### Understanding the Uninsured: Health Impacts and Economic Challenges ###

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

4. Who Are The Uninsured? *Students>18, Homemakers, Disabled, Early retirees Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS

5. Chronically Ill and Uninsured

6. Unmet Health Needs of the Uninsured

7. 18,314 Adult Deaths Annually Due to Uninsurance

9. Full Time Jobs Provide LittleProtection for Hispanics Source: Commonwealth Fund, 3/2000

11. Rising Out-of-Pocket Costs for SeniorsVoucher/Premium Support Proposals Would Worsen Percent of Income Source: Senate Select Committee on Aging; AARP 4/95 & 3/98; and Commonwealth Fund May, 1999 projections (adjusted to include nursing home costs)

12. Who Pays for Nursing Home Care? Source: Health Affairs 2000; 19(3):44

13. Illness and Medical Costs,A Major Cause of Bankruptcy • 45.6% of all bankruptcies involve a medical reason or large medical debt • 326,441 families identified illness/injury as the main reason for bankruptcy in 1999 • An additional 269,757 had large medical debts at time of bankruptcy • 7 per 1000 single women, and 5 per 1000 men suffered medical-related bankruptcy in 1999 Source: Norton's Bankruptcy Advisor, May, 2000

14. Many With Insurance Lack Choice42% Are Offered Only 1 Plan Note: Those without choice were 70% more likely to give their plan a low rating Source: Health Affairs 1998; 17(5):184

16. Patients Refused Authorization for ER Care • 8% to 12% of HMO patients presenting to 2 ERs were denied authorization • Authorization delayed care by 20 to 150 minutes • Of those denied: 47% had unstable vital signs or other high risk indicators 40% of children were not seen in f/u by primary MD Eventual diagnoses included: meningococcemia (2), ruptured ectopic (2),shock due to hemorrhage (2), septic hip, PE, MI (2), ruptured AAA, pancreatitis, peritonsillar abscess, small bowel obstruction, unstable angina, pneumothorax, appendicitis, meningitis(3) Source: J Emerg Med 1997; 15:605; Acad Emerg Med 1997; 4:1129; Ann Emerg med 1990; 19:59

17. Financial Suffering at the End of Life Source: Ann Int Med 2000; 132:451 - Study of 988 terminally ill patients* Out-of-pocket medical costs > 10% of household income** Patient or family sold assets, took out mortgage, used savings or took extra job

18. Why Women Delay Prenatal CareWhen They Know They Are Pregnant Note: 11.1% of pregnant women failed to get timely prenatal care despite knowing they were pregnant Source: MMWR 5/12/2000; 49:393

19. Distribution of Wealth, 1976 & 1998

21. Poverty Rates, 1997U.S. and Other Industrialized Nations Source: Luxembourg Income Study Working PapersNote: U.S. figure for 1997, other nations most recent available year

22. Americans Lead the World in Hours Worked Source: International Labor Organization, 1999

26. Causes Of Excess Deaths AmongAfrican Americans Cardiovascular 39% Cardiovascular 25% Source: Himmelstein & Woolhandler - Analysis of data from NCHS

27. Racial Disparity in Access to Kidney Transplants

28. Pharmacies in Minority NeighborhoodsFail to Stock Opioids Source: N Engl J Med 2000; 242:1023

29. Minority Physicians ProvideMore Care for the Disadvantaged Ethnicity of Physician Source: AJPH 1997;87:817

31. Are Emily and Brendan More Employable than Lakisha and Jamal?

32. Growth of Registered Nurses and Administrators1970-2002 Source: Bureau of Labor Statistics & Himmelstein/Woolhandler/Lewontin Analysis of CPS data

33. Growth of Physicians and Administrators1970-2002 Source: Bureau of Labor Statistics & NCHS

34. High Risk HMO Patients FaredPoorly in the Rand Experiment Source: Rand Health Insurance Experiment, Lancet 1986; i:1017Note: High Risk = 20% of population with lowest income + highest medical risk

35. The Elderly and Sick Poor did Worse in HMOs Changes in Physical Health at 4 Years Source: Medical Outcomes Study - JAMA 1996;276:1039

36. Elderly HMO Stroke PatientsGet Less Specialist Neurology Care Source: Medical Care 1999; 37:1186Note: Patients receiving specialist neurology care had 23% lower 1 year mortality

37. HMOs' Stroke Patients:Fewer Go Home or to Rehab, More to Nursing Homes Source: JAMA 1997; 278:119

38. HMOs Push Heart Surgery Patientsto High-Mortality Hospitals Source: JAMA 2000; 283:1976*CABG = coronary artery bypass graft surgery

39. Fee-For-Service Managed Care Primary Care Patients Depression Detected 53.7% 41.8% Appropriately Treated 60.7% 46.4% Patients Seeing Psychiatrist # Functional Limitations - Baseline 1.3 1.5 # Functional Limitations - 2 Years 1.2 2.0 Depressed Patients:Fee-for Service Vs. Managed Care SOURCE: Medical Outcomes Study - JAMA 1989;262:3298 & Arch Gen Psych 1993; 50:517

40. Managed Mental Health: Audit Report • Plans overstated utilization by 45% • Delay from initial call to starting care > contractor's written standard by 97%-347% • Plans rarely site-visited or interviewed providers • No providers in 15% of counties "covered"; no child provider in 25% of counties • Quality problem in 30-58% of charts reviewed • Criteria for inpatient care dangerously restrictive (eg. requiring DTs prior to detox admit) • Overhead + profit NEVER consumed < 45% of premiums Source: J. Wrich - Audit findings submitted to CBO, 3/98

41. Primary Care Physicians: Patients Can't Get Quality Mental Health Services Source: Center for Studying Health System Change, 1997 - survey of 5,160 primary care physicians Note - Data shown are for inpatient care; responses regarding outpatient care were similar

42. States that Limit New Heart Surgery Programs: Higher Volumes, Lower Mortality

44. Unnecessary Procedures

47. Seniors Without Drug Coverage Forego Cardiac Medications

48. Out-of-Pocket Costs for Medicare HMO Enrollees, 1999-2002

50. Can Seniors Make Informed HMO Choices?Proportion with Knowledge of How HMOs Work Source: AARP Survey - Health Affairs 1998; 17(6):181