You Bet Your Life: Why We Need a
National Health Program
Richard D. Quint, MD, MPH
Health Sciences Clinical Professor of Pediatrics,
Emeritus (UCSF)
California Physicians Alliance
Universal Health Care:
The International Communist
Conspiracy
US National Health Program
Efforts Pre-WWII
• American Association for Labor
Legislation, 1915
• Social Security, 1935
The Road to Employment-Based
Private Insurance in the US
The Provider - Insurer Pact
• Health insurance plans initially sponsored
by hospital and physician organizations
• Hospitals and physicians wrote “costbased” payment rules
1943-1948: The Murray Wagner Dingell Bill
Keep Politics Out of This Picture
When the life – or health – of a loved one is at stake,
hope lies in the devoted service of your Doctor.
Would you change this picture? Compulsory health
insurance is political medicine. It would bring a third
party – a politician – between you and your doctor. It
would bind up your family’s health in red tape. It
would result in heavy payroll taxes – and inferior
medical care for you and your family. Don’t let that
happen here!
1965
• Medicare
• Medicaid
1970-1974
Nixon vs. Kennedy
Proposals
The Watery Demise of Health Care Reform
California Activism 1985-89
• Anti-patient dumping legislation
• Proposals for Universal Coverage
• Birth of California Physicians’ Alliance and
Physicians for a National Health Program
The sincerest form of
flattery...
Here Comes the AMA Again...
1994
Proposition
186
Number Uninsured
California: 6.6 million
PNHP, 2004; California Healthcare Foundation, 2005
Health Care Options
Project (HCOP)
• Convened by California Health and
Human Services Agency in 1999
• Examined options for extending health
care coverage in California
• Analyzed and compared by consultants
from The Lewin Group and AZA
Consulting
How do the HCOP Plans Compare?
Incremental
Example
Pay or
Play
Example
Universal
Care
Example
Reduction in
Uninsured
2.6
5.7
6.6
Change in Total Health
Spending
+ $1.4 billion + $3.0
billion
-($7.6)
billion
2006: Where do we go from here?
First, let’s look at what we’ve got
High quality?
Cost efficient?
Ready for change?
Overall Health System Performance
The US ranks 37th out of the 191 WHO
member states, placing it below
Colombia, Saudi Arabia, and Portugal
WHO 2000 World Health Report
Lack of insurance increases
morbidity and mortality
• 18,000 excess deaths per year
due to lack of health coverage
• People without health insurance:
– Receive less medical care and receive it later
– Are sicker when diagnosed
– Have 25% higher mortality rates
– Earn less because of poorer health
– 81% are from working families
“Care Without Coverage”, Institute of Medicine, May 2002
“Sicker and Poorer”, Medical Care Research and Review, June 2003
Life Expectancy
81.8
80
78.5
78.4
U.K.
Germany
79.4
79.7
79.9
France
Canada
Italy
77.2
75
70
U.S.
Ranking: 21/30; OECD, 2005
Japan
Infant Mortality per 1000 Births
8
7
7
6
5.4
4.8
5
4.7
4.2
4
3.9
3
3
2
1
0
U.S.
Canada
Australia
Source: OECD Health Data 2005
Italy
Germany
France
Japan
MRI Units per Million People
40
35.3
35
30
25
20
15
10
5
2.7
4.2
8.2
8.6
U.S.
Denmark
10.4
5.5
0
France
Canada
Germany
Italy
OECD, 2004 (2002 Data, U.S., Canada, and Germany are 2001)
Japan
% finding it difficult to get care
How hard is it to get care?
30
28
25
21
20
15
15
15
New Zealand
Australia
U.K.
15
10
5
0
U.S.
Canada
Commonwealth Fund Survey, 1998
% with same doctor > 5 years
Continuity of Care
100%
80%
60%
45%
52%
65%
65%
Australia
U.K.
57%
40%
20%
0%
U.S.
