HealthCare/Prescriptions for Californians: There Is a Train Wreck Ahead – in fact, it’s here!

1. HealthCare/Prescriptions for Californians: There Is a Train Wreck Ahead – in fact, it’s here! 8/9/2014 Margie Metzler 916-921-5008 margiemetz@hotmail.com Website: www.gpcal.org This program operates under a grant from the California Wellness Foundation

2. -- and how can we talk about it so people “get it?” “Of all the forms of inequality, injustice in health care is the most shocking and inhumane.” Martin Luther King, Jr. What is the Healthcare Train Wreck?

3. Just the Facts, Ma’am! • Highest Cost of American Medical Care in the world! • We are number 37 in the world for med. outcomes (between Costa Rica/Slovenia) (http://www.who.int/whosis/indicators/2007compendium/en/index.html) • Who gets medical care? (hint: rich, good insurance, children covered by SCHIP, Medicare recipients, Medicaid recipients)

4. Some people still say we have the best healthcare in the world. • Dick Cheney does. He is in a single-payer healthcare plan provided by the Federal government. • Are you? The government is not an alien force. It is us.

5. Medical Issues • Who doesn’t get medical care? (Underinsured and uninsured, plus people kicked out by insurers) • The Uninsured: 47 Million and growing (7 million in California) • Medicare Part D is still a mess and getting worse! • Other Prescription Drug Issues: Errors and Collusion

6. Why don’t they get health care? • Working poor • Those who work part-time jobs: temp, teachers, seasonal • Unemployed • People who are really sick (the dreaded pre-existing condition!) Without Health Care for All, we will not regain our dignity as a nation.

7. History: 1700 to 1840 • Hospitals provide isolation and maintenance, cures happen at home. • Financed through: (1) taxes (public hospitals); and (2) charity (private hospitals, often with religious sponsorship). • hospital is a substitute home for the indigent and mentally ill. • Anyone can practice "medicine." • Sickness is caused by moral turpitude or  imbalance with nature. • 1798: Congress established the National Marine Health Service (now the Public Health Service) financed by compulsory deductions of 20 cents a month from seamen's wages. http://faculty.smu.edu/tmayo/health%20care%20timeline.htm

8. 1840-1860: Industrialization and beginning of Middle Class • People moved out of home and need hospitals. Maintenance; self pay. • Cities have “pest” facilities for mentally ill and “alms” houses for the poor (forerunner of public hospitals) • No financing; poor paid for with taxes or charity, or doctors “socialized medicine;” Barter common. • Doctors form AMA in 1847. • Anyone can still practice medicine.

9. 1860s - early 1900s • Hospital becomes place of Healing • Medicine becomes a Science (Crimean and Civil Wars) • Surgery and Nursing • Pasteur’s germ theory • Laboratories for diagnosis, X-rays and anesthetics. Enhance role of hospitals. • Public Health Service est. in 1887; became National Institutes of Health. • In Germany, Bismarck provides “safety net” to workers • AMA role advances

10. 1910’s • Medicine becomes a profession with state licensing, self-regulation; peer evaluation. • 1914 American Association for Labor Legislation (AALL), first national conference on “social insurance”: free medical care, paid sick leave and small death benefit. Doctors and insurance companies kill it. • Some unions support, but Samuel Rompers, AFL, denounced as a “menace to the rights, welfare, and liberty of American workers.” • Insurance companies offer health insurance to kill future efforts.

11. 1920’s • Doctors incomes (and prestige) skyrocket • General Motors contract to insure 180,000 workers.

12. 1930’s • Depression: need for unemployment insurance and “old age” benefits • Social Security Act passed. Many fought for health insurance but failed. • Hospitals create the first structured pooled financing mechanism: Blue Cross. Blue Shield for surgery follows. Blue Cross offers private coverage for hospital care: insurance companies fight. • 1933: Federal Emergency Relief Administration: limited medical, dental and nursing for indigent. • 1935: Works Project Administration to construct and improve hospitals

13. 1930’s Continued • Employers begin to provide health benefits • Group practices set up (early HMO’s). Medical profession want to prohibit. • Commercial insurers compete with “The Blues”, which are non-profit. • 1939: Survivors benefits added to Social Security.

