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Health Care in the U. S. and the World Martin Donohoe Health Care in the U. S. and the World Martin Donohoe

Determinants of Health n n n n n Era Socioeconomic status Sex Race Location Determinants of Health n n n n n Era Socioeconomic status Sex Race Location Environment Genetics Health Habits Access to Care Quality of Care

Health Care n. Prevention n. Diagnosis n. Treatment Health Care n. Prevention n. Diagnosis n. Treatment

The health impact pyramid Frieden, T. R. Am J Public Health 2010; 100: 590 The health impact pyramid Frieden, T. R. Am J Public Health 2010; 100: 590 -595 Copyright © 2010 American Public Health Association

The State of U. S. Health Care n Before PPACA: 42 million (13%) uninsured The State of U. S. Health Care n Before PPACA: 42 million (13%) uninsured n 45, 000 deaths/year n. Now 29 million uninsured (9%) n. Estimated 29, 000 deaths/yr

The State of U. S. Health Care n 30 million more underinsured n Remain The State of U. S. Health Care n 30 million more underinsured n Remain in dead-end jobs n Go without needed care and/or prescriptions n Marry n 106 million Americans lack dental insurance n ¼ U. S. adults has untreated dental caries n 1/5 Americans cannot pay for needed dental care n Only 20% of dentists treat Medicaid patients

Reasons for No Health Insurance Coverage (2009, pre-PPACA) Reasons for No Health Insurance Coverage (2009, pre-PPACA)

The State of U. S. Health Care n US ranks near the bottom among The State of U. S. Health Care n US ranks near the bottom among westernized nations in overall population health, life expectancy, infant and maternal mortality, etc. n U. S. health care system ranks 37 th/191 countries n U. S. has poorest health among all rich nations n 14% of Americans live in poverty n 21% of US children live in poverty

Health Care Expenditures per Capita n U. S. = $9, 255 (almost 18% of Health Care Expenditures per Capita n U. S. = $9, 255 (almost 18% of GDP) n U. S. #1 in spending on health care, #25 in spending on social services n Canada, Australia, Japan, Europe: $3, 000 to $6, 000 n Average for low income developing nations = $22 -$25

Who Pays for Health Care? n n n Government (federal, state, and local) n Who Pays for Health Care? n n n Government (federal, state, and local) n Medicare, Medicaid, VA, IHS, jails and prisons Private insurance: n 806 companies, each with an assortment of plans) n Just 2 companies control over 50% of the market in 45 states, 5 control 83% of US market n Primarily employer-based Out-of-pocket n ¾ of hospitals use point-of-service collections (i. e. , prepay before non-emergent treatment) n Hits poor hardest

Who Pays for Health Care? n Health care costs = Almost 18% of GDP Who Pays for Health Care? n Health care costs = Almost 18% of GDP (1/2 of worldwide health care costs) n Huge variability in charges n Chargemaster

Per capita health expenditures Per capita health expenditures

Health Insurance Industry Pre-existing conditions (illegal under PPACA) n Delisting n Cherry picking (since Health Insurance Industry Pre-existing conditions (illegal under PPACA) n Delisting n Cherry picking (since 5% of people account for 50% of health care costs, and 1% account for 20%) n n E. g. , have no specialist in network for a given specialty; limit access to needed meds (e. g. , anti-HIV or chemo drugs)

Health Insurance Industry Drug tiering (keeps sickest patients away) n Charging uninsured 2 -3 Health Insurance Industry Drug tiering (keeps sickest patients away) n Charging uninsured 2 -3 X more n Hiring debt collection agencies, which sometimes hound patients in the ER (in violation of EMTALA) n

Health Insurance Industry/Bureaucracy n High administrative costs n $450 billion/yr n 15 -30% (vs. Health Insurance Industry/Bureaucracy n High administrative costs n $450 billion/yr n 15 -30% (vs. 2 -3% for Medicare and Medicaid) n No change with PPACA n Hospital bureaucracy consumes ¼ of hospital budgets n Highest at for-profit hospitals n No effect on quality of care

Health Insurance Industry/Bureaucracy n High administrative costs n Average full-time physician spends over $86, Health Insurance Industry/Bureaucracy n High administrative costs n Average full-time physician spends over $86, 430/yr on billing and insurance functions n $83, 000 trying to recoup payment; $3430 on prior authorizations n 17, 849 different billing codes (in 2011) - now 141, 058

