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The Business Case for Single-Payer National Health Insurance Ana Malinow, MD Associate Professor Pediatrics, The Business Case for Single-Payer National Health Insurance Ana Malinow, MD Associate Professor Pediatrics, BCM Co-founder, Health Care for All Texas September 22, 2009

The Basics § § § Rising health care costs are the root of most The Basics § § § Rising health care costs are the root of most of the problems in health care Most costs are fixed whether health care is used or not Other countries cover everyone, have more services, higher quality and live longer yet spend far less than we do We are already paying the whole bill You can’t hold down costs without a system!

Rising Health Care Costs Rising Health Care Costs

Average Health Insurance Premiums and Worker Contributions for Family Coverage, 1999 -2009 $13, 375 Average Health Insurance Premiums and Worker Contributions for Family Coverage, 1999 -2009 $13, 375 131% Premium Increase $5, 791 128% Worker Contribution Increase Note: The average worker contribution and the average employer contribution may not add to the average total premium due to rounding. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999 -2009.

Cumulative Changes in Health Insurance Premiums, Inflation, and Workers’ Earnings, 1999 -2009 Note: Due Cumulative Changes in Health Insurance Premiums, Inflation, and Workers’ Earnings, 1999 -2009 Note: Due to a change in methods, the cumulative changes in the average family premium are somewhat different from those reported in previous versions of the Kaiser/HRET Survey of Employer-Sponsored Health Benefits. See the Survey Design and Methods Section for more information, available at http: //www. kff. org/insurance/7936/index. cfm. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999 -2009. Bureau of Labor Statistics, Consumer Price Index, U. S. City Average of Annual Inflation (April to April), 1999 -2009; Bureau of Labor Statistics, Seasonally Adjusted Data from the Current Employment Statistics Survey, 1999 -2009 (April to April).

Percentage of All Firms Offering Health Benefits, 1999 -2008* *Tests found no statistical differences Percentage of All Firms Offering Health Benefits, 1999 -2008* *Tests found no statistical differences from estimate for the previous year shown (p<. 05). Note: Estimates presented in this exhibit are based on the sample of both firms that completed the entire survey and those that answered just one question about whether they offer health benefits. Source: Kaiser/HRET Survey of Employer-Sponsored Health Benefits, 1999 -2008.

Total Annual Household Income and Federal Poverty Level Texas U. S. $44, 861 $49, Total Annual Household Income and Federal Poverty Level Texas U. S. $44, 861 $49, 901 $22, 050 200% FPL family of 4, 2007 $44, 100 Minimum Wage $7. 25/hr $15, 080 Total Median Annual Household Income www. kff. org 100% FPL family of 4, 2007 Dept of US Health and Human Services or $8. 00/hr Ave*. Annual ES HI $13, 375 Premiums for Family of *Does not include out-of-pocket costs; group market only 4, 2009

Getting Public Insurance in Texas Take a family with a 2 -mo old, 4 Getting Public Insurance in Texas Take a family with a 2 -mo old, 4 y/o & parents who make $40, 792/year (185% FPL) and no employer-sponsored health insurance: The 2 month-old qualifies for Medicaid The 4 year-old qualifies for S-CHIP Parents make over the limit to qualify for public health insurance. The limit? $6, 000 / year

Public Health Insurance Taxes Public Health Insurance is financed through federal and state taxes Public Health Insurance Taxes Public Health Insurance is financed through federal and state taxes State Fed Pays % Medicaid TX pays 40% Medicaid bill and 30% S-CHIP bill 40 60 CHIP 30 70 Medicare 0 100 VA 0 100 FEHBP 0 100 Source: www. kff. org State Facts

Distribution of Total Population by FPL <100%FPL Texas % 22 Mass % 16 U. Distribution of Total Population by FPL <100%FPL Texas % 22 Mass % 16 U. S. % 17 100 -199% 21 15 19 Low Income 200%+ 43 31 36 57 71 64 www. statehealthfacts. org Nonelderly Population and Poverty Rate: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau's March 2007 and 2008 Current Population Survey (CPS: Annual Social and Economic Supplements). Data are for states (2006 -2007) and U. S. (2007).

Number of Uninsured Americans 1976 - 2006 Number of Uninsured Americans 1976 - 2006

44, 840 Adult Excess Deaths Annually Due to Uninsurance in U. S. 17 -64 44, 840 Adult Excess Deaths Annually Due to Uninsurance in U. S. 17 -64 years State Texas Total % Excess Deaths Uninsured 2005 29. 7 4, 675 Sourxe: AP Wilper, et al. American Journal of Public Health, Dec 2009, Vol 99, No. 12

Administration is the Fastest Growing job in Health Care Source: Bureau of Labor Statistics Administration is the Fastest Growing job in Health Care Source: Bureau of Labor Statistics and NCHS

One-Third of Health Spending is Consumed by Administration Clinical Care Administrative Costs 31% 69% One-Third of Health Spending is Consumed by Administration Clinical Care Administrative Costs 31% 69% $775 Billion Total: $2. 5 Trillion Source: Woolhandler, et al, New England Journal of Medicine, August 2003 & Int. Jrnl. Of Hlth. Services, 2004

Costs Are Fixed Costs Are Fixed

Distribution of National Health Expenditures, by Type of Service, 2007 74% Fixed Costs Note: Distribution of National Health Expenditures, by Type of Service, 2007 74% Fixed Costs Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http: //www. cms. hhs. gov/National. Health. Expend. Data/ (see Historical; National Health Expenditures by type of service and source of funds, CY 1960 -2007; file nhe 2007. zip).