14. 1940’s • 1942: WWII, wage and price controls are imposed on employers; offer health benefits to compete. • 1945: Truman proposes universal healthcare system. Denounced by AMA, doctors, US Chamber of Commerce. Plan called a communist plot by a House subcommittee Southern politicians feared healthcare would lead to federal action against segregation.

15. 1950’s • 1954: IRS exempts employer-purchased health benefits • 1956: CHAMPUS (govt financing of health services to military dependents in civilian facilities • National health care expenditures are 4.5% of GNP • Huge growth in medications; beg. of organ transplants. • Employer coverage goes from 1 to 32 million people

16. 1960’s: Pressures for gov’t Ins. System fought by org. medicine and insurers • Price of hosp. care doubles • People (esp. aged) can’t afford healthcare or insurance (over 700 for-profits cherry pick young and healthy people and costs go up.) • 1960: Fed. Employees health benefits • In Europe, organized labor worked with politicians for HC for everyone. Not here! • Kennedy campaigns on HC issues

17. 1965-70: Johnson Years • 3 separate bills: Wilbur Mills combines into one bill. • 1965: Medicare and Medicaid authorized. Signed in Independence MO with Truman present. • Civil Rights legislation • Doctors and hospitals overcharge and costs of Medicare and Medicaid spiral

18. 1970’s: Limits • 1971: Sen. Edward Kennedy becomes chair of Senate Health Services Subcommittee and promotes National health insurance. Issues a report, “The Health Care Crisis in America.” • Pres. Nixon senses competition in 1972 election and releases his own health-care plan., the National Health Insurance Partnership Act, aimed to preserve the private insurance market while requiring employers to either cover workers or make payments into a government insurance fund. (Sound familiar?) Supported by many major US corporations. • Watergate happens… both plans die.

19. 1970’s continued • Kennedy tries compromise national health insurance bill and pleases no one. • New president Gerald Ford urges lawmakers to approve a national health insurance bill. Goes nowhere. • 1973-75: 90 sep. bills introduced in 93rd Congress

20. Late 1970’s and 80’s • Carter wanted national program but focuses on reining n in costs: In the previous 10 years, the consumer price index went up 79%, while hospital costs went up 237 %. Carter proposed caps on hospital charges, but hospitals and business lobbied fiercely against it. • Reagan elected on promise to limit government; no one tries again until Clinton. • Managed care resurrected.

21. Clinton: Will it work again? "Harry and Louise," 1993 Never again!

22. So we’ve had all this time… …And what have we got? • Millions uninsured • Millions underinsured • Millions dumped when they get sick • Millions getting MRSA and other conditions form hospitals • Millions refused because they have pre-existing conditions • Millions hounded into bankruptcy by hospital debt collectors • Millions forced to pay hospitals tens of thousands of dollars before they can even be seen

23. …And how’s that working for us?

24. Can we agree on a set of universal principles? • Every working parent must be able to take their kids to the doctor • Medical decision must be made by us and our doctors, not insurance company bean counters • No one should profit from people’s suffering • Pricing for care must not be a secret • We should not be herded to a “panel” of physicians because it’s good for insurance company executives

25. A philosophical divide • Guaranteed, affordable health care vs. forcing people to buy insurance? • Health care for profit or for people? • Is our goal care or insurance?

26. Per Capita Spending on Health Care – 2004(How Does GM Compete In A Global Market?) $7,000 $6,102 $6,000 $5,000 $4,077 $3,966 $4,000 $3,159 $3,165 $3,041 $2,825 $3,000 $2,546 $2,249 $2,000 $1,000 $0 U.S. U.K. Switz Japan Nether Canada Norway Sweden Germany S Source: Organization for Economic Co-Operation and Development (OECD) Health Data 2006 (in U.S. dollars adjusted for purchasing power parity)

27. Percentage of GDP Spent on Health Care

28. Remember Part D? • How’s privatizing working for you? • Did it really work? • Who’s happy now? • Can the mess be cleaned up?

