1. Universal Health Care:
Health Care Reform
Universal Health Care:
The Only Solution
Diljeet K. Singh, MD, DrPH
Physicians for a National Health Program
29 E Madison Suite 602, Chicago, IL 60602
Phone (312) | Fax: (312)

2. PERSPECTIVE - Philosophical
Health care is…
A Human Right
A social service distributed according to need
Not a commodity distributed according to ability to pay
Not a business whose “beneficiaries” are company executives and investors not patients
Most Americans believe everyone should have access to good care without financial hardship

3. PERSPECTIVE - Philosophical
We are the only developed nation that does not provide comprehensive health care to all its citizens
47 million Americans are uninsured
Many are underinsured - lack comprehensive coverage egs preventive care, long-term care & drug costs
45,000 die a year from lack of coverage
Markets are good for many things, but they are not a good way to distribute health care

4. PERSPECTIVE- Practical
Current system is unsustainable
Burden it places on our economy/businesses
Private health insurance premiums are  at unsustainable rate of 13%/year – & as much as 25% in some areas of country
Coverage is shrinking, as more employers decide to cap their contributions to health insurance & workers find they cannot pay their rapidly growing share
Most expensive health care system in the world

5. PERSPECTIVE - Practical
Spend twice as much as other developed nations
But we don’t get more care - Canadians, see their doctors more often & spend more time in hospital
We don’t get better results - do worse than most other developed countries on usual measures of health such as life expectancy, infant mortality, immunization rates
& we still don’t cover everyone - 47 million uninsured
In sum, our health care system is outrageously expensive, yet inadequate.
Why?
There’s something enormously inefficient about the way we finance & deliver health care

6. Problem with For-Profit Payers
Investor-owned firms compete not by  quality or  costs, but by avoiding unprofitable patients & limiting services
Creates paradox of a health care system based on avoiding the sick
It generates huge administrative costs, which, along with profits, divert resources from clinical care to demands of business.
Doctors & hospitals maintain costly admin staff to deal with bureaucracy
Adminstration consumes 31% of our health care $
To understand what’s happening, let’s look at how the health care market works.
Most Americans receive tax-free health benefits from their employers, who pay insurers a portion of the premiums for health coverage. But not all employers offer benefits, and when they do, the benefits may not be comprehensive. It’s entirely voluntary. When employers are competing for workers, they offer good benefits; when unemployment rises, they drop them.
The insurers with whom employers do business are mostly investor-owned, for-profit managed care businesses. They try to keep premiums down and profits up by stinting on medical services. In fact, the best way for insurers to compete is by not insuring high-risk patients at all; limiting the coverage of those they do insure (for example, by excluding expensive services, such as heart transplantation); and by passing costs back to patients by denying claims or as deductibles and co-payments. We are the only nation in the world with a health care system based on dodging sick people. These practices add greatly to overhead costs because they require a mountain of paperwork. They also require creative marketing to attract the affluent and healthy and avoid the poor and sick. Not surprisingly, the U. S. has by far the highest overhead costs in the world.
It’s instructive to follow the health care dollar as it wends its way from employers toward the doctors and nurses and hospitals that actually provide medical services. First, private insurers regularly skim off the top a substantial fraction of the premiums – anywhere from 10 to 25 percent – for their administrative costs, marketing, and profits. The remainder is then passed along a veritable gauntlet of satellite businesses that feed on the health care industry, including brokers to cut deals, disease-management and utilization review companies, drug-management companies, legal services, marketing consultants, billing agencies, information management firms, and so on and so on. Their function is often to limit services in one way or another. They, too, take a cut, including enough for their own administrative costs, marketing, and profits. I would estimate that no more than 50 cents of the health care dollar actually reaches the providers – who themselves face high overhead costs in dealing with multiple insurers.