The Implications of Fixed costs § § § The cost of the infrastructure is The Implications of Fixed costs § § § The cost of the infrastructure is there whether or not it is used (nurse, hospital) 84% of hospital costs are fixed Cost containment for utilization won’t work if most costs are in infrastructure Trying to save money by keeping patients out of the hospital is like trying to save money on schools by keeping kids home for the day It is much more cost effective to invest in only what we need.

Important Question Whose responsibility should it be to pay for the health care services Important Question Whose responsibility should it be to pay for the health care services we all expect to be there should we need them?

Do we really have the best health care in the world? Do we really have the best health care in the world?

Out of Pocket Costs are Higher $/per capita Source: OECD 2006 Data are for Out of Pocket Costs are Higher $/per capita Source: OECD 2006 Data are for 2004 or for most recent year available Figures adjusted for purchasing power parity

Administrative Costs US vs Canada U. S. (%) Canada (%) 31 17 Source: Woolhandler Administrative Costs US vs Canada U. S. (%) Canada (%) 31 17 Source: Woolhandler et al. New England Journal of Medicine 349 (8): 768 August 21, 2003

Fewer Americans Smoke Compared with Other Nations OECD, 2006 (2003 Data) Fewer Americans Smoke Compared with Other Nations OECD, 2006 (2003 Data)

We Drink Less Alcohol OECD, 2006 (2003 Data) We Drink Less Alcohol OECD, 2006 (2003 Data)

But… We Don’t Live as Long OECD, 2006 (2003 Data) But… We Don’t Live as Long OECD, 2006 (2003 Data)

More Babies Die in the U. S. in the First Year of Life OECD, More Babies Die in the U. S. in the First Year of Life OECD, 2006 Data are for 2004 or more recent year available

We Do an Average Number of Bone Marrow Transplants per million people OECD, 2006 We Do an Average Number of Bone Marrow Transplants per million people OECD, 2006 (2003 Data)

We are Average in Number of Renal Transplants (2001/2002) Transplants/million population OECD, 2004 We are Average in Number of Renal Transplants (2001/2002) Transplants/million population OECD, 2004

We are Average in the Number of MRI Units MRIs/ million population Source: OECD, We are Average in the Number of MRI Units MRIs/ million population Source: OECD, 2005 Note: data are for 2004 , or most recent year available

We Do Fewer Hip Replacements Procedures per 100, 000 population Source: OECD 2006 Data We Do Fewer Hip Replacements Procedures per 100, 000 population Source: OECD 2006 Data are for 2004 or most recent year available 197

Our Quality is Not the Best in the World Survival Rates for 5 Countries Our Quality is Not the Best in the World Survival Rates for 5 Countries Australia Canada England 2 nd best worst 2 nd best 4 th 3 rd best 4 th worst 3 rd worst 3 rd best 4 th 3 rd * 2 nd best 4 th 2 nd worst 3 rd AMI, ages 20 -84 best worst NA 2 nd NA Stroke, ages 20 -84 2 nd best NA worst NA Breast Cancer Colorectal Cancer Cervical Cancer Childhood Leukemia Kidney Transplant Liver Transplant Non-Hodgkin’s Lymphoma Source: Health Affairs Vol 23: #3 , 2004 N. Z. U. S.

(2007=$7, 421/p/y www. cms. hhs. gov) (2007=$7, 421/p/y www. cms. hhs. gov)

US Health Costs Rise Faster than Other Countries’ Costs Source: Health United States 2005, US Health Costs Rise Faster than Other Countries’ Costs Source: Health United States 2005, Natl. Center for Health Statistics

Other Industrialized Countries ØAvailability of expensive technology ØRising drug costs ØHave similar demographics ØSimilar Other Industrialized Countries ØAvailability of expensive technology ØRising drug costs ØHave similar demographics ØSimilar levels of service Why are their costs so much lower?