Administrative Work Average doctor spends 17% of working hours (8. 7 hrs/wk) on administration Administrative Work Average doctor spends 17% of working hours (8. 7 hrs/wk) on administration (not including charting, patient phone calls, usual care n IM residents spent 5 hrs/d on e-charting; echarting can decrease productivity n n n But specialist e-consultations can save time and costs Doctors spending more time on administration have lower career satisfaction (and primary care doctors have the highest administrative loads)

Health Insurance Industry n Amount actually spent on patient care referred to as “medical Health Insurance Industry n Amount actually spent on patient care referred to as “medical loss ratio” n Excessive CEO pay Median pay of health care CEOs = $11. 1 million (2012) n Healthcare CEOs passed bankers as best paid (2011) n

Health Insurance Industry Large profit margins n Nation’s 5 largest health insurers control 83% Health Insurance Industry Large profit margins n Nation’s 5 largest health insurers control 83% of the market n Corruption n Loyalty: shareholders (not patients) n

Distribution of National Health Expenditures Distribution of National Health Expenditures

Some Reasons for Rising Health Care Costs Aging population n Chronic diseases n Technological Some Reasons for Rising Health Care Costs Aging population n Chronic diseases n Technological advances n Exploding drug costs n Increasing specialist referrals n RVUs/pay much higher for procedural services n Specialists provide 40% of primary care n

Some Reasons for Rising Health Care Costs n Procedural variability n Overuse of diagnostic Some Reasons for Rising Health Care Costs n Procedural variability n Overuse of diagnostic tests, medications, and therapeutic procedures n Administrative costs

Drug Companies’ Cost Structure Drug Companies’ Cost Structure

Innovation: Published Research Leading to Drugs Innovation: Published Research Leading to Drugs

Pharmaceutical Industry n Only 10% of new drugs treat life- threatening conditions n 90% Pharmaceutical Industry n Only 10% of new drugs treat life- threatening conditions n 90% of new drugs little or no better than pre-existing agents (or cause harm) n Thus only 1% of new drugs “life-saving”

Pharmaceutical Industry Pay-for-delay costs consumers and taxpayers $3. 5 billion in additional drug costs/yr Pharmaceutical Industry Pay-for-delay costs consumers and taxpayers $3. 5 billion in additional drug costs/yr n Patent trolls delay access to medications (by not developing drugs but suing companies for copyright infringement) n PATENT act awaiting vote in Congress n

Pharmaceutical Industry n Salami slicing (obtaining multiple “orphan drug” status approvals helps increase profits Pharmaceutical Industry n Salami slicing (obtaining multiple “orphan drug” status approvals helps increase profits by prolonging market exclusivity (e. g. , 33 for IFN, 7 for Gleevec) n Over 40, 000 drug-related deaths not reported to FDA, as required, over last decade

Pharmaceutical Industry n Often quoted cost of developing new drugs (Tufts study) based on Pharmaceutical Industry n Often quoted cost of developing new drugs (Tufts study) based on myriad biased/unreal assumptions =$1. 3 billion n Actual median cost to drug company = $60 million (DW Light, Biosciences 2011; 6: 1 -17) n Medicins sans Frontiere estimates $50 million, $186 million if failed drug candidate costs included

Pharmaceutical Industry n n Cancer drugs increasingly expensive n 11/12 FDA approved anti-cancer agents Pharmaceutical Industry n n Cancer drugs increasingly expensive n 11/12 FDA approved anti-cancer agents cost over $100, 000/yr (2014) n High profile cancer patient advocacy organizations have a median of 7 biopharmaceutical funders (money buys silence) Some drug prices have gone up dramatically (e. g. , Epipen [although generic now available], colchicine, doxycycline, insulin, hepatitis C drugs)

Pharmaceutical Industry There is little correlation between the price of a particular drug and Pharmaceutical Industry There is little correlation between the price of a particular drug and a company’s R&D investment, nor between a drug’s price and the cost of its production n Universal drug coverage with tiered pricing would be cost-saving n

Drug Company Malfeasance n The pharmaceutical industry is the biggest defrauder of the federal Drug Company Malfeasance n The pharmaceutical industry is the biggest defrauder of the federal government, as determined by payments made for violations of the federal False Claims Act (FCA) n Accounted for 25% of all FCA payouts between 2000 and 2010 n Defense industry – 11%

Drug Company Malfeasance The pharmaceutical industry gives billions in gifts, speaking fees, and research Drug Company Malfeasance The pharmaceutical industry gives billions in gifts, speaking fees, and research grants to about ¾ of physicians n Inappropriate donations of nearly-expired, unnecessary drugs to poor countries, disaster areas, conflict zones to get tax writeoffs n n Aid organizations responsible for security/disposal