29. Medicare Part D • Monthly Premium Varies • Annual Deductibles vary • Co-payments vary and change yearly • No coverage during donut hole • Still pay premiums, even though no coverage • Can’t easily compare plans

30. Part D: Who Wins?? • Average senior: saved $9 per month • Jay Gellert, Health Net: $11,639,834 • William McQuire, United Health Group: $10,697,442 • Larry Glasscok, Wellpoint (Blue Cross): $8,523,139 • Edward Harnway, Cigna, $12,373,300 • Insurance Company profits increased 234% from 2000 to 2004 Modern Healthcare: April and July Issues 2006

31. No More Vioxxes! • Register all clinical trials and make results public • Regulation of industry marketing • JAMA standards • Litigation (PAL) • Best Buy Drugs (www.consumersunion.org) • Drug Effectiveness Review Project (DERP): Oregon Health & Science University Evidence-Based Practice Center. Medication Errors Panel Report (CA State Cap.)

32. Rx Marketing to Doctors • Industry spends $12 B/year on drug marketing to MDs, or $13,000/doctor • There is 1 sales rep for every 5 MDs • Gifts, lunches, trips, educational grants, entertainment, free samples • Even small gifts create obligation and influence prescribing decisions • Free samples create loyalty to brand and unwillingness to use generics (30-80% lower cost) • Doctors are paid to promote expensive new drugs and off-label uses

33. The FDA and the Pharmaceutical Industry • US drug prices are the highest in the world and getting worse. We paid 81% more for brand drugs (average) than Switzerland, Britain, Germany, Canada, Sweden, France, and Italy. • FDA ties to Pharma (Tauzin)

34. What is to be done? “I don’t believe there’s any problem in this country, no matter how tough it is,that Americans, when they roll up their sleeves, can’t completely ignore.” George Carlin

35. Germany 1883 Switzerland 1911 New Zealand 1938 Belgium 1945 UK 1946 Sweden 1947 Greece 1961 Japan 1961 Canada 1966 Denmark 1973 Australia 1974 Italy 1978 Portugal 1979 Spain 1986 South Africa 1996 Thailand 2006 When did other countries get guaranteed, accessible healthcare systems?

36. Doctors Hospitals Providers Businesses Voters need to provide politicians a safe haven so they can do the right thing What will it take to win? Everybody in one risk pool! YOU and your family and friends!

37. How do we talk about Health care? • Iraq War, Economy, Healthcare. Combine them! • Voters are concerned will cost more • Voters are frightened and resent that insurance companies deny coverage • Voters support reform proposals in principle — but are afraid they will lose what they have. • The concept of “quality affordable health care” is more appealing than “universal coverage” • Voters strongly support Medicare but believe it has problems. (Part D has hurt us)

38. Core Beliefs • Core value – pursuit of American Dream, our country’s destiny, family’s well-being and future. • Voters use moral terms – no American should be denied health care. • Voters see it as a necessity. Market forces are not enough. • Voters believe everyone should have access to quality, affordable health care — but don’t want to pay for “undeserving”. • Voters want an “American” solution. Skeptical of “government run,” but role as a watchdog.