7. Solution - Single-Payer
Simpler & more efficient than our private health care system
Health care $ distributed by one entity, so that health care could be coordinated to eliminate gaps
Conceptual extension of Medicare to entire population.
Medicare is:
Government-financed single-payer system embedded within our private, market-based system.
Most efficient part of our health-care system, with overhead costs of < 3%
Covers virtually everyone over 65
Most popular part of U S health care system

8. Solution - Single-Payer
Universal, Comprehensive Coverage
No out-of-pocket payments Co-payments & deductibles are barriers to access, administratively unwieldy, & ineffective for cost containment
Single insurance plan in each region, administered by public or quasi-public agency
Global operating budgets for hospitals, nursing homes, allowed group & staff model HMOs & other providers with separate allocation of capital funds Billing on per-patient basis creates unnecessary administrative complexity & expense. A budget separate from operating expenses will be allowed for capital improvements

9. Key Features of Single-Payer
Free Choice of Providers Patients should be free to seek care from any licensed health care provider, without financial incentives or penalties
Public Accountability, Not Corporate Dictates The public has an absolute right to democratically set overall health policies & priorities, but medical decisions must be made by patients & providers in the region rather than dictated by corporate executives. Market mechanisms principally empower employers & insurance bureaucrats pursuing narrow financial interests
Ban on For-Profit Health Care Providers Profit seeking inevitably distorts care & diverts resources from patients to investors
Protection of health care & insurance workers

10. 47 Million Uninsured 45,000 Deaths Per Year
Well how about the 47 million with no health insurance. In this country no health insurance means no access to health care. Even though federal law requires when any patient presents to a health care facility requesting care, they are to receive a medical screening exam before it is determined how that visit will be paid for, every patient understands they will p\be required to provide proof of insurance before they get care.
But simply helping them buy private insurance is not a solution. 10

11. Meet Thomas Wilkes Born in 2004 with Severe Hemophilia A.
Dad: Senior Engineer at a small high-tech computer firm with good benefits.
2005: Develops an inhibitor to his hemophilia treatment.
$750,000 annual claims.

12. Private Insurance for Thomas
Company faces 40% to 55%  in premiums.
Only insurer that will cover them requires $10,000 out-of-pocket & $1 million cap.
Thomas is projected to reach the $1 million benefit cap in summer 2009
Options
Dad can quit job he loves & work for mega-firm that will take longer to be affected by high claims
Mom can go to work for a mega-firm.
Thomas’ father can divorce his mother to leave her & Thomas legally destitute & eligible for public programs.

13. Who Are the Uninsured? Children 25% Unemployed 5% *Out of labor force
50%
Children
25%
Unemployed 5%
*Out of labor
force
20%
3/4 of the uninsured are working people and their families 13

14. -No Longer President Bush
“…,people have access to health care in America. After all, you just go to an emergency room.”
-No Longer President Bush 14

15. America’s Underinsured
Proportion of Americans Going Without Care due to Costs, 2005
(skipping doctor visit, specialist appointment, treatment or prescription when needed)
Source: Commonwealth Fund Biennial Health Insurance Survey, 2005

17. Medical Bankruptcy Had Insurance
Illness & Medical Bills Contributed to 1,000,000 Personal Bankruptcies in (Half of All Bankruptcies)
Insurance Status at Onset of Illness
Uninsured
Had Insurance
Source: Himmelstein, Health Affairs 2005 (state estimates provided by author)

19. International Health Spending, 2005
U.S. Public Spending is Greater than Other Nations’ Public/Private Spending Combined
Source: OECD 2007; Japan data are from 2004

20. The Healthcare Americans Want
Guaranteed access
Free choice of doctor
High quality
Affordability
Trust & respect

21. Other Industrialized Nations
Have similar demographics
Availability of expensive technology
Rising drug costs
Similar levels of service
Why are their costs
so much lower? 21

22. Why are costs lower in other countries?
Administrative simplicity
Lower prices
Higher ratio of primary care to specialists
Health planning
Global budgets

