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

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

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

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

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

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

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

A Brief History Wage and price controls in WW II Truman pushes for National Health Insurance 1949. AMA opposes. A new story that has a sort of happy ending, at least for one man.

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

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

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

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

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

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

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

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”

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

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

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

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 349:768-75 8/21/2003, CBO, GAO

…. 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

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

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? *

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)

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

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

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

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

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)

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

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

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

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

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)

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

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)

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

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

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

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.

International Timeline of Universal Health Care Germany 1883 Switzerland 1911 New Zealand 1938 Belgium 1945 France 1945 United Kingdom 1946 Sweden 1947 USA 1948* Greece 1961 Japan 1961 Canada 1966 Denmark 1973 Australia 1974 Italy 1978 Portugal 1979 Spain 1986 South Africa 1996 Also Taiwan and Iraq could be added to the list if there were room.

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

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?

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

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

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

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.

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.

“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.

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.

“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.

www.HCHP.info

PHYSICIANS FOR A NATIONAL HEALTH PROGRAM 29 EAST MADISON SUITE 602 CHICAGO, IL 60602 TEL: (312) 782-6006 WWW.PNHP.ORG

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%.

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.

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.

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.