New
Zealand
Commonwealth Fund Survey, 1998
Canada
Financing healthcare in the U.S.
Individuals /
Businesses
Taxes
Premiums
Health Service
Providers
Direct or Out-of-Pocket Payments
Medicare,
Medicaid, etc.
Government
[payer]
Provider
Payments
Public employees’
premiums
Private
Insurers
[payers]
|------Collection of funds-------||---------Reimbursement--------|
Percent of GDP Spent on Health 2003
The Economist, January 27, 2006
Cost Excesses in the US
• Administrative waste
• Over-utilization of non-beneficial hightech care
• Inadequate, inefficient primary care
infrastructure
• Excess pricing of pharmaceuticals
D.McCanne, Quote of the Day, PNHP
Health-care spending per capita, 2005
Japan
U.K.
Sweden
France
$2,139
$2,231
$2,520
$2,903
Germany
$2,996
Canada
$3,001
U.S.
$5,635
$ Per Capita
Source: OECD Health Data 2005
Health-care spending per capita, 2005
Japan
U.K.
Sweden
France
$2,139
$2,231
$2,520
$2,903
Germany
$2,996
Canada
$3,001
U.S.
$5,635
$ Per Capita
Source: OECD Health Data 2005
Insurance Overhead Spending
$350
$ per capita
$300
$250
$200
$150
$100
$50
$0
U.S.
OECD, 2003
Canada
France
Australia Germany
U.S. Overhead Spending
30%
26.5%
19.9%
20%
16.3%
10%
0%
Medicare
Non-Profit Blues
Commercial
Carriers
International Journal of Health Services 2005; 35(1): 64-90
Investor-Owned
Blues
U.S. Overhead Spending
30%
26.5%
19.9%
20%
16.3%
10%
3.1%
0%
Medicare
Non-Profit Blues
Commercial
Carriers
International Journal of Health Services 2005; 35(1): 64-90
Investor-Owned
Blues
HMO Overhead Spending
30%
21.2%
19.7%
18.9%
18.5%
17.3% 17.8%
20%
14.1%
10%
2.4%
Managed Care Magazine July, 2003; Kaiser data: CMA Knox-Keane Report, May 2005
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lth
ca
re
el
lp
oi
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W
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Pa
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fic
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C
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na
0%
Which administrative costs should
we reduce?
Source: Kenneth Thorpe, 1992.
Government Health Insurance for All,
Even if Taxes Increase?
No opinion
5%
No opinion 5%
Oppose
30%
Favor
65%
Pew Report, May 2005
The Institute of Medicine recommends
that health-care should…
•
•
•
•
Be universal: Everybody in, nobody out
Be comprehensive and continuous
Be affordable to individuals and families
Use an insurance strategy that is affordable and
sustainable for society
• Enhance health and well-being by promoting access to
high-quality care that is effective, efficient, safe, timely,
patient-centered, and equitable
Institute of Medicine Report, 2004
2006: What are Solutions?
• Market (consumer driven health care)
• Incremental Reform
• More Major Reform (“national” health care,
“universal” health care, “Medicare for All” or
“single payer health care”)
– California
• SB 840
– US
• HR 676 "Expanded & Improved Medicare For All Bill
(Conyers)"
What does Dobie Gillis have to do with
healthcare in California?
State Senator Sheila Kuehl
(D, Santa Monica)
California Single Payer SB 840
Eligibility
• All state residents eligible.
• Individuals lacking legal immigration
status (i.e., “undocumented”)
included if they document residence.