23. If you were in an insurance CEO, who would you want to insure?
73%
Percent of
health
Care
Costs
80% uses less than $1000
of care per year
This graph shows a population divided into 10ths. It shows how health care services are utilized in any one year in any population. Take even 1000 people in a population and you will find that the majority of them (80%) are healthy and use very little care. 30% of them in fact, use no care at all!. In actuality most of the services are used in any one year by a small percentage. 10% use 72 % of the health care dollar.If we add to that the 10% who use 13% of the care we find that 20% use 86% of health care services. It is worth keeping in mind that these are not the same people all the time. All of us move in and out of this group at one or many times in our lives. And when we are in that group ( birth of a baby, coronary bypass, cancer diagnosis) we expect health care services to be there waiting for us. Health care is not like other human needs. We all have the same basic needs for food. shelter, clothing etc. When you look at the population’s needs in regard to health care needs are vastly different. Because at any one time the healthy majority use very little care - 80% of the population in Vermont use only 14% of the health care dollar. On the other hand, 10% use 73%of the health care dollar.. Another important point is that the most expensive services The NICU, the trauma unit, dialysis to name a few are used by a very small number of people. Dialysis is used by only 380 people per year in Vermont. Yet the infrastructure costs of sustaining these services are enormous.
13% 6% 4%
0% 0% 0%
1% 1% 2%
Source:Agency for Healthcare Research & Quality
MEPS

24. The Health & Profitable to the “Market,” the Sick & Poor to the Taxpayer
73%
Government Programs
Percent of
health
Care
Costs
Private Insurers
13% 6% 4%
0% 0% 0%
1% 1% 2%
Source:Agency for Healthcare Research & Quality
MEPS

25. Rising Costs = Less Benefits = Under/Uninsurance
Proportion of Americans Covered by Employer Insurance
Source: US Census

26. Life Expectancy, 2005
(Data in Years)

27. (Deaths in first year of life per 10,000 live births)
Infant Mortality, 2005
(Deaths in first year of life per 10,000 live births)

29. Growth of Physicians & Administrators 1970-2005
Source: Bureau of Labor Statistics & NCHS

30. One-Third of Health Spending is Consumed by Administration
31%
Potential Savings: $350 billion per year
Enough to Provide Comprehensive Coverage to Everyone
Source: Woolhandler, et al, New England Journal of Medicine, August 2003 & Int. Jrnl. Of Hlth. Services, 2004

31. Health care benefits are the fastest growing part of he benefits package.

32. Costs to Business
Skyrocketing costs for health care are hurting U.S. business:
Health care cost General Motors $5.6 billion in 2005 adding $1500 to the price of each car
Companies that offer coverage often pay 10% or more of payroll on health benefits and are at a disadvantage competing with companies that don’t offer coverage or where there is public coverage
Toyota located a new plant in Canada and Lifesavers moved a Michigan factory to Ontario
Appleby et al, “Ailing GM Looks To Scale Back On Generous Health Benefits,” USA Today, 6/24/2005
Keenan, “Canada Wins Major Toyota Factory,” Globe and Mail, 6/23/2005
Frammolino, “Workers Feel Like Suckers,” Los Angeles Times, 3/20/2002
That is why we have the first work stoppage in 30 years in the auto industry. 32

33. GM retiree cost is $60 Billion!
Source: Wall St. Journal, March 11, 2004 33

34. Lesson #2: Real Solution to Health Crisis Must Do 2 Things:
Lesson #1: Simply Giving More People Existing Private Insurance Policies Is Not Solution:
Current Private Insurance Policies Offer Inadequate Protection.
Any Gains in Coverage Will Be Quickly Offset as Costs Rise & Employers Shed Benefits.
Lesson #2: Real Solution to Health Crisis Must Do 2 Things:
1) Offer Coverage More Comprehensive than that Currently Available on the Private Market.
2) Control Costs so that Benefits are Sustainable.

35. Only Two Paths to Reform
Preserve Private Insurance Companies & their Waste
Create a National Health Insurance System

36. Single-Payer Benefits
Comprehensive Coverage for all medically necessary services (doctor, hospital, long-term care, mental health, vision, dental, drug, etc.) in a single-tier system.
Free Choice of doctor & hospital.
Health Workers Unleashed from corporate dictates over patient care.
Hospitals guaranteed a secure, regular budget.

37. Financing Single-Payer
Medicare
Single-Payer Health Care Fund
$$$
Medicaid
Payroll Tax
Income Tax
Bonus: Negotiated formulary with physicians, global budget for hospitals,  primary & preventive care, bulk purchasing of drugs & medical supplies = long term cost control.

