The American Healthcare *$y$tem* A Physician’s Perspective David Mair MD Physicians for a National Health Program – Minnesota January 24, 2010
Definitions • Health Insurance • Public • Medicare, Medicaid, VA • Private • BlueCross BlueShield, United, HealthPartners • Health Care • Public • VA, county hospitals • Private • Most hospitals, nursing homes, and doctor’s offices
Definitions • Universal Coverage • Everyone covered • Every industrialized nation except US • Socialized Medicine • Britain, New Zealand • VA Health System • Single-Payer • Canada, Taiwan • Traditional Medicare Source: The Washington Post. “5 Myths About Health Care Around the World”. Aug, 2009.
The Problem • 46.3 million Americans (15.4%) with no health insurance (2008) • 444,000 Minnesotans (8.7%) with no health insurance Source: http://www.census.gov/hhes/www/hlthins/hlthins.html
The Uninsured • Age • 0-18: 20% • 19-64: 80% • 65+ eligible for Medicare • Family work status • 81% working • 69% full-time • 12% part-time Source: Kaiser Family Foundation. "The Uninsured: A Primer." Oct, 2008.
The Uninsured • 305 Minnesotan deaths in 2008 Source: American Journal of Public Health, 2009.
44,000 American deaths in 2008
The Insured • 62% of personal bankruptcies due to medical expenses (2007) • 50% in 2001 • 78% of people with medical bankruptcies had health insurancewhen they got sick Source: American Journal of Medicine, 2009.
Health Care Spending per Person Source: OECD, 2009
Health Care Spending, Percent of GDP Source: Organisation for Economic Co-operation and Development (OECD), 2009
Health Insurance Premiums Source: American Family Physician, 2005.
Health Insurance Premiums Source: American Family Physician, 2005.
Health Care Spending per Person, 2007 Source: OECD, 2009
Health Care Spending per Person, 2006 Sources: OECD, 2009 Health Affairs, 2002 – Data from 2006
Infant Mortality Rate Deaths per 1,000 Live Births Source: OECD, 2009
Life Expectancy Source: OECD, 2009
Source: National Geographic Blog, 2009 Data from OECD, 2009
Life Expectancy vs Spending (US$, 2007) Source: OECD, 2009
Our “System” (Simplified) Taxes Out-of-Pocket Money Flow Healthcare Delivery Source: OECD, 2009
Why is our “system” so expensive? • Huge, wasteful bureaucracy • 31% of all health spending in the US is on administrative waste Sources: New England Journal of Medicine, 2003 PNHP, 2009
Insurance Overhead (12-20%) Marketing Underwriting Lobbying Denying Payment Assembling Networks Executive Salaries Profit Denying Treatment
Provider Overhead (11-19%) Prior Authorization Coverage? Formulary? Billing Departments Office Staff
Employer and Patient Overhead Bidding Open Enrollment Premiums Deposits Withdrawals ? Explanation of Benefits Bills
How do they do it? • No (or fewer) middlemen • Government or highly regulated, non-profit insurance • Negotiate drug prices • VA spends 40% less on medications • No need to “import” drugs from Canada • Better access to primary care • Better primary care physician reimbursement • Other methods easier to implement • EMRs, preventive medicine • Public health initiatives (smoking cessation, weight loss, vaccination)
Rationing • There are wait times for someelective procedures in other countries with single-payer systems (Canada) • They also spend half or less what we do (and cover everyone) • More hip replacements, CABGs, and angioplasties are done in the US, per capita • Most are paid for by Medicare (single-payer) • Canada has more hospital beds, acute care beds, and doctor visits per capita than the US Sources: OECD, 2009 Health Affairs, 2007
Rationing • In 2007, 23% of Americans “skipped medical test, treatment, or follow-up recommended by doctor” • 5% of Canadians • Has anyone in the US ever had to wait to be seen? • 44,000 Americans died awaiting treatment in 2008 Sources: American Journal of Public Health, 2009. Health Affairs, 2007
Choice
Fill-The-Gaps • In seven states, including Minnesota in 1992, fill-the-gaps “Universal Coverage” proposals have failed to cover everyone or control costs • Leaves dysfunctional bureaucracy in place Source: International Journal of Health Services, 2008
Fill-The-Gaps Source: International Journal of Health Services, 2008
Fill-The-Gaps Source: International Journal of Health Services, 2008
Colorado (2007) • Better Health Care for Colorado • …public program expansion and access to private insurance coverage with low-income subsidies through a Health Insurance Exchange. • Solutions for a Healthy Colorado • …core Limited Benefit Plan in the private sector and expands coverage under Medicaid and Child Health Plus (CHP+). Source: Lewin Proof Report-Technical Assessment of Health Reform Proposals, 2007
Colorado (2007) • A Plan for Covering Colorado • …public program expansion and a mandatory private pool for all residents not eligible for the public program. • Colorado Health Services Single Payer Program • …single payer plan that would provide coverage to all residents of the state, including state and local workers, and residents currently covered under Medicare, Tricare, Veteran’s Health, Indian Health Services and Federal Health Benefits programs. Source: Lewin Proof Report-Technical Assessment of Health Reform Proposals, 2007
Uninsured, Change in Spending Source: Lewin Proof Report-Technical Assessment of Health Reform Proposals, 2007
Uninsured, Change in Spending Source: Lewin Proof Report-Technical Assessment of Health Reform Proposals, 2007
Uninsured, Change in Spending Source: Lewin Proof Report-Technical Assessment of Health Reform Proposals, 2007
Uninsured, Change in Spending Source: Lewin Proof Report-Technical Assessment of Health Reform Proposals, 2007
The Solution: Single-Payer • 59% of United States physicians support single-payer • 64% of Minnesota physicianssupport single-payer • Why? • Despite spending the most, our health is mediocre • Frustration with massive bureaucracy • Our current non-system interferes with the physician-patient relationship Sources: Annals of Internal Medicine, April 2008 Minnesota Medicine, February, 2007
Canadian Doctor Emigration
The Solution: Single-Payer • Single-payer has been shown to: • Reduce costs • Reduce administrative waste (US wastes 31%) • Negotiate drug prices (VA spends 40% less on medications) • All other cost control methods easier to implement • Cover everyone • Improve our health • Protect against financial ruin • Provide real choice Sources: New England Journal of Medicine, 2003 PNHP, 2009
Emergency
