Healthcare Reform: Is It Necessary?
Subroto Kundu, M.D.
Consultant Neurologist SF Bay Area
Public Opinion is often a mish-mash of misconceptions and myths..
(…and then there is Fox News)
Tally of Assets
Let us look at what are our strengths and weaknesses…
What is Right with our System?
Excellent hospitals, equipment, and health care facilities
Enough well trained professionals Superb research Sufficient spending
What is Wrong with our System?
We spend far more money than any other country on health care...
…but get far fewer benefits, far worse health outcomes, and far less patient satisfaction.
The Healthcare Americans Want Guaranteed access
Free choice of doctor
High quality
Affordability
Trust and respect
The Healthcare Americans Get
1/3 are uninsured or underinsured HMOs deny care to millions Death rates higher than other wealthy nations’ Costs double Canada's, Germany's, or
Sweden's - and rising faster Executives and investors making billions Destruction of the doctor/patient relationship
Approaching these myths with appropriate scientific validation
is not hard to do….
Myth #1: We Have The Best Health Care System In The World
Just the facts, please
45 MillionUninsured
Who Are The Uninsured?
Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS
*Students>18, Homemakers,
Disabled, Early retirees
»Employed»50%
»Children»25%
»Unemployed»5%
»*Out of labor »force»20%
Maternal Mortality 1999
Infant Mortality, 1999Deaths In First Year Of Life/1000 Live Births
Source: OECD, 2002
5.75.3 5.1
4.5 4.33.4
7.1
012
3456
78
U.S.
AUSTRALIA
CANADAIT
ALY
GERMANY
FRANCE
SWEDEN
Life Expectancy For Women, 1999
Source: OECD, 2002 - Data on Italy are for 1998
82
80.7
82.5
79.8
81.6 81.7
79.4
77
78
79
80
81
82
83U.S
.
U.K.
GERM
ANY
ITALY
CANADA
SWEDEN
FRANCE
YE
AR
S
Life Expectancy For Men, 1999
Source: OECD, 2002 - Data for Italy are for 1998
74.7 75 75 75.3
76.376.7
73.9
70
71
72
73
74
75
76
77
78
U.S.
GERMANY
FRANCEUK
ITALY
CANADA
SWEDEN
YE
AR
S
Hospital Inpatient Days Per Capita, 2000
Source: OECD, 2002
1.1 1.2
2.42.6 2.7
4
0.8
0
1
2
3
4
U.S.
Canad
aU.K
.
France
Austra
lia
Germ
any
Japan
Day
s/pe
rson
Consider Associated Statistics…..
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
6%
8%
9%
11%
11%
11%
17%
0% 5% 10% 15% 20%
Netherlands
France
Sweden
Canada
UK
Germany
US
% of Population Below Poverty Level
Americans Lead the World in Hours Worked
Source: International Labor Organization, 1999
1399
1560
1656
1731
1889
1883
1966
0 250 500 750 1000 1250 1500 1750 2000
Norway
Germany
France
U.K.
Japan
U.S. (1980)
U.S. (1997)
Hours/worker-year - 1997
Incarceration Rates, 2000
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
Myth #1: We Have The Best Health Care System In The World
Certainly does not seem like the best, does it?
Myth #2: We Don’t Have the Money to Cover Everyone
Health Care Spending
2009 value: $2.5 trillion !! (17.6% of GDP)
2018 projection: $4.4 trillion
Source: National Coalition on Health Care www.nchc.org
US Spends More Than Any Other NationPer Capita Spending, U.S. Dollars, 1998
$1.424
$1.461
$1.822
$2.043
$2.07
$2.077
$2.133
$2.312
$2.424
$2.425
$2.794
$4.178
New Zealand
United Kingdom
Japan
Australia
Netherlands
France
Denmark
Canada
Germany
Norway
Switzerland
United States
Source: Anderson & Hussey, Health Affairs, May/June 2001.
Per Capita National Health Spending Reached $4,637 in 2000
$82 $105 $141 $202$341
$582
$1052
$1733
$2690
$3637
$4637
1950 1955 1960 1965 1970 1975 1980 1985 1990 1995 2000
SOURCE: Centers for Medicare and Medicaid Services
HEALTH COSTS AS % OF GNP:U.S. & CANADA, 1960-2001
CANADA'S NHP ENACTED
NHP FULLY IMPLEMENTED
Source: Statistics Canada, Canadian Inst. for Health Info., & NCHS/Commerce Dept
5
6
7
8
9
10
11
12
13
14
15
1960
1965
1970
1975
1980
1985
1990
1995
2000
% o
f G
NP
CANADA
U.S.
Myth # 3: Government Is Less Efficient Than the Private Sector
Overhead & Profit As Percent of Premium
Cigna
RC Aetna Wellpoint
UnitedHumana Pacific
Medicare0
5
10
15
20
25
30
35
Cigna RC Aetna Wellpoint United Humana Pacific Medicare
Private insurers’ High Overhead
Medicare Coverage is Better than Private
Healthcare Cradle to Grave…
Productive years
90% of healthcareexpenditure donein last 10% of life
Medicare: governmentspending
Healthiest portion of lifeleast healthcare
spending
HMO/PPO Spending
Only earning period of lifeHighest contribution to healthcare
25 65
services
Patients Medical Providers
Pvt HealthInsurance
payment
payment
AutoInsurance
WorkmensCompensation
Home OwnersInsurance
Misc HealthInsurance
payment
payment
payment
payment
MediCareMediCaid
So, what would you say to a plan that reduced the multiple payments with a single coverage…
servicesPatients Medical
Providers
payment payment
Single InsurancePayer
Specially one with 3.1% overhead
And no profit
56% of Medical Students & FacultyFavor Single Payer, Med School Deans
Source: NEJM 1999; 340:928
22%
56%
3%19%
Managed Care Single PayerNo Preference Fee-for-service
“What is the best health care system for the most people?”
