 billion Amount of money needed each year (in addition to current expenditures) to provide water and sanitation for all people in developing nations = $9 billion Amount of money spent annually on cosmetics in the U.S. = $8 billion Amount of money spent annually on cosmetics in the U.S. = $8 billion

37. Overpopulation World population - exponential growth World population - exponential growth 1 billion in 1800 1 billion in 1800 2.5 billion in 1950 2.5 billion in 1950 6 billion in 2000 6 billion in 2000 7 billion in 2011 7 billion in 2011 est. 8-10 billion by 2050 est. 8-10 billion by 2050

38. Status of Women Women do 67% of the world’s work Women do 67% of the world’s work Receive 10% of global income Receive 10% of global income Own 1% of all property Own 1% of all property

39. Worldwide, every minute 380 women become pregnant (190 unplanned or unwanted) 380 women become pregnant (190 unplanned or unwanted) 110 women experience pregnancy-related complications 110 women experience pregnancy-related complications 40 women have unsafe abortions 40 women have unsafe abortions 1 woman dies from childbirth or unsafe abortion 1 woman dies from childbirth or unsafe abortion Reason: Lack of access to reproductive health services Reason: Lack of access to reproductive health services

40. Deaths in War 18 th Century = 19/million population 18 th Century = 19/million population 19 th Century = 11/million population 19 th Century = 11/million population 20 th Century = 183/million population 20 th Century = 183/million population Civilian Casualties: Civilian Casualties: 10% late 19 th Century 10% late 19 th Century 85-90% in 20 th Century 85-90% in 20 th Century

41. Inverse Care Law Those countries that need the most health care resources are getting the least

42. Brain Drain U.S. is largest consumer of health care personnel U.S. is largest consumer of health care personnel Five times as many migrating doctors flow from developing to developed nations than in the opposite direction Five times as many migrating doctors flow from developing to developed nations than in the opposite direction

43. Tobacco – Weapon of Mass Destruction Direct medical costs = $100 billion/yr Direct medical costs = $100 billion/yr Lost productivity = $97 billion/yr Lost productivity = $97 billion/yr Medical care and lost productivity due to tobacco use costs each U.S. citizen approximately $600/yr Medical care and lost productivity due to tobacco use costs each U.S. citizen approximately $600/yr

44. Consequences of Environmental Destruction Global warming: 160,000 deaths and 5.5 million disability-adjusted life years lost per year (will double by 2020) Global warming: 160,000 deaths and 5.5 million disability-adjusted life years lost per year (will double by 2020) Air pollution: 60,000 - 75,000 premature deaths/yr. (U.S.); 1.8 million worldwide Air pollution: 60,000 - 75,000 premature deaths/yr. (U.S.); 1.8 million worldwide

45. Consequences of Environmental Destruction Pesticides in food → 1,000,000 deaths over the last 6 years; 1 million cancers in current generation of Americans Pesticides in food → 1,000,000 deaths over the last 6 years; 1 million cancers in current generation of Americans Lead and mercury exposure multi-billion dollar problems Lead and mercury exposure multi-billion dollar problems

46. Toxic Pollutants ¼ US citizens live within 4 miles of a Superfund site ¼ US citizens live within 4 miles of a Superfund site Environmental Racism Environmental Racism Waste dumps/incinerators more common in lower SES neighborhoods Waste dumps/incinerators more common in lower SES neighborhoods

47. Extinction/Species Loss Mass Extinction Mass Extinction More than 1/2 of the top 150 prescription drugs from plants, other living organisms More than 1/2 of the top 150 prescription drugs from plants, other living organisms More than 250,000 known flowering species More than 250,000 known flowering species <0.5% surveyed for medicinal value <0.5% surveyed for medicinal value

