1. Beyond the ACA: A Physicians’ Proposal for Single-Payer Health Care Reform PNHP National Meeting November 15, 2014 Adam Gaffney, MD

2. Why a New Proposal? 1989 2003

3. Why a New Proposal? Policy: Changes in the health care system – The Affordable Care Act – Consolidation and growth of large delivery systems – Expansion of for-profit health care Advocacy: – Outreach/organization – Publicity and discussion – Organizational, chapter growth

4. The New PNHP Proposal: Premise A right to health care remains “a dream deferred” – Uninsurance and underinsurance persist. 1, 2 – Cost sharing increasingly burdensome 3 – Inefficiencies (bureaucracy and administration, for both providers and patients) remain 4 – Costs still high. – US health outcomes/quality continue to lag. 5

5. I. Coverage All medically necessary services covered. – Prescription medications – Dental care – Long term care – Mental health No cost sharing: copayments, deductibles, co- insurance Private insurance duplicating NHP coverage prohibited.

6. II. Hospital Payment Hospitals funded with a “global budget” lump sum. – Eliminates billing departments, gaming incentives; lessens administrative burden on clinicians. Covers all operating expenses, but not profits, bonuses, advertising. In some cases, hospital budgets might be part of global budgets of large integrated health systems. – Integrated systems encouraged, but large regionally dominant systems publicly controlled.

7. III. Payment for Physicians and Outpatient Care Includes: different modes of payment – Fee-for-service: simple, binding fee schedule. – Salaries: hospitals, capitated practices, HMOs, and integrated health care systems. Excludes: – Investor ownership. – Bonuses for decreased/increased utilization or profitability. – Capital costs Eliminates billing tasks for many, simplifies for all

8. IV. Long-Term Care (LTC) Premise: LTC essential component of universal health care Other countries (Japan, Germany) provider universal LTC coverage spending similar or less than the US. 6,7 Coverage of full spectrum of LTC care for the disabled.

9. V. Health Planning and Explicit Capital Funding Premise: Operating costs and capital investments should be separated to ensure efficient, rational, and equitable distribution of health resources. Regional planning boards allocate capital funds for new facilities and equipment. Education: NHP would fully subsidize health care professionals’ education.

10. VI. Medications, Devices, and Supplies All medically necessary prescription medications, devices and supplies covered. No drug copayments. Prices directly negotiated with pharmaceutical companies. Benefits – Large savings – Fewer “me-too” drugs

11. VIII. Funding Transition period – All public monies currently spent on health directed to the NHP (already accounts for majority of expenditures) 8 – Additional funds through various measures (redirecting current health benefit spending to NHP). Longer term – Direct funding through progressive taxation – Benefits for US business.

12. References 1. Congressional Budget Office. Updated Estimates of the Effects of the Insurance Coverage Provisions of the Affordable Care Act, April 2014. 2. Woolhandler S, Himmelstein DU. Life or Debt: Underinsurance in America. J Gen Intern Med 2013;28:1122-4. 3. Schoen C, Lippa J, Collins S, Radley D. State trends in premiums and deductibles, 2003-2011: eroding protection and rising costs underscore need for action. Issue brief (Commonw Fund) 2012;31:1-39. 4. Woolhandler S, Campbell T, Himmelstein DU. Costs of health care administration in the United States and Canada. N Engl J Med 2003;349:768-75 5. Nolte E, McKee M. Variations in amenable mortality--trends in 16 high-income nations. Health policy 2011;103:47-52. 6. Campbell JC, Ikegami N, Gibson MJ. Lessons from public long-term care insurance in Germany and Japan. Health Aff (Millwood) 2010;29:87-95. 7. Cuellar AE, Wiener JM. Can social insurance for long-term care work? The experience of Germany. Health Aff (Millwood) 2000;19:8-25. 8. Woolhandler S, Himmelstein DU. Paying for national health insurance--and not getting it. Health Aff (Millwood) 2002;21:88-98.

13. Questions