Harris Poll: “Government Should ProvideQuality Medical Coverage to All Adults . . .”
Source: USA Today/Harris Poll - 11/23/98
77%
53% 52%47%
0%
20%
40%
60%
80%
GeneralPublic
Employers StateLegislators
Congressional Aides
Per
cent
agr
eein
g
•Since everyone is covered in this system, there are no:
--“Pre-existing conditions”--“loss of coverage” e.g., by change of job, moving--and multiple other ills of the present system
Myth #4: Single Payer Means Single Delivery System
Myth #5: We Will Have Rationing “Like They Have in Canada”
We do have “rationing” already. We only recognize them differently, such as by limited access to healthcare, denials by insurance companies, high cost
Access is already restricted!
1 of 5 Americans postponed getting needed health care last year
1 of 7 Americans had a problem paying for medical bills last year
1 of 10 did not get a prescription drug they needed due to cost
Kaiser Commission on Medicaid and the Uninsured, July 2002
U.S. Public Spending Per Capita for Healthis Greater than Total Spending in Other Nations
Note: Public includes benefit costs for govt. employees & tax subsidy for private insuranceSource: NEJM 1999; 340:109; Health Aff 2000; 19(3):150
$1,670
$1,750
$1,850
$2,230
$2,430
$2,620
$1,760$2,600
$0 $1,000 $2,000 $3,000 $4,000 $5,000
U.K.
Sweden
Japan
France
Canada
Germany
U.S.
$ Per Capita
Total Spending U.S. Public U.S. Private
Out-of-Pocket Payments, 2000
Myth # 6: It is Bad for Business
Employers’ Health Benefit Costs US vs. Canada
Healthcare cost to US businesses…
Myth # 7: Our population is older than the rest of the world
Elderly as Percent of Total Population, 2000
Source: Health Affairs 2000; 19(3):192
12.1% 12.8%
15.9% 16.0% 16.4% 17.1%
12.5%
0%
5%
10%
15%
20%
U.S
.
Aus
tral
ia
Can
ada
Fra
nce
U.K
.
Ger
man
y
Japa
nPer
cent
of
Pop
ulat
ion
Old
er T
han
65
Infant Deaths by Income, Canada 1996Even the Poor Do Better than U.S. Average
3.94.7 5.1 5.2
6.5
7.8
0123456789
Wealthiest20%
Middle20%
Poorest20%
U.S.Average
Infa
nt
Mo
rtali
ty
MYTH # 8: Doctors will leave
“DOCTORS ARE LEAVING CANADA IN DROVES FOR THE PROMISED LAND OF THE USA”
Few Canadian Physicians Emigrate
Applicants per Medical School Place
2.4
5.5
0.0
1.0
2.0
3.0
4.0
5.0
6.0
United States Canada
Source: JAMA; 282:892; Canadian Medical Education Statistics, 1999:150
Myth # 9: We Don’t Want All That Government Intrusion
Instead, We Now Have Private Sector Intrusion
The Administrative Nightmare
$384 Billion Spent on Administrative Costs Last Year. Saving Half of This
Would Easily Cover the Uninsured
Physicians' Billing & Office ExpensesUnited States & Canada, 2000
Source:Woolhandler/Himmelstein NEJM 1991;324:1253 (updated)
$430
$102
$0
$100
$200
$300
$400
$500
U.S. CANADA
$ P
ER
CA
PIT
A
Hospital Billing & AdministrationUnited States & Canada, 2000
Source: Woolhandler/Himmelstein NEJM 1991; 324:1253 & 1993; 329:400 (updated)
$372
$68
$0
$100
$200
$300
$400
$500
U.S. CANADA
$ P
ER
CA
PIT
A
Growth of Physicians, RNs & Administrators 1970-1998
0
500
1000
1500
2000
2500
1970 1975 1980 1985 1990 1998
AdministratorsRNsPhysicians
Bureau of Labor Statistics, NCHS
Percentage Growth
0
500
1000
1500
2000
2500
1970 1975 1980 1985 1990 1995
Administrators
RNs
Physicians
Do you want your
health care dollars spent
Here or
Here?
What are the options?
No intervention … maintain status quo Reform health care market. Expand public programs. Improve the employer approach (pay or
play). Single payer.
The Single Payer System
What do we get from Single-Payer?
Administrative efficiency via simplified reimbursement. Patient freedom to choose/change health care providers,
without paying more. Provider freedom to choose mode of practice (fee-for-
service, capitation, or salary). Fairer financing (lower cost to sick, poor/middle-income). Explicitness in priorities (e.g., prevention) and financing
(e.g., risk adjustment) Shared dedication to success, via universal participation.
How Does Single-Payer Do It?
Global Budgeting controls costs while leaving clinical decision-making in the hands of the patient’s chosen health care professional.
Just collects money and pays bills without needing to intrude into individual doctor-patient relationships to make a profit.
That is, review the flow of healthcare dollars, but leave HEALTHCARE alone!
• Eliminates hidden sources of waste and profiteering
NO NEED TO REINVENT THE WHEEL
THAT IS HOW ALL THE INDUSTRIALIZED NATIONS OF THE WORLD DO IT !!
Who Benefits from the Single Payer System?
You do!!
And do all providers who are not paidfor their services, but look towards
their “HMO” kickbacks
Who Loses from the Single Payer System?
The Insurance Company and its brokers!!
Money Managers
HENCE THE NEED OF THE HOUR IS…
NOT NECESSARILY HEALTHCARE REFORM
BUT CERTAINLY HEALTH INSURANCE REFORM !
THANK YOU !