Lobbying n Almost 12, 000 full-time lobbyists n Health insurance, pharmaceutical, and organized medicine Lobbying n Almost 12, 000 full-time lobbyists n Health insurance, pharmaceutical, and organized medicine spend huge sums of money to influence legislation and policy n More than twice the amount spent by the defense, aerospace, and oil and gas industries combined

The “Global Economy” n 53 of the world’s 100 largest economies are private corporations; The “Global Economy” n 53 of the world’s 100 largest economies are private corporations; 47 are countries n. Wal-Mart is larger than Israel and Greece n. AT&T is larger than Malaysia and Ireland

Premature Deaths in the U. S. n 10% due to inadequate medical care n Premature Deaths in the U. S. n 10% due to inadequate medical care n 60% due to behaviors, social circumstances, and environmental exposures

Address Social Factors Responsible for Illness and Death n Deaths in 2000 attributable to: Address Social Factors Responsible for Illness and Death n Deaths in 2000 attributable to: n Low education: 245, 000 n Racial segregation: 176, 000 n Low social support: 162, 000 n Individual-level poverty: 133, 000 n AJPH 2011; 101: 1456 -1465

Address Social Factors Responsible for Illness and Death n Deaths in 2000 attributable to: Address Social Factors Responsible for Illness and Death n Deaths in 2000 attributable to: n Income inequality: 119, 000 (population- attributable mortality – 5. 1%) n Area-level poverty: 39, 000 (populationattributable mortality – 1. 7%) n AJPH 2011; 101: 1456 -1465

Address Social Factors Responsible for Illness and Death n Deaths in 2000 attributable to: Address Social Factors Responsible for Illness and Death n Deaths in 2000 attributable to: n AMI – 193, 000 n CVD – 168, 000 n Lung CA – 156, 000 n AJPH 2011; 101: 1456 -1465

Deaths per year n n n n n Tobacco = 438, 000 (+ 42, Deaths per year n n n n n Tobacco = 438, 000 (+ 42, 000 ETS) Obesity = 300, 000 Alcohol = 100, 000 Microbial agents = 90, 000 Toxic agents = 60, 000 (likely higher) Firearms = 35, 000 Sexual behaviors = 30, 000 Motor vehicles = 25, 000 Illicit drug use = 20, 000

Major Contributors to Illness and Death Estimated that medical care accounts for only 10% Major Contributors to Illness and Death Estimated that medical care accounts for only 10% of overall health n Social, environmental, behavioral, and genetic factors = 90% n 40% of US mortality due to tobacco, poor diet, physical inactivity, and misuse of alcohol n Every $1 invested in programs covering above items saves $5. 60 in health care costs n

Prevention 2 -4% of national health care expenditures n Every $1 spent on building Prevention 2 -4% of national health care expenditures n Every $1 spent on building biking trails and walking paths would save nearly $3 in medical expenses n Every $1 spent on wellness programs, companies would save over $3 in medical costs and almost $3 in absenteeism costs n

Public Health Spending n Public health spending minimal n 1. 4% in 1960, 3. Public Health Spending n Public health spending minimal n 1. 4% in 1960, 3. 2% in 2002, 2. 6% in 2014 n Mortality rates fall 1 -7% for every 10% increase in public health spending n If US welfare state was average (c/w OECD countries), life expectancy would be 3. 8 yrs longer

Compliance n n n 33% of prescriptions go unfilled Only 50 -65% of patients Compliance n n n 33% of prescriptions go unfilled Only 50 -65% of patients take medicines as prescribed Noncompliant patients more likely to be hospitalized and to die Noncompliant patients have twice the annual medical care costs of those who are compliant Cost, health literacy contribute to noncompliance n 25% of Americans functionally illiterate; large majority health care-illiterate

Poverty and Hunger n n US: 15% of residents and 22% of children live Poverty and Hunger n n US: 15% of residents and 22% of children live in poverty Rates of poverty in Blacks and Hispanics = 2. 5 X Whites Poverty associated with worse physical and mental health Income inequality associated with higher death rates among those at low end of economic spectrum

Economic Disparities n Women 75 cents/$1 Men n Median income of black U. S. Economic Disparities n Women 75 cents/$1 Men n Median income of black U. S. families as a percent of white U. S. families 62% n 60% in 1968 n 63% for Hispanic families

Educational Apartheid High levels of de facto school segregation by race and SES n Educational Apartheid High levels of de facto school segregation by race and SES n Gross discrepancies in per-pupil spending and teacher salaries n Achievement and graduation gaps growing n