39. Barriers • Cynicism about government • Concerns about government bureaucracy, red tape, high costs • Who pays for it? • Fear of higher costs, higher taxes • Scarcity – voters worry about what they will lose in quality • Illegal immigrants and other “undeserving” people • Perceived impact on small businesses • The ability of powerful interests to block action

40. Dealing with Barriers • Incorporate “personal responsibility” • Include options and choices in proposals – make sure it’s employee choice, not just employer choice • Use preventive care as a stepping stone • Find a uniquely American solution, including choice • Emphasize security and peace of mind • Focus on support for small business • Define a role for government as watchdog and rule maker • Animate anger, not fear

41. Say what? Not Universal coverage But Quality affordable health care Not A system like Social Security; Canadian Style Health Care But American health care Not Medicare for All But a choice of public and private plans Not Free But Sliding scale Not Wellness But Prevention Not Inexpensive But Smart investments; investing in the future Not Competition But Choice

42. When we pass Clean Air Legislation, build roads, or open new schools it’s for everyone in our community Immigration is a federal issue Covering undocumented workers actually improves California’s rates Public Health Risk Providing preventive care is less expensive than treating someone who is very ill Only 6% of the uninsured population are immigrants 85% of the uninsured are people who don’t get health coverage from their employer Only $11 per household per year is spent on taxes to cover care to undocumented workers Dealing with Barriers:Immigrants

43. Myths, Misinformation, and the Pursuit of Profit • America has the best health care system in the world. There is an ever-widening disparity between rich and poor, and esp. in HC. WE are #1 in spending and technology. 37th overall, 54th in fairness (tied with Fiji). • Everybody has access to care through the emergency room. (Most expensive and inconvenient way possible.) Many don’t go till it’s too late. • The free market is always the solution. We’ve given it half a century. It isn't getting better. (“How’s that working for you?”) • Private is always better than public. Fraud: Tenet paid $300 million in fines, HCA/Columbia paid $740 M. Blue Cross of Illinois paid $140. Government does lots of things best: • Socialized military • Socialized schools • Socialized Airport security • Socialized Defense • Socialized Road construction • Socialized Police • Socialized Firefighters

44. More myths • Overhead: private ins. companies pay as much as 30% in overhead costs, such as advertising and administration. Medicare pays 2-3%. • Medicare is going broke. Changes will always have to be made, as in any business. This is totally fraudulent. Every developed industrialized country assures coverage for everyone, and they spend much less than we do. The AMA and other organizations intentionally spread this falsehood. • Americans will not accept health care rationing like they have in other countries. Rationing is a loaded, deceptive word that triggers gut reactions. We already have waiting times here. And in this country we ration on money, not need for care. Is this fair or rational? • Canada’s health care system is terrible and failing. Not true. I usually ask them to name someone who is a normal Canadian who would prefer our system. Most other nations regard our healthcare system as barbaric. (My brother lives in Germany and became a citizen years ago… precisely for health care.)

45. More myths 2 • Drug prices are higher in the US because our pharmaceutical industry spend billions of dollars on research and development. Our drug companies have the highest profit margin, 19%, of all US corporations, with average 5%. They spend three times as much on marketing and admin. costs as on R&D. (HHS report lied about this). They have manipulated patent law to keep cheaper generic products off the market; given kickbacks to doctors who overcharge Medicare for drugs, price fixing, paying off various professionals including physicians, bribed legislators (Medicare Part D), and created phony grassroots groups like “Citizens for a Better Medicare.” (See Marcia Angell, editor of The New England Journal of Medicine.

46. More myths 3 • We can get to Universal Coverage Through Incremental Changes. And how is that working for you? • We do have successful single payer models: Medicare, Medicaid, Indian Health System, VA, SCHIP. They all work better than the private system.

47. “You Can’t Cross a Chasm in Small Steps” – David Lloyd George

48. Why have incremental reforms proven so ineffective in practice?

49. The masses will move to California because we have healthcare • SB 840 requires residency • California was the first state in our nation to pass Social Security • Will the masses move here from other states? (think about it!) Tactics used to scare us

50. Student loans Doctors spend years in school Important jobs Anesthesiologists $425,000 Specialists $274,000 General Practitioners $173,000 Earnings roughly twice as much as elsewhere –incomes 6. 6 times greater than the average patient $58 billion in excess income after loans are paid off $8 billion as investors in diagnostic labs and outpatient surgical clinics Doctors will leave Tactics to Scare Us!