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in Am e ric a
June 21, 2009 DRAFT 2.9 Assembled By Lyle Brecht
Today, in America, there are two forcing functions driving an immediate need for reform of the U.S. health care system: (1) the large number of uninsured. This is a national security issue. Today, millions of citizens do not have access to primary care. In the advent of a pandemic, this situation could prove catastrophic. Also, having this many people neglecting basic care requirements may cost the economy as much as $1,000 billion annually in lost productivity. (2) the U.S. system of health care is expensive and does not produce the best health care results. The high costs drain needed capital from other areas of the economy to create jobs, invest in new technology, address climate change, solve environmental degradation problems, educate our children, invest in public transportation options, etc. as most other developed countries are doing today. National security threats are: “actions that can degrade the quality of life for the inhabitants of a state or signiﬁcantly narrow the range of policy options available to the government or private citizens of a state” Richard Ullman, Redeﬁning Security (1983). U.S. National Security Strategy (2006): "Public health challenges like pandemics (HIV/AIDS, avian inﬂuenza) ... recognize no borders. The risks to social order are so great that traditional public health approaches may be inadequate, necessitating new strategies and responses.”
“Each year 300 million cases of malaria kill two million people. An estimated 3% of the worldʼs population - 170 million people - is chronically infected with hepatitis C virus. About four million people are newly infected each year, 80% of whom will progress to a chronic infection associated with cirrhosis in about 20% and liver cancer in about 5%. One third of the world is infected with the bacterium that causes tuberculosis with 10 million cases every year accounting for two million deaths. “Approximately 40 million people worldwide are infected with HIV, which killed 3.9 million people in 2005. In Russia, Vladimir Putin just recommended ﬁnancial incentives to citizens to increase fertility because the death rate outstrips the birth rate. While cardiovascular deaths lead the list, the incidence of HIV/AIDS and tuberculosis are on the rise. In recognition of this demographic nightmare, Russia will make the prevention and control of infectious diseases one of the priorities of the upcoming G8 summit in St. Petersburg. “Some lethal pandemics are still not as well known to the general public. For example, an ongoing cholera pandemic started in Indonesia in 1961 is causing close to 120,000 deaths per year.” Harvey Rubin, M.D, Ph.D., is Director, University of Pennsylvania Institute for Strategic Threat Analysis and Response (ISTAR), and a Professor of Medicine, Microbiology and Computer Science, “A New, Global Approach to Pandemics and National Security” (May 30, 2006).
The World Health Organization's ranking of the world's health systems (2000)
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 France Italy San Marino Andorra Malta Singapore Spain Oman Austria Japan Norway Portugal Monaco Greece Iceland Luxembourg Netherlands United Kingdom 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 Ireland Switzerland Belgium Colombia Sweden Cyprus Germany Saudi Arabia United Arab Emirates Israel Morocco Canada Finland Australia Chile Denmark Dominica Costa Rica
37 38 39 40 41 42 43 44 45 46 47 48 49 50
U. S. A Slovenia Cuba Brunei New Zealand Bahrain Croatia Qatar Kuwait Barbados Thailand Czech Republic Malaysia Poland
The World Health Organization has carried out the ﬁrst ever analysis of the worldʼs health systems. Using ﬁve performance indicators to measure health systems in 191 member states, it ﬁnds that France provides the best overall health care followed among major countries by Italy, Spain, Oman, Austria and Japan. The U. S. health system spends a higher portion of its gross domestic product than any other country but ranks 37 out of 191 countries according to its performance, the report ﬁnds. The United Kingdom, which spends just six percent of gross domestic product (GDP) on health services, ranks 18th . Several small countries – San Marino, Andorra, Malta and Singapore are rated close behind second- placed Italy. WHOʼs assessment system was based on ﬁve indicators: overall level of population health; health inequalities (or disparities) within the population; overall level of health system responsiveness (a combination of patient satisfaction and how well the system acts); distribution of responsiveness within the population (how well people of varying economic status ﬁnd that they are served by the health system); and the distribution of the health systemʼs ﬁnancial burden within the population (who pays the costs). "In many countries without a health insurance safety net, many families have to pay more than 100 percent of their income for health care when hit with sudden emergencies. In other words, illness forces them into debt."
