Achieving Universal Health Care
for Kids (& Adults): The Minnesota
Health Plan
Ann Settgast, MD
University of Minnesota
Pediatric Grand Rounds
August 31, 2011
Disclosures
• No financial relationships
• No discussion of off label or investigational use
The U.S. health care system
becomes a more embarrassing
disaster each year…
— Donald Kennedy, former President,
Stanford University; former Editor
Science, August 15, 2003
America has the best health care
system in the world, pure and
simple.
— President George W. Bush, addressing
the American Hospital Association, May 1,
2006
The U.S. health care system
becomes a more embarrassing
disaster each year…
— Donald Kennedy, former President,
Stanford University; former Editor
Science, August 15, 2003
America has the best health care in
the world, pure and simple.
— President George W. Bush, addressing
the American Hospital Association, May 1,
2006
- National research & education organization of ~
18,000 physicians and medical students
advocating universal, comprehensive, singlepayer health insurance
- Single-payer care provides a more cost efficient
and equitable way to administer health care
- “…access to high-quality health care is a right of
all people and should be provided equitably as a
public service rather than bought and sold as a
commodity…”
Objectives
• Distinguish single-payer healthcare reform
from other reform proposals
• Define the problems of uninsurance and
underinsurance as they relate to US
children
• Introduce the Minnesota single-payer
movement
Definitions
• Universal health care
– Access for all
– Doesn’t specify how
• Socialized medicine
– Publicly financed
– Publicly owned
• Single-payer system
– Publicly financed
– Privately owned
(delivered)
What is Single-Payer?
• Hospitals & clinics now bill > 1000 payers
(insurers)
• In a single-payer system, there would be no
private health insurance
• Recovery of $400 billion annually due to
drastically reduced administrative costs
Why Single-Payer?
Access
US
has
major
problems
in all 3 areas
Cost
Quality
480,000
Uninsured
68% of the uninsured
nonelderly have a
FULL-TIME worker in
the household.
Source: http://www.census.gov/hhes/www/hlthins/hlthins.html
Does being uninsured matter?
45,000 adult
deaths per
year
Source: Wilper et al. American Journal of
Public Health, 2009
Likelihood of Hospitalization After
an Injury by Coverage Type
n=1847 injuries in children <18 yrs
Hospitalization
Insurance
Type
Adjusted OR
95%
Private
2.21
0.73-6.63
Medicaid
Ref
Uninsured
4.07
1.13-14.66
S Hostetler et al., Health Care Access After Injury by Insurance Type in a Pediatric Population, Pediatric Emergency Care
Vol. 21 (7) July 2005 National Health Interview Survey 2000,01,02
* Adjusted for gender, race,
age, region, hospital type,
comorbid disease
J Public Health (2010) 32 (2): 236-244 (Data from 23 535 491 pediatric
inpatient hospitalizations over 18 years from 37 US states were analyzed).
“The Hidden Uninsured”
Among Children Insured in Jan 2006, Percent
Uninsured in Each Month, Jan 2006 to Dec 2007
Underinsurance
• 62% of personal
bankruptcies due to
medical expenses (2007)
– 50% in 2001
• 78% of people with
medical bankruptcies had
health insurance when
they got sick
“Medical impoverishment,
although common in poor
nations, is almost unheard
of in wealthy countries
other than the US.”
Himmelstein et al, American Journal of Medicine, June 4, 2009
“Underinsurance Among Children in
the United States”, NEJM, 2010, 363;9
• 14.1 million US children with continuous
coverage are underinsured
• Underinsurance defined:
– “Insurance does not provide adequate
benefits, provider choices, or coverage of
costs.”
Data: 2007 National Survey of Children’s Health – sample size 91,642 children
“Underinsurance Among Children in the United
States”, NEJM, 2010, 363;9
Why Single-Payer?
Access
US
has
major
problems
in all 3 areas
Cost
Quality
Growth in Total Health Expenditure Per Capita,
U.S. and Selected Countries, 1970-2008
$8,000
Per Capita Spending - PPP Adjusted
$7,000
$6,000
United States
$5,000
Switzerland
Canada
$4,000
OECD Average
Sweden
$3,000
United Kingdom
$2,000
$1,000
$0
1970
1975
1980
1985
1990
1995
2000
2005
Source: Organisation for Economic Co-operation and Development (2010), "OECD Health Data", OECD Health Statistics (database). doi: 10.1787/data-00350en (Accessed on 14 February 2011).