Patient Education n Patient education materials typically written at 10 th-14 th grade level Patient Education n Patient education materials typically written at 10 th-14 th grade level n Average patient reads at 8 th grade level n <50% of visits for major illnesses involve health education (across all provider types)

Education n Medical advances averted a maximum of 178, 000 deaths between 1996 and Education n Medical advances averted a maximum of 178, 000 deaths between 1996 and 2002 n Correcting disparities in educationassociated mortality would have save 1. 3 million lives during the same period n AJPH 2007; 97: 679 -83

Benefits of Education For every $1 spent on early childhood education, up to $17 Benefits of Education For every $1 spent on early childhood education, up to $17 are saved from increased school achievement, improved health, reduced crime, and reduced reliance on public assistance n Income increases 11% for every year of education n College graduates live 5 years longer than high school dropouts n

Urban/Rural Disparities n 25% of the U. S. population lives in rural areas n Urban/Rural Disparities n 25% of the U. S. population lives in rural areas n Only 10% of U. S. physicians practice in rural areas

Racial Disparities: Health Care n n n Higher maternal and infant mortality Higher death Racial Disparities: Health Care n n n Higher maternal and infant mortality Higher death rates for most diseases Shorter life expectancies for African-Americans n Not for Hispanic Americans (healthy immigrant effect and Hispanic paradox may be relevant, but largely due to decreased tobacco use)

Racial Disparities: Health Care n Fewer diagnostic tests / therapeutic procedures / pain medications Racial Disparities: Health Care n Fewer diagnostic tests / therapeutic procedures / pain medications n US spending on cystic fibrosis R & D/patient advocacy = 3 X spending on sickle cell disease n CF afflicts 1/3 as many US citizens as SCD

Health Disparities Among Latinos n Higher rates of: n Overweight and obesity n Certain Health Disparities Among Latinos n Higher rates of: n Overweight and obesity n Certain cancers n Stroke n Diabetes n Asthma/COPD n Chronic liver disease/cirrhosis n HIV/AIDS n Homicide

Racial Disparities in Health Care: African-Americans n. Equalizing the mortality rates of whites and Racial Disparities in Health Care: African-Americans n. Equalizing the mortality rates of whites and African-Americans would have averted 686, 202 deaths between 1991 and 2000 n. Whereas medical advances averted 176, 633 deaths n AJPH 2004; 94: 2078 -2081

Racial Disparities in Health Care Coverage n Percent uninsured: n Whites = 7% n Racial Disparities in Health Care Coverage n Percent uninsured: n Whites = 7% n Asians = 8% n African-Americans = 11% n Hispanics = 16% n Undocumented immigrants = 40% (emergency care exception) n CA Proposition 189

Outside the US n 650 million people lack clean drinking water and 2. 3 Outside the US n 650 million people lack clean drinking water and 2. 3 billion lack sanitation n 13, 000 -15, 000 deaths per day worldwide from water-related diseases n Hunger kills as many individuals in eight days as died during the atomic bombing of Hiroshima

Water n Amount of money needed each year (in addition to current expenditures) to Water n Amount of money needed each year (in addition to current expenditures) to provide water and sanitation for all people in developing nations = $9 billion n Amount of money spent annually on cosmetics in the U. S. = $8 billion

Human Poverty Human Poverty

Percentage of population living on less than one dollar per day Percentage of population living on less than one dollar per day

HIV Prevalence HIV Prevalence

Malaria Deaths Malaria Deaths

Overpopulation n World population - exponential growth n 1 billion in 1800 n 2. Overpopulation n World population - exponential growth n 1 billion in 1800 n 2. 5 billion in 1950 n 6 billion in 2000 n 7 billion in 2011 n est. 9 billion by 2050

Status of Women n. Women do 67% of the world’s work n. Receive 10% Status of Women n. Women do 67% of the world’s work n. Receive 10% of global income n. Own 1% of all property

Worldwide, every minute n 380 women become pregnant (190 unplanned or unwanted) 110 women Worldwide, every minute n 380 women become pregnant (190 unplanned or unwanted) 110 women experience pregnancy-related complications 40 women have unsafe abortions 1 woman dies from childbirth or unsafe abortion n Reason: Lack of access to reproductive health services n n n

Deaths in War n 18 th Century = 19/million population n 19 th Century Deaths in War n 18 th Century = 19/million population n 19 th Century = 11/million population n 20 th Century = 183/million population n Civilian Casualties: n 10% late 19 th Century n 85 -90% in 20 th Century

Contemporary Wars n 250 wars in the 20 th Century n. Most conflicts within Contemporary Wars n 250 wars in the 20 th Century n. Most conflicts within poor states • Many over oil