48. Overconsumption (“Affluenza”) U.S. = 6.3% of world’s population U.S. = 6.3% of world’s population Owns 50% of the world’s wealth Owns 50% of the world’s wealth U.S. responsible for: U.S. responsible for: 25% of world’s energy consumption 25% of world’s energy consumption 33% of paper use 33% of paper use 72% of hazardous waste production 72% of hazardous waste production

49. But Are We Happier? Average American works 200 more hrs/yr than in 1960 (#1 in world) Average American works 200 more hrs/yr than in 1960 (#1 in world) Vacations shorter Vacations shorter No guaranteed paid sick leave No guaranteed paid sick leave 8/10 Americans want a new job 8/10 Americans want a new job

50. But Are We Happier? Fewer close friends Fewer close friends More loneliness/depression More loneliness/depression Pharmaceutical fixes Pharmaceutical fixes

51. US Charity Care Suffering Public hospitals and ERs closing Public hospitals and ERs closing Long waits mean many leave before being seen Long waits mean many leave before being seen Free clinic demand increasing, more patients being turned away Free clinic demand increasing, more patients being turned away Hospitals turning to lucrative initiatives to improve financial situation Hospitals turning to lucrative initiatives to improve financial situation Cosmetic surgery, luxury clinics, aggressive billing practices (including charging uninsured more than insured), recruiting wealthy foreign patients Cosmetic surgery, luxury clinics, aggressive billing practices (including charging uninsured more than insured), recruiting wealthy foreign patients

52. Maldistribution of Wealth U.S: Richest 1% of the population owns 50% of the country’s wealth -poorest 90% own 30% -widest gap of any industrialized nation U.S: Richest 1% of the population owns 50% of the country’s wealth -poorest 90% own 30% -widest gap of any industrialized nation

53. Maldistribution of Wealth is Deadly 880,000 deaths/yr in U.S. would be averted if the country had an income gap like Western European nations, with their stronger social safety nets 880,000 deaths/yr in U.S. would be averted if the country had an income gap like Western European nations, with their stronger social safety nets

54. Maldistribution of wealth Less than 4% of the combined wealth of the 225 richest individuals in the world would pay for ongoing access to basic education, health care (including reproductive health care), adequate food, safe water, and adequate sanitation for all humans

55. Health Requires Equality “All men are created equal” “All men are created equal” Declaration of Independence Declaration of Independence “Some people are more equal than others” “Some people are more equal than others” George Orwell George Orwell

56. Hudson River, 2009

57. U.N. Declaration of Human Rights “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care”

58. Solutions Pay as you go Pay as you go Insurance Insurance Government-run program Government-run program VA, IHS VA, IHS PPACA PPACA Single Payer Single Payer

59. What You Can Do Educate yourselves and others Educate yourselves and others “Information is the currency of democracy” (Thomas Jefferson) “Information is the currency of democracy” (Thomas Jefferson) Join groups working to improve health care Join groups working to improve health care

60. Act Now! "If you think you are too small to have an impact, try going to bed with a mosquito in your tent“ - African Proverb

61. Further Info/References/Contact Info Public Health and Social Justice Website http://www.phsj.org Physicians for a National Health Plan http://www.pnhp.org/ Kaiser Family Foundation http://www.kff.org/ Martin Donohoe martindonohoe@phsj.org

63. PPACA Patient Protection and Affordability Care Act 2014: 26 million uninsured adults with incomes under $29,327 will gain coverage through Medicaid with little or no premium or cost sharing 2014: 26 million uninsured adults with incomes under $29,327 will gain coverage through Medicaid with little or no premium or cost sharing 2014: Up to 17 million adults with incomes between $29,327 and $88,200 for a family of 4 will get tax credits to help purchase private health plans through new state insurance exchanges (sliding scale) 2014: Up to 17 million adults with incomes between $29,327 and $88,200 for a family of 4 will get tax credits to help purchase private health plans through new state insurance exchanges (sliding scale)