Why Costs Are So Much Lower in Other Countries ØAdministrative simplicity ØNegotiated prices ØMore Why Costs Are So Much Lower in Other Countries ØAdministrative simplicity ØNegotiated prices ØMore primary care and prevention ØHealth planning ØGlobal budgets They have a system

Japan Has a $1400 Competitive Advantage on Every Car They Sell $/Car Source: Modern Japan Has a $1400 Competitive Advantage on Every Car They Sell $/Car Source: Modern Healthcare 10/24/05: 14

Fundamental Features of a True Health Care System ØEveryone Included ØPublic Financing ØClear Accountability Fundamental Features of a True Health Care System ØEveryone Included ØPublic Financing ØClear Accountability ØPublic Stewardship ØBudget Process

We Already Pay for National Health Insurance! We Already Pay for National Health Insurance!

In the End Individual Households Pay for All of Health Care INDIVIDUAL HOUSEHOLDS Lower In the End Individual Households Pay for All of Health Care INDIVIDUAL HOUSEHOLDS Lower wages Private employers pay for health insurance Taxes for Medicare and Medicaid Individual health insurance Out of pocket Property taxes Higher prices for goods Health insurance for public employees

How Much is the U. S. Health Care System Costing You NOW? What Americans How Much is the U. S. Health Care System Costing You NOW? What Americans Pay Into the U. S. Health Care System Today Household Income Level $25, 000 $50, 000 $75, 000 Share and Amount of Income Going to Health Care via Taxes Alone without Insurance 9. 0% ($2, 425) 9. 8% ($5, 300) 10. 7% ($8, 633) Share and Amount of Individual Total Wage Packet Going to Health Care for Household with Insurance (not Family including out of pocket costs) 22. 0% ($6, 904) 16. 8% ($9, 779) 15. 4% ($13, 112) 37. 2% ($14, 531) 26. 4% ($17, 406) 22. 3% ($20, 749) Share of total wage packet going to HC= (amount of total tax burden going to health + annual health insurance premium) (annual salary + payroll tax [FICA and Medicare] + annual health insurance premium) Source: Dollars & Sense, May/June 2008 OOP = co-pays, deductibles, co-insurance, uncovered expenses

60% of our Health Care is Financed through Taxes 100% Financed by Us! $2. 60% of our Health Care is Financed through Taxes 100% Financed by Us! $2. 5 Trillion Individuals 20% Taxpayers Private Employers {Deferred Wages} 20% 60% $1, 500 B Source: NEJM 1999; 340: 109; Health Affairs 2000; 19(3): 150 {Medicare, Medicaid, Public employees, tax subsidies}

We Need a System We Need a System

One-Third of Health Spending is Consumed by Administration Clinical Care Administrative Costs 31% 69% One-Third of Health Spending is Consumed by Administration Clinical Care Administrative Costs 31% 69% $775 Billion Total: $2. 5 Trillion Source: Woolhandler, et al, New England Journal of Medicine, August 2003 & Int. Jrnl. Of Hlth. Services, 2004

Clinical Care $387 B + $1. 75 T = $2. 14 Trillion 85% Enough Clinical Care $387 B + $1. 75 T = $2. 14 Trillion 85% Enough to pay for all uninsured and underinsured!

Investment Model § Healthcare is regarded as a public good with investment in needed Investment Model § Healthcare is regarded as a public good with investment in needed services for the whole population § The costs of these shared services are spread across the whole population (when you are not using them, someone else is—that’s what keeps them operational) § Pools money and pays for health care directly

Single Payer Health Care Systems § Sweden, Norway, Denmark, Canada, Finland, Iceland, Australia, and Single Payer Health Care Systems § Sweden, Norway, Denmark, Canada, Finland, Iceland, Australia, and Taiwan all have single payer financing § Single publicly financed risk pool that pays for health care directly from a fund ear-marked for health care § Everyone has access to privately delivered, publicly financed health care services § Public can buy health insurance for services not covered by public plan.

National Health Insurance • • • Everybody in, nobody out Portable Uniform, comprehensive benefits National Health Insurance • • • Everybody in, nobody out Portable Uniform, comprehensive benefits Prevention oriented Choice of physician Ends insurance industry influence Reduced administrative waste Cost savings Common sense budgeting Public oversight Source: http: //thomas. loc. gov/cgi-bin/thomas Single-Payer

Financing Single-Payer Medicare Medicaid Payroll Tax Single-Payer Health Care Fund $$$ Income Tax Negotiated Financing Single-Payer Medicare Medicaid Payroll Tax Single-Payer Health Care Fund $$$ Income Tax Negotiated formulary with physicians, global budget for hospitals, increased primary and preventive care, reduction in unnecessary high-tech interventions, bulk purchasing of drugs and medical supplies = long term cost control.

US National Health Insurance Act US National Health Insurance Act

Health Care Calculator Estimate your Savings with: HR 676 “The United States National Health Health Care Calculator Estimate your Savings with: HR 676 “The United States National Health Care Act” or “Expanded and Improved Medicare for All” http: //www. mirelestech. com/Calc. Wizard/Heal thcare. Calculator. aspx

Ana Malinow, MD amalinow@bcm. edu Health Care for All Texas www. healthcareforalltexas. org Ana Malinow, MD [email protected] edu Health Care for All Texas www. healthcareforalltexas. org