War Deaths, 1945 -2000 War Deaths, 1945 -2000

The Medical Brain Drain U. S. is largest consumer of health care personnel n The Medical Brain Drain U. S. is largest consumer of health care personnel n U. S. (4. 5% of world’s population) has 8% of world’s doctors and 7% of world’s nurses n Five times as many migrating doctors flow from developing to developed nations than in the opposite direction n Even greater imbalance for nurses n

The Medical Brain Drain n 2011: WHO estimates developing world shortage of 7. 2 The Medical Brain Drain n 2011: WHO estimates developing world shortage of 7. 2 million health professionals n Europe: 330 physicians/100 K population n US: 280/100 K n India: 60/100 K n Sub-Saharan Africa: 20/100 K

The Medical Brain Drain n Example of “inverse care law”: n Those countries that The Medical Brain Drain n Example of “inverse care law”: n Those countries that need the most health care resources are getting the least n Voluntary WHO Global Code of Practice on the International Recruitment of Health Care Personnel (adopted 2010) n U. S. working on implementing

Tobacco n. Cigarettes most heavily marketed products in the world n$2 billion/year in the Tobacco n. Cigarettes most heavily marketed products in the world n$2 billion/year in the U. S. n. U. S. leading exporter of cigarettes

Tobacco – Weapon of Mass Destruction n Direct medical costs = $100 billion/yr n Tobacco – Weapon of Mass Destruction n Direct medical costs = $100 billion/yr n Lost productivity = $97 billion/yr n Medical care and lost productivity due to tobacco use costs each U. S. citizen approximately $600/yr

Consequences of Environmental Destruction n Global warming: 160, 000 deaths and 5. 5 million Consequences of Environmental Destruction n Global warming: 160, 000 deaths and 5. 5 million disability-adjusted life years lost per year (will double by 2020) n Causes 200, 000 premature deaths/yr. in U. S. (8. 9 million worldwide = 1/8 deaths)

Consequences of Environmental Destruction Pesticides in food → 1, 000 deaths over the last Consequences of Environmental Destruction Pesticides in food → 1, 000 deaths over the last 6 years; 1 million cancers in current generation of Americans n Lead and mercury exposure multi-billion dollar problems n Other toxins – linked with heart disease, asthma, cancer, infertility, Parkinson’s disease, Alzheimer’s, autism, etc. n

Toxic Pollutants n ¼ US citizens live within 4 miles of a Superfund site Toxic Pollutants n ¼ US citizens live within 4 miles of a Superfund site n Environmental Racism n Waste dumps/incinerators more common in lower SES neighborhoods n e. g. , “Cancer Belt” (Baton Rouge to New Orleans)

Extinction/Species Loss n Mass Extinction n More than 1/2 of the top 150 prescription Extinction/Species Loss n Mass Extinction n More than 1/2 of the top 150 prescription drugs from plants, other living organisms n More than 250, 000 known flowering species n <0. 5% surveyed for medicinal value

Overconsumption (“Affluenza”) n U. S. = 4. 5% of world’s population n Owns 50% Overconsumption (“Affluenza”) n U. S. = 4. 5% of world’s population n Owns 50% of the world’s wealth n U. S. responsible for: n 25% of world’s energy consumption n 33% of paper use n 72% of hazardous waste production

New Remote Control Can Be Operated by Remote: No More Leaning Forward To Get New Remote Control Can Be Operated by Remote: No More Leaning Forward To Get Remote From Coffee Table Means Greater Convenience For TV Viewers

But Are We Happier? n U. S. ranks 24 th in citizen satisfaction with But Are We Happier? n U. S. ranks 24 th in citizen satisfaction with quality of life n Average American works 200 more hrs/yr than in 1960 (#1 in world) n Vacations shorter

But Are We Happier? n No guaranteed paid sick or maternity leave n Although But Are We Happier? n No guaranteed paid sick or maternity leave n Although many cities, some states now guarantee n 8/10 Americans want a new job

But Are We Happier? n Fewer close friends n Loneliness - common among the But Are We Happier? n Fewer close friends n Loneliness - common among the elderly n Linked to physical and cognitive decline and eclipses obesity as a predictor of early death n Pharmaceutical fixes

Worldwide Health: Can Aid Help? n US ranks 21 st in the world in Worldwide Health: Can Aid Help? n US ranks 21 st in the world in foreign aid as a percentage of GDP (0. 7%) n Foreign Aid: n 1/3 military n 1/3 economic n 1/3 food and development