California Single Payer SB 840
Benefits
•
•
•
•
•
Inpatient and outpatient
ER visits
All physician services
Prescription drugs
Laboratory and diagnostic
tests
• Mental health and
substance abuse
treatment
•
•
•
•
Vision care, incl. glasses
Hearing exams and aids
DME
Home health and adult
daycare
• Rehabilitation
• Dental care
Single payer financing: simplified
Individuals /
Businesses
Direct or Out-of-Pocket Payments
Health Service
Providers
CHIRA
Taxes
(SB 840)
Government
[payer]
|------Collection of funds-------||---------Reimbursement--------|
Projected Savings SB 840: 2006-2015
(in billions)
Year
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
Lewin Report, 2004
State/local
0.9
1.6
2.2
2.8
3.6
4.5
5.3
6.4
7.6
8.8
43.7
Total
8.0
12.3
17.0
22.4
28.4
35.0
42.2
50.2
59.2
68.9
331.3
Single payer financing: reality
Individuals /
Businesses
Direct or Out-of-Pocket Payments
CHIRA
Taxes
Premiums
Health Service
Providers
(SB 840)
Government
[payer]
Provider
Payments
Private
insurers (noncovered
services)
|------Collection of funds-------||---------Reimbursement--------|
California Single Payer SB 840
Administration
• Health Care Agency
• Elected commissioner
• Statewide boards/offices: Health Policy;
Consumer Advocacy; Medical Practice
Standards.
• … responsible for financial management
of the system; establishing eligibility and
benefits; negotiating reimbursement.
California Single Payer SB 840
Delivery system
• Private and public, as currently.
• Fee-for-service and capitated (integrated health
delivery systems such as Kaiser Permanente).
Providers and participants choose one.
• Maintains choice
After SB 840: Anticipated Changes
•
•
•
•
Decreased emergency room use
Increased access to care
Improved continuity of care
Increased emphasis on preventative
care and health education
• More integrated systems?
• Regionalization of high risk services?
Advantages of single payer to…
• Patients:
– Improved health
– Free choice of provider
– Portability of coverage
Advantages of single payer to…
• Physicians
– Restoration of clinical autonomy
– Lower malpractice premiums
– Improved patient care
– Simplified billing
Advantages of single payer to…
• Businesses
– Decreased health care costs
– Level the playing field
– Improved global competitiveness
Potential disadvantages
• Threat of underfunding by hostile
government
• Strength of special interests that would seek to
undermine the system
• Potential imbalance between quality controls
and expenditure growth
Potential disadvantages
• Transition from current system will be difficult
• Important tradeoffs: will America make them?
– You can’t give every health care intervention to every person
– Less choice in insurance plan
– More government control for less private control
Sounds Great….
How About Political Reality?
What can you do?
First, remember Pogo:
What can you do?
• Educate yourself and others
• Organize sessions on universal health
insurance
• Participate in grass-roots organizing
• Support universal health-care
legislation
• Write op-ed pieces, letters to editors
• JOIN PNHP and CaPA
What is CaPA?
• The California Physicians Alliance, a chapter of
Physicians for a National Health Program (PNHP)
WWW.PNHP.ORG
• CaPA’s goals are to:
– Promote universal health access in California and
the US
– Protect the provider-patient relationship
– Promote justice in health care
• Basic assumptions are:
– Health care is a human right
– Equity in health care
CaPA-Medical School Organizing Project
capa@jps.net
richardquint@sbcglobal.net
Thanks to……
Bree Johnston, M.D., MPH (UCSF, CaPA)
Kevin Grumbach, M.D. (UCSF, CaPA)
Kao-Ping Chua (MS IV, Washington U.)
Physicians for a National Health Program
In Summary
• Our health Care System is a Disgrace
• Part of our Role as Professionals should be
advocating for a system that serves our patients
well
• What Can We Do?
– Urge our professional societies to support universal
health insurance
– Dispel Myths about “Government Run Health Care”
– Join groups working for reform
Results by Specialty
Pediatric Subspecialty
Psychiatry
General Pediatrics
General Internal Medicine
Emergency Medicine
Governmental Legislation
to Establish NHI
General Surgery
Federal Government as
Sole Payer for NHI
Medical Subspecialty
Obstetrics/Gynecology
Family Practice
Surgical Subspecialty
Anesthesiology
0%
10%
20%
30%
40%
50%
60%
Percent Supporting
Ann Intern Med. 2003 Nov 18;139(10):795-801
70%
80%
90%
100%
What would it look like?