38. Health Savings Accounts
A bank account in which a limited amount of money may be deposited tax-free for expenditures on health services.
Must be paired with a “high-deductible” health plan. (e.g., $5,000).
First few thousand dollars are paid from the HSA, at some point, “catastrophic” coverage kicks in.
Theory: Patients now using “their own money” = better consumers = lower costs.

39. High-Deductibles = No Savings
73%
Percent of
health
Care
Costs
13% 6% 4%
0% 0% 0%
1% 1% 2%
Source:Agency for Healthcare Research & Quality
MEPS

41. Health Savings Accounts Won’t
Provide Meaningful Choice for Patients
Reduce Administration
Produce Savings
Health Savings Accounts Will
Discourage Preventive & Primary Care
Create Huge New Administrative Waste
Produce Few Savings (a few sick people cost the most)

42. “Let them buy insurance.”
“Individual Mandate”
“Let them buy insurance.”

43. Criminalizing the Uninsured: A Massachusetts Punitive Index#
The Crime
The Fine 1
Violation of Child Labor Laws
$50 2
Illegal Sale of Firearms, First Offense
$500 max. 3
Driving Under the Influence, First Offense
$500 min. 4
Domestic Assault
$1000 max. 5
Cruelty to or Malicious Killing of Animals 6
Communication of a Terrorist Threat
$1000 min. 7
Being Uninsured*
$1500 min.
*Note: Original version of House Bill would have suspended individuals’ driving licenses for uninsurance as well.

44. Subsidy & Individual Mandate Schemes
Substandard Coverage: forces uninsured to buy defective insurance industry products that are already causing families to face bankruptcy & go without needed care.
Unaffordable: Without savings achievable with single-payer, taxes must raised or funds diverted from other needy programs.
Micro-coverage, Macro-costs: Preserves wasteful private insurers & adds yet another layer of state administrative waste. Rather than provide care to uninsured through a relatively efficient program like Medicare, the plan launders tax dollars through wasteful private insurers.
No Realistic Cost Control: Any gains in public coverage will be unsustainable due to rising costs.

45. “Sounds Great, but it’s not politically feasible”
2/3rds of population want it
Most (59 percent) of physicians want it
Business community is now realizing the need for it.

46. Single-Payer:
Glen Barton Former CEO, Caterpillar Inc. (Fortune 100) Past Chairman, Health & Retirement Task Force Business Roundtable Represents 150 Largest Employers Total Assets: $4.0 Trillion
“The quickest & simplest solution… is to go to a single-payer system” - Written Testimony to AHCTF, Feb

47. CNBC / MSN Money -Ben Brewer, WSJ, April 18, 2006
“If done right, health care in America could be dramatically better with true single-payer coverage.”
-Ben Brewer, WSJ, April 18, 2006
“[single-payer] is an idea that's so easy to slam politically yet so sensible for business that only Republicans can sell it! …it may take a Republican President to bless the socialization of health spending we need.”
-Matt Miller, Fortune, April 18, 2006
CNBC / MSN Money
“Think, as a small business, how you could benefit from a single-payer system: you wouldn’t lose potential employees to larger firms that offer more attractive health benefits; health insurance costs would cease to be a line item in your budget. A serious illness befalling you or an employee wouldn’t be a company-wide financial crisis. You might even save money.”
-Joseph Antony, CNBC / MSN Money, Winter 2003

50. Is “The Perfect the Enemy of the Good?”
The central flaws of the “Obama” plan remain the central flaws of our current system
Uncontrolled Costs
Lack of Universal Coverage
Without eliminating the overhead of a patchwork for-profit system we will not achieve the system we deserve

51. Is “The Perfect the Enemy of the Good?” The Radical & the Republican
“Many of Lincoln’s admirers have painted him as a man who wanted exactly what the abolitionists did but cannily waited for a perfect moment to achieve it. [In fact], radicals like Douglass set an agenda Lincoln gradually adopted as his own. Without abolitionists, there would have been no Lincoln.”
- James Oakes, Historian, UC Berkeley

52. Single-Payer: “Politically Feasible?”
Other “Politically Infeasible” Movements
Abolition of Human Slavery
(1860s)
Women’s Suffrage Movement
( )
Civil Rights Act
(1964)