Worldwide Health: Can Aid Help? n U. S charitable giving approximately $250 billion/year n Worldwide Health: Can Aid Help? n U. S charitable giving approximately $250 billion/year n 2. 5% of income n 2. 9% at height of Great Depression n Poor donate higher percentage of their incomes than rich; blacks more than whites n Most stays in US

US Charity Care Suffering n Hospitals provide very little charitable care (<1% when adjusted US Charity Care Suffering n Hospitals provide very little charitable care (<1% when adjusted for Medicare charges; includes bad debt) n Non-profit hospitals flourishing n Tax breaks; net income up; subsidized care as low as 2 -3% of total expenses in many (or 1/2 of profits)

US Charity Care Suffering n Only 42% notify patients about their charity care policies US Charity Care Suffering n Only 42% notify patients about their charity care policies before trying to collect unpaid bills n Public hospitals and ERs closing n Long waits mean many leave before being seen

US Charity Care Suffering n Free clinic demand increasing, more patients being turned away US Charity Care Suffering n Free clinic demand increasing, more patients being turned away n Hospitals consolidating n Decreases competition, can increase costs n Hospitals turning to lucrative initiatives to improve financial situation n Cosmetic surgery, luxury clinics, aggressive billing practices (including charging uninsured more than insured and employing harsh debt collection practices), recruiting wealthy foreign patients

Maldistribution of Wealth n The world’s richest 62 people own as much wealth as Maldistribution of Wealth n The world’s richest 62 people own as much wealth as the bottom 50% of the world’s population n U. S: Richest 1% of the population owns 50% of the country’s wealth -poorest 90% own 30% -widest gap of any industrialized nation

Income Inequality Kills Higher income inequality is associated with increased mortality at all per Income Inequality Kills Higher income inequality is associated with increased mortality at all per capita income levels

Income Inequality Lower life expectancy n Higher rates of infant and child mortality n Income Inequality Lower life expectancy n Higher rates of infant and child mortality n 20 million deaths per year worldwide n Short height n Poor self-reported health n AIDS n

Income Inequality Depression n Mental Illness n Obesity n Crime n Diminished trust in Income Inequality Depression n Mental Illness n Obesity n Crime n Diminished trust in people and institutions n

Maldistribution of Wealth is Deadly n 880, 000 deaths/yr in U. S. would be Maldistribution of Wealth is Deadly n 880, 000 deaths/yr in U. S. would be averted if the country had an income gap like Western European nations, with their stronger social safety nets n BMJ 2009; 339: b 4471

Maldistribution of Wealth n In countries with moderate levels of wealth, happiness is highest Maldistribution of Wealth n In countries with moderate levels of wealth, happiness is highest where income inequalities lowest and taxes most progressive n Major League Baseball: teams are more successful when players’ salaries are more equitably distributed n In more equal societies, people attend more cultural events, read more books

Maldistribution of wealth Less than 4% of the combined wealth of the 225 richest Maldistribution of wealth Less than 4% of the combined wealth of the 225 richest individuals in the world would pay for ongoing access to basic education, health care (including reproductive health care), adequate food, safe water, and adequate sanitation for all humans

Health Requires Equality n“All men are created equal” n. Declaration of Independence n“Some people Health Requires Equality n“All men are created equal” n. Declaration of Independence n“Some people are more equal than others” n. George Orwell

Hudson River, 2009 Hudson River, 2009

U. N. Declaration of Human Rights “Everyone has the right to a standard of U. N. Declaration of Human Rights “Everyone has the right to a standard of living adequate for the health and well-being of himself and of his family, including food, clothing, housing and medical care”

Solutions n Pay as you go n Insurance n Government-run program n. VA, HIS Solutions n Pay as you go n Insurance n Government-run program n. VA, HIS n PPACA n Single Payer

PPACA Patient Protection and Affordability Care Act n 2010: Health plans must provide preventive PPACA Patient Protection and Affordability Care Act n 2010: Health plans must provide preventive services without cost-sharing n 50% cost-sharing discount for seniors in Medicare “donut hole” n Prevents hospitals from overbilling the uninsured

PPACA Patient Protection and Affordability Care Act 2010: Young adults up to age 26 PPACA Patient Protection and Affordability Care Act 2010: Young adults up to age 26 may stay on parents’ health plan n 2010: Small business tax credits to offset costs of insuring employees n 2010: Insurers cannot deny coverage to children with preexisting conditions n 2010: No lifetime benefit limits and no rescissions n