64. PPACA Patient Protection and Affordability Care Act 2014: No denial of coverage or higher premiums for preexisting conditions 2014: No denial of coverage or higher premiums for preexisting conditions Up to ½ of Americans Up to ½ of Americans 2010: Uninsured with preexisting conditions eligible for special insurance plans after 6 months without insurance 2010: Uninsured with preexisting conditions eligible for special insurance plans after 6 months without insurance 2010: Young adults up to age 26 may stay on parents’ health plan 2010: Young adults up to age 26 may stay on parents’ health plan

65. PPACA Patient Protection and Affordability Care Act 2010: Small business tax credits to offset costs of insuring employees 2010: Small business tax credits to offset costs of insuring employees 2010: Insurers cannot deny coverage to children with preexisting conditions 2010: Insurers cannot deny coverage to children with preexisting conditions 2010: No lifetime benefit limits and no rescisions 2010: No lifetime benefit limits and no rescisions

66. PPACA Patient Protection and Affordability Care Act 2010: Health plans must provide preventive services without cost-sharing 2010: Health plans must provide preventive services without cost-sharing 50% cost-sharing discount for seniors in Medicare “donut hole” 50% cost-sharing discount for seniors in Medicare “donut hole” Creates public website listing payments from drug, device, biological, and medical products companies to physicians Creates public website listing payments from drug, device, biological, and medical products companies to physicians

67. PPACA Patient Protection and Affordability Care Act Problems: Problems: Complex, increases bureaucracy Complex, increases bureaucracy Leaves 23 – 40 million without insurance Leaves 23 – 40 million without insurance 40% of these eligible for, but not enrolled in, Medicaid or CHIP 40% of these eligible for, but not enrolled in, Medicaid or CHIP 22% undocumented immigrants 22% undocumented immigrants

68. PPACA Patient Protection and Affordability Care Act Problems: Problems: No effective cost control measures No effective cost control measures Will not reduce medical bankruptcies Will not reduce medical bankruptcies Will drain $billions from Medicare payments to safety net clinics, threatening the remaining uninsured Will drain $billions from Medicare payments to safety net clinics, threatening the remaining uninsured

69. PPACA Patient Protection and Affordability Care Act Unfair to women - segregation of abortion funding, may affect contraceptive coverage Unfair to women - segregation of abortion funding, may affect contraceptive coverage Poor likely to purchase less expensive plans with worse coverage and higher deductibles and copayments Poor likely to purchase less expensive plans with worse coverage and higher deductibles and copayments ?Penalties if poor do not buy insurance? ?Penalties if poor do not buy insurance?

70. PPACA Patient Protection and Affordability Care Act Problems: Problems: Loopholes allow charges up to 3x higher for elderly, higher charges for large companies with predominantly female workforces Loopholes allow charges up to 3x higher for elderly, higher charges for large companies with predominantly female workforces Benefits insurance companies, continues present inefficiencies Benefits insurance companies, continues present inefficiencies

71. PPACA Patient Protection and Affordability Care Act Problems: Inadequate numbers of primary care providers Inadequate numbers of primary care providers Communities with a high number of PCPs per capita have lower medical costs and better outcomes Communities with a high number of PCPs per capita have lower medical costs and better outcomes

72. "If anyone...has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know." -- President Obama, State of the Union, 1/27/10 "If anyone...has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know." -- President Obama, State of the Union, 1/27/10

73. Single Payer Cradle to grave, portable insurance for everyone Cradle to grave, portable insurance for everyone All medically-necessary services covered All medically-necessary services covered Free choice of doctor and hospital Free choice of doctor and hospital Global and local budgeting determined by physicians, patients, other health professionals Global and local budgeting determined by physicians, patients, other health professionals Cost saving Cost saving Broad support Broad support

74. Single Payer Not socialism any more than having a police force and fire department which serve everyone or offering free public education to children through grade twelve is socialism Not socialism any more than having a police force and fire department which serve everyone or offering free public education to children through grade twelve is socialism Imagine if insurance companies ran the fire department Imagine if insurance companies ran the fire department