• Everyone gets a US NHI card
• Complete choice of doctor and hospital
• Doctors and hospitals remain
independent
• Govt processes and pays bills
Other savings
•
•
•
•
No more co-pays
No more deductibles
No more premiums
NO MORE OUT OF POCKET EXPENSES
Summary: Universal health care…
•
•
•
•
Leads to better outcomes
Would cost no more or save money
Americans want it
So do MDs, but won’t come out for a
single-payer approach
• Can be accomplished in California
California Single Payer SB 840
Cost-sharing
• No cost sharing for 2 years.
• After 2 years, cost-sharing option with limits of
$250 per person/$500 per family per year.
• Exemption for individuals who meet income rules,
and for prevention.
“Would you prefer the current system or
Universal Health Insurance…”
Don't
Know, 6%
Current,
32%
NHI, 62%
Washington Post/ABC News Poll, 10/20/03
Managed Care:
• Another Socialist Conspiracy:
– Prepaid Group Practices
• Nixon-Ellwood Conservative Reinvention:
– HMOs
Inpatient Days per Capita
1.4
1.2
1.2
1.0
1.0
Canada
Australia
1.1
1.1
U.K.
France
1.0
0.8
0.7
0.6
0.4
0.2
0.0
U.S.
OECD, 2004, (2001 Data)
Switzerland
Impact of SB 840 on State and Local
Government Health Spending: 2006-2015
(billions)
Current
Spending
Net Transfer
to Single-Payer
Net
Savings
2006
$18.7
$17.7
($0.9)
2007
$20.0
$18.4
($1.6)
2008
$21.4
$19.2
($2.2)
2009
$22.9
$20.1
($2.8)
2010
$24.5
$20.9
($3.6)
2011
$26.3
$21.8
($4.5)
2012
$28.2
$22.9
($5.3)
2013
$30.5
$24.1
($6.4)
2014
$32.8
$25.2
($7.6)
2015
$35.2
$26.4
($8.8)
Lewin Report, 2004
2005: Where are we now, and are we ready
for universal healthcare?
• Eroding safety net
• Market (consumer driven health care)
• Reform Proposals
– California
• Children’s “100% Campaign”
• SB 840
– US
• The United States National Health Insurance Act (HR676
- Conyers)
("Expanded & Improved Medicare For All Bill")
• Physician’s Proposal (PNHP)
Gov’t Insurance for All,
Even If Taxes Increase
Liberals
Dis. Dem.
Con. Dems
Disaffect.
Oppose
Favor
Upbeats
Pro-Gov. Con
Soc. Con.
Enter.
Total
0
Pew Survey, 2005
20
40
60
80
100
What About MDs?
1. Support or oppose governmental legislation to
establish national health insurance?
2.Support or oppose a national health insurance
plan where all health care is paid for by the
federal government?
Ann. Intern. Med. 2003
Government Legislation to
Establish NHI
Oppose
Strongly
Strongly
40%
Support
49%
Generally
Generally
Neutral
11%
Ann Intern Med. 2003 Nov 18;139(10):795-801
Government as Single Payer
Strongly
Strongly
Oppose
Support
25%
Generally
Generally
60%
Ann Intern Med. 2003 Nov 18;139(10):795-801
Neutral
14%
Percent of Children Immunized
(MMR)
100.0%
84.5%
85.9%
U.K.
France
91.6%
94.5%
99.0% 100.0%
Canada
Denmark
80.0%
60.0%
40.0%
20.0%
0.0%
OECD, 2004, (2002 Data)
U.S.
Japan
Infant Deaths by Income
8
6.5
7
6
5
4
4.7
5.1
6.8
5.2
3.9
3
2
1
0
Wealthiest
20%
Middle 20%
Poorest
20%
U.S.