PPACA Patient Protection and Affordability Care Act 2010: Uninsured with preexisting conditions eligible for PPACA Patient Protection and Affordability Care Act 2010: Uninsured with preexisting conditions eligible for special insurance plans after 6 months without insurance n 2011: Insurers must spend at least 80 -85% of premium dollars on health care n Even so, no impact on percentage of insurer expenditures spent on administration and marketing, or on profits over first 3 yrs n

PPACA Patient Protection and Affordability Care Act 2014: 26 million uninsured adults with incomes PPACA Patient Protection and Affordability Care Act 2014: 26 million uninsured adults with incomes under $29, 327 will gain coverage through Medicaid with little or no premium or cost sharing n 2014: Up to 17 million adults with incomes between $29, 327 and $88, 200 for a family of 4 will get tax credits to help purchase private health plans through new state insurance exchanges (sliding scale) n

PPACA Patient Protection and Affordability Care Act 2014: No denial of coverage or higher PPACA Patient Protection and Affordability Care Act 2014: No denial of coverage or higher premiums for preexisting conditions n Up to ½ of Americans have preexisting conditions n Deadline for compliance extended to 2017 n 2014: Premiums vary 3 -fold across country for those not getting coverage through employer n

PPACA Patient Protection and Affordability Care Act Creates public website listing payments from drug, PPACA Patient Protection and Affordability Care Act Creates public website listing payments from drug, device, biological, and medical products companies to physicians n Levies 2. 3% medical device excise tax on manufacturers n Establishes 10% tanning salon tax n Employers must provide time and space for mothers to nurse babies up to age 1 n

PPACA Patient Protection and Affordability Care Act n Problems: n Complex, increases bureaucracy n PPACA Patient Protection and Affordability Care Act n Problems: n Complex, increases bureaucracy n 906 page bill n. Computer problems n 19 states have opted out n Delays in implementation

PPACA Patient Protection and Affordability Care Act n Problems: n Leaves 32 million without PPACA Patient Protection and Affordability Care Act n Problems: n Leaves 32 million without insurance n 40% of these eligible for, but not enrolled in, Medicaid or CHIP (unaware of availability) n 22% undocumented immigrants n Translates into 32, 000 excess annual deaths

PPACA Patient Protection and Affordability Care Act n Problems: n No effective cost control PPACA Patient Protection and Affordability Care Act n Problems: n No effective cost control measures (e. g. , no authority for federal government to negotiate drug prices; continues federal prohibition on importation of lower priced prescription drugs from many foreign countries) n Will not reduce medical bankruptcies n Only 6 states provide online information regarding cots of medical tests and procedures (19 more developing databases)

PPACA Patient Protection and Affordability Care Act Will drain $billions from Medicare payments to PPACA Patient Protection and Affordability Care Act Will drain $billions from Medicare payments to safety net clinics, threatening the remaining uninsured n $716 billion cut in Medicare payments used to help fund PPACA n Thus Medicare payments fo doctors and hospitals to decrease by 11% by 2021 n Estimated 7, 000 – 17, 000 deaths estimated due to lack of Medicaid expansion in opt-out states n

PPACA Patient Protection and Affordability Care Act Unfair to women - segregation of abortion PPACA Patient Protection and Affordability Care Act Unfair to women - segregation of abortion funding, may affect contraceptive coverage n Poor likely to purchase less expensive plans with worse coverage and higher deductibles and copayments (and deductibles are increasing) n Copayments of any size reduce necessary care n ? Penalties if poor do not buy insurance? n Only 39% of the 20% of Americans with a mental health or substance use disorder receive treatment n

PPACA Patient Protection and Affordability Care Act n Problems: n Loopholes allow charges up PPACA Patient Protection and Affordability Care Act n Problems: n Loopholes allow charges up to 3 x higher for elderly, higher charges for large companies with predominantly female workforces n Benefits insurance companies, continues present inefficiencies n Administrative costs increasing n $billions just to enroll people n Projected $250 billion in extra insurance overhead between 2014 and 2022

PPACA Patient Protection and Affordability Care Act n Problems: n Pay for Performance likely PPACA Patient Protection and Affordability Care Act n Problems: n Pay for Performance likely to backfire per behavioral economics research, incentivizes greed n ACOs contributing to upcoding/overdiagnosis arms race n Limits provider discussions re gun ownership and safety

PPACA Patient Protection and Affordability Care Act Electronic health records mandated, but no evidence PPACA Patient Protection and Affordability Care Act Electronic health records mandated, but no evidence of cost savings or better care n Problems with EHRs: n Increase workload n Contracts may leave vendors unaccountable for down time n Physicians can be locked out during pay disputes n