The “American health care system is neither, healthy, caring, nor a system” Walter Cronkite The United States is the only industrialized nation that does not have a HEALTH CARE SYSTEM. The current way health care is managed in the U.S. is more than dysfunctional. Some consider it unethical and highly immoral. Unlike health care in other developed countries where a citizenʼs right to health care and the health of the nationʼs workforce is primary, in the U.S. proﬁts, of hospitals, insurance companies, medical equipment manufacturers appears to be the ﬁrst priority. Today, in America, patients are often considered consumers from whom to extract proﬁts, especially when they are sick or injured. Instead of a system, a thinly regulated market drives health care decisions, oftentimes to the detriment of ordinary citizens. Consequences: Bankruptcy due to medical bills; millions uninsured; millions under-insured; thousands of people die each year unnecessarily; expensive; poor outcomes; lack of prevention; people avoid medical care; increasing disparities among rich & poor; losing primary care doctors.
There are many initiatives to reform the way health care operates in the U.S. being discussed both at the federal level in in state legislatures. Before all is said and done $2 billion may be spent by special interests (insurance, pharmaceutical, and medical equipment companies) for campaign contributions, lobbying, and advertising to convince the public (us) and our elected ofﬁcials that they have the best idea for reforming health care in America, or why some ideas should be not be on the table. The purpose of this discussion is not to convince you of any particular way to reform health care. The purpose is just to inform. Once you have the facts, you can decide how to participate in the discussion forearmed with knowledge so that you are not so easily swayed by all the advertising and misinformation that you will come across as this issue is debated over the next months.
Health Care Infrastructure:
Enough to serve all Americans
As of 2004, the U.S. had:
13.5 million health care jobs 7,228 hospitals with a total of 955,768 staffed beds 210,939 physician’s offices 70,589 nursing homes 19,006 home care agencies 121,172 dentist’s offices
Source: National Center for Health Statistics
This is the basic health care delivery infrastructure system that we have available in the U.S. in case we get sick. The O&M expenses of this infrastructure accounts for 70% of the annual costs of health care in the U.S. Even when we are not sick, we are required to share the ﬁxed costs of this infrastructure so that it is available when we need it. If the ﬁxed costs to maintain this health care infrastructure are not met, the infrastructure will shrink, degrade or even disappear. This chart does not show the army of clerks, payment processors, screeners, and insurance administrators. That is because these jobs are not part of the health care delivery infrastructure. And, only in the dysfunctional U.S. system are these jobs even necessary. Most other countries have re-engineered their health care systems to eliminate paperwork, whereas in the U.S., more paperwork is generated every year. Paperwork is not health care delivery work. The more paperwork we require of our health care delivery personnel, the less time is available to do the real work of health care. Source: 2004 County Business Patterns NAICS, U.S. Census Bureau
Where does insurance come from?
Private/ Non-group 5% Medicaid/ Public Health Insurance 16%
Health care in the U.S. is known as an “employer-sponsored health insurance” system. The U.S. is the only developed country in the world that has such a system of insurance sponsored primarily by employers. In some countries employers contribute to the system but people don't lose their access to care when they lose their job. We usually say that in the U.S., health insurance is tied to employment.
This means of ﬁnancing health care puts a tremendous burden on employers and employees. According to Towers Perrin's annual Health Care Cost Survey, the average corporate health beneﬁt expenditure in 2009 will be $9,660 per employee. Underscoring the growing affordability gap, the Towers Perrin survey database shows that total health care costs have increased by 33% since 2004, with the employee share increasing by 42% during the same period. Also, this system places a tremendous paperwork burden on employers, employees, and health care providers. A survey just published in Health Affairs shows that physicians spend 43 minutes a day—or 3 hours a week—dealing with insurance companies. Nurses spend even more time dealing with insurance companies at 3.8 hours a day, or 19 hours a week.