Average
EDUCATE & ADVOCATE
When a
Political
Opening
Comes,
MOVE FAST!!
WORK FOR INCREMENTAL REFORMS
Myth: Canadians don’t get mental
health services
Percent receiving care
60
52.3
50
37.1
40
U.S.
Canada
26.3 27.7
30
20
11.3 10.4
10
6.3
3.4
0
No
disorder
Mild
Disorder
Health Affairs 2003; 22(3): 128
Moderate
Disorder
Severe
Disorder
By What Criteria Should We Judge Reform
Proposals? Institute of Medicine Report: 2004
•
•
•
•
•
Health care coverage should be universal.
Health care coverage should be continuous.
Health care coverage should be affordable to
individuals and families.
The health insurance strategy should be
affordable and sustainable for society.
Health insurance should enhance health and
well-being by promoting access to high-quality
care that is effective, efficient, safe, timely,
patient-centered, and equitable.
Universal healthcare should…
•
•
•
•
•
Cover everybody
Be comprehensive and continuous
Be simpler – one payer, one plan
Be accountable – transparent and public
Maintain choice
Institute of Medicine Report, 2004
How would such a system
contain costs?
• Set Budget
• Health planning
• Negotiate
reimbursement
• Formulary
• Prevention
• Simplify
Administration
profile of the uninsured
•
•
•
•
•
•
•
45.5 million non-elderly Americans in 2004
64% from low-income families
81% from working families
80% are adults
52% are ethnic minorities
79% are American citizens
More likely to be employed in small businesses,
service industries, and blue-collar jobs
You Bet Your Life:
A Marxist
Approach to Health Care in the U.S.?
(Or Why We Really Need a National
Health Plan)
Richard Quint, M.D., M.P.H.
California Physicians Alliance
Number of Uninsured in the US
40
35
30
25
20
15
10
5
Source: US Census Bureau, Current Population Surveys
1990
1985
1980
1975
0
National Health Programs
• Germany: 1883
• UK: 1912, 1948
• Canada: 1947, 1971
• Japan: 1922, 1961
1992
Health Care Reform:
“An Aura of Inevitability”
-George Lundberg, JAMA
A NATIONAL HEALTH PROGRAM FOR THE
UNITED STATES: A Physicians' Proposal
DAVID U. HIMMELSTEIN, M.D., STEFFIE
WOOLHANDLER, M.D., M.P.H.,
AND THE WRITING COMMITTEE OF THE
WORKING GROUP ON PROGRAM DESIGN
New England Journal of Medicine 320:102-108
(January 12), 1989
The Human Cost: Personal Bankruptcies*
54%
46%
*N=1771 bankruptcy filers
Health Affairs, February 2, 2005
Medical
Other
Myths About US Health-care
• It’s the best
• A national health program would
be more expensive
• Americans don’t want change
Myths about US health-care
• Better outcomes under national health
programs
• A national health program would be
more expensive
• Americans don’t want change
Four scenarios: Spending reductions
2006-2015 (billion)
1200
1000
800
600
400
200
0
Mandates
Expansion
National Coalition on Health Care, May 2005
FEHB
Single-payer
Myths about US health-care
• Universal healthcare leads to better
outcomes
• Universal health care would save money
• Americans don’t want change
Summary: Universal health care…
•
•
•
•
Leads to better outcomes
Saves money
Americans want it
What are the prospects for changes?
FINANCING UNIVERSAL
HEALTHCARE
Rx
MEDICARE
EYE CARE
MEDICAID
EMPLOYER
PAYROLL
TAX
SINGLE PAYER
HEALTHCARE
FUND
$$$$$$$$$$
DOCTOR
EMPLOYEE
PAYROLL
TAX
Objectives: Understand…
History of universal healthcare movement
Current state of US health-care system
Universal health insurance legislation in
California