PPACA Patient Protection and Affordability Care Act n Problems with EHRs: Vendors could block PPACA Patient Protection and Affordability Care Act n Problems with EHRs: Vendors could block patient data or terminate service over payment/contract disputes via kill switch n Gag clauses prevent physicians from sharing suability or safety issues with 3 rd parties (e. g. , patient safety groups), using information in research, or even making disparaging remarks about the technology n

PPACA Patient Protection and Affordability Care Act n Problems: n Inadequate numbers of primary PPACA Patient Protection and Affordability Care Act n Problems: n Inadequate numbers of primary care providers n 33% of US doctors are primary care doctors (vs. 50 -70% in other countries) n Communities with a high number of PCPs per capita have lower medical costs and better outcomes n But only 49% of physician visits in 2013 were with primary care doctors n High levels of burnout and career dissatisfaction

PPACA Patient Protection and Affordability Care Act n Problems: n Over 1/3 of physicians PPACA Patient Protection and Affordability Care Act n Problems: n Over 1/3 of physicians are accepting no new Medicaid patients, and ¼ see no Medicaid patients n Due to low reimbursements, multiple social needs

PPACA Patient Protection and Affordability Care Act n Problems: n Overall physician acceptance rates PPACA Patient Protection and Affordability Care Act n Problems: n Overall physician acceptance rates (2014) n Medicaid 46% n Medicare: 76% n Varies by region of country n Availability of some subspecialists extremely limited (e. g. , psychiatry)

PPACA Patient Protection and Affordability Care Act n Problems: Many plans exclude services for PPACA Patient Protection and Affordability Care Act n Problems: Many plans exclude services for children with special needs (e. g. , autism) n Some plans limit access to medications for certain high-cost conditions n Some insurers pulling out of cooperatives, leaving future of health insurance exchanges in doubt n Trump/Republicans may overturn n

PPACA Patient Protection and Affordability Care Act n Career arc of Elizabeth Fowler (architect PPACA Patient Protection and Affordability Care Act n Career arc of Elizabeth Fowler (architect of plan): VP for Public Policy and External Affairs (informal lobbying) at Well. Point (nation’s largest insurer) n Chief health policy counsel to Senator Max Baucus (who drafted legislation) n Head of Global Health Policy at pharmaceutical giant Johnson and Johnson n

n n "If anyone. . . has a better approach that will bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, let me know. " -- President Obama, State of the Union, 1/27/10 (challenge repeated at Farewell Address)

Single Payer n Cradle to grave, portable insurance for everyone n All medically-necessary services Single Payer n Cradle to grave, portable insurance for everyone n All medically-necessary services covered n Free choice of doctor and hospital n Global and local budgeting determined by physicians, patients, other health professionals n Cost saving, job-creating n Public accountability n Broad support

Paying for Health Care Today Paying for Health Care Today

How Single Payer Could Be Paid For: One Example from a Recent Study of How Single Payer Could Be Paid For: One Example from a Recent Study of a California Plan

Covering Everyone with No Additional Spending Additional costs Covering the uninsured and poorly-insured +6. Covering Everyone with No Additional Spending Additional costs Covering the uninsured and poorly-insured +6. 4% Elimination of cost-sharing and co-pays +5. 1% Savings Total Costs +11. 5% Reduced insurance administrative costs -5. 3% Reduced hospital billing costs -1. 9% Reduced physician office costs -3. 6% Bulk purchasing of drugs & equipment -2. 8% Primary care emphasis & reduce fraud -2. 2% Total Savings -15. 8% Net Savings - 4. 3% Source: Health Care for All Californians Plan, Lewin Group, January 2005

Single Payer n Not socialism any more than having a police force and fire Single Payer n Not socialism any more than having a police force and fire department which serve everyone or offering free public education to children through grade twelve is socialism n Imagine if insurance companies ran the fire department

What You Can Do Educate yourselves and others n “Information is the currency of What You Can Do Educate yourselves and others n “Information is the currency of democracy” (Thomas Jefferson) n Take care of your body – you only get one (no trade-ins) n Live, laugh, and love – life is short n Join groups working to improve health care n

Act Now! Act Now! "If you think you are too small to have an impact, try going to bed with a mosquito in your tent“ - African Proverb

Further Info/References/Contact Info Public Health and Social Justice Website http: //www. phsj. org Physicians Further Info/References/Contact Info Public Health and Social Justice Website http: //www. phsj. org Physicians for a National Health Plan http: //www. pnhp. org/ Kaiser Family Foundation http: //www. kff. org/ Martin Donohoe [email protected] org