Notes: Data from Australia and Japan are 2007 data. Figures for Belgium, Canada, Netherlands, Norway and Switzerland, are OECD estimates. Numbers are
PPP adjusted. Break in series: CAN(1995); SWE(1993, 2001); SWI(1995); UK (1997). Numbers are PPP adjusted. Estimates for Canada and Switzerland in
2008.
Why Single-Payer?
Access
US
has
major
problems
in all 3 areas
Cost
Quality
US
ranked
37th by
the WHO
World
Health
Report
Why do we pay more and get
less?
• 31 cents of each healthcare $ is spent on
administration
• Administrative spending comes from two
sides:
– Providers
– Payers
(Steffie Woolhandler et al., “Costs of Health Care Administration in the United
States and Canada,” New England Journal of Medicine 2003;349:768-75)
Interactions between physician
practices & insurers are costly
$90,000
$80,000
$70,000
$60,000
$50,000
$40,000
$30,000
$20,000
$10,000
$0
Ontario
physician
practices
US physician
practices
Spending per physician per
year interacting with
payer(s)
Morra et al, Health Affairs, August 2011, 30:8, 1443-1450
Why do we pay more and get
less?
• 31 cents of each healthcare $ is spent on
administration
• Administrative spending comes from two
sides:
– Providers
– Payers
(Steffie Woolhandler et al., “Costs of Health Care Administration in the United
States and Canada,” New England Journal of Medicine 2003;349:768-75).
Insurance (Payer) Overhead
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
Why are their administrative
costs higher than Medicare’s?
•
•
•
•
•
•
•
•
•
Advertising/marketing
Enrolling/disenrolling
Underwriting
Denial of claims
Deciding what to cover (exclusions, pre-existing
conditions)
Negotiating multiple contracts with providers
Lobbying ($1.2 billion in 2009)
Salaries (CEO pay at top 10 insurers in 2009 =
$228 million)
Profit (Top 5 insurers reported $11.7 billion in 2010)
April 13, 2011
UnitedHealth Group Inc. CEO Stephen
Hemsley took home $48.8 million in total
compensation in 2010.
Admin costs of private payers
versus Medicare:
• Do these “services” make our patients
healthier?
• Should we be spending these healthcare
dollars on healthcare??
• Do these “services” help you as a doctor
to diagnose, treat, or prevent illness?
Is it feasible???
• We already have…
– Excellent hospitals and well-trained professionals
– A nation of vast wealth with sufficient spending
– Acceptance of pooled resources to publicly fund the
military, the NIH, the CDC, highways and roads,
police and fire services, schools, libraries, water
sanitation, etc.
• And…
– Every other industrialized nation is doing it!
What do doctors think of singlepayer?
• 5000 surveys, 2008: 51% response rate
• “In principle, do you support or oppose
government legislation to establish
national health insurance?”
• 59% supported (49% in 2002)
Support for government legislation to establish National
Health Insurance in 2007 and 2002, by specialty
Annals of Internal Medicine, 1 April 2008, Volume 148 Issue 7, Pages 566-567
But didn’t we just pass historic
national reform?
• Individual Mandate
– Mandated health insurance for some (23 million
will remain uninsured in 2019)
– Policies required to cover at least 60% of
expected health costs (problem of underinsurance
remains alive and well)
– Raises costs
“While the legislation will enhance access to
insurance, the trade-off will be an accelerated
crisis of costs and perpetuation of the current
dysfunction…” – Jeffrey Flier, dean of Harvard
Medical School
SF 8/HF 51
Chief author Senator John Marty
Minnesota Health Plan
• Who: All Minnesota residents
• What: All medically necessary services
– Inpatient/outpatient services
– Rehab care/NH care/HHC/Hospice
– Immunizations/preventive care
– Prescription drugs/Medical equipment
– Mental health care
– Dental and vision care
• How: Funded through premiums based on ability
to pay + a business health tax
Unique features of a SinglePayer System
•
•
•
•
•
Guaranteed care for all
Decreased costs
Healthcare de-linked from employment
Free choice of provider
Publicly accountable & responsive
Thank you for your attention!
• Educate yourself and
others (www.pnhp.org)
• Join PNHP-MN and/or
sign our physician
resolution
• Invite a PNHP speaker
to your organization or
group’s event
• Support the single payer
resolution at the 2012
AAP annual leadership
meeting
“Of all the forms of inequality, injustice
in healthcare is the most shocking and
inhumane.”
- Dr. Martin Luther King, Jr.