Japan Has a $1400 competitive advantage on every car they sell
$1,500 $1,500 $1,309 $1,125 $1,040
$750 $375 $0
GM Ford Chrysler BMW Mercedes Toyota (US)
$419 $207 $97
Source: Modern Healthcare 10/24/05: 14
This way of ﬁnancing health care also puts some American industries at a competitive disadvantage against competitors from other nations.
The costs of the present health care system to employers in America are very large. This affects the productivity of American workers and the proﬁtability of American corporations. Presenteeism is the opposite of absenteeism. In contrast to absenteeism, when employees are absent from work, presenteeism discusses the problems faced when employees come to work in spite of illness, which can have similar negative repercussions on business performance.
While the vast majority of working Americans receive health insurance beneﬁts through their jobs, almost 32 million full time workers and their families are not covered by an employer provided health insurance plan. Of those 32 million workers, more than half are employed or self-employed in ﬁrms w/ fewer than 50 employees. [In the U.S., 99% of businesses have fewer than 50 employees. These small businesses create 80-85% of the jobs in the U.S. More than half of the uninsured work for these small ﬁrms.] Adding the poor and the unemployed, 51 million Americans have no health insurance.
WHO ARE THE UNINSURED?
The majority of uninsured are workers whose businesses do not provide group insurance and individual insurance is unaffordable.
In nearly 3 in 10 (29%) households, someone skips a medical treatment, cuts pills, or does not ﬁll a prescription because of cost Nearly 1 out of 4 (23%) Americans have problems paying medical bills More than 1 in 5 (21%) Americans had an overdue medical bill at the time of a 2004 survey 1 million people experience medical bankruptcy each year.
Health Insurance Costs Keep Rising
Health insurance premiums are rising 2-3 times as fast as inﬂation and wages. 18,314 Die Every Year Due to Lack of Health Insurance: more than six times the number of soldiers killed in Iraq; Equal to a 747 jet crash every week; More than 6 times the number who died on September 11th Source: Care Without Coverage; Institute of Medicine, 2002
More than 51 million Americans under age 65 do not have health insurance as of January 2009,16 and millions more drift in and out of coverage as their employment and ﬁnancial situation changes. According to a March 2009 study from Families USA, approximately 87 million Americans under 65—nearly one in three—went without health insurance for some period in 2007 or 2008. The number of uninsured Americans is rising sharply.
The United States spends $650 billion more on health care than might be expected given the countryʼs wealth and the experience of comparable members of the Organisation for Economic Co-operation and Development (OECD). The research also pinpoints where that extra spending goes. Roughly two-thirds of it pays for outpatient care, including visits to physicians, same-day hospital treatment, and emergency-room care. This large out patient component is may be largely due to uninsured use of emergency rooms for primary care. That amounts to $436 billion, or two-thirds of the $650 billion ﬁgure. The cost of drugs and the cost of health care administration and insurance (all nonmedical costs incurred by health care payers) account for an additional $98 billion and $91 billion, respectively, in extra spending. By contrast, US expenditures on long-term and home care, as well as on durable medical equipment (such as eyeglasses, wheelchairs, and hearing aids), is actually less than would be expected given the countryʼs wealth. Source: McKinsey & Co study, “Why Americans pay more for health care: (December 2008).
Many Americans are underinsured! "Dr. David Himmelstein, the lead author of the study [August 2009 issue of the American Journal of Medicine] and an associate professor of medicine at Harvard, commented: "Our ﬁndings are frightening. Unless you're Warren Buffett, your family is just one serious illness away from bankruptcy. For middle-class Americans, health insurance offers little protection. Most of us have policies with so many loopholes, co-payments and deductibles that illness can put you in the poorhouse. And even the best job-based health insurance often vanishes when prolonged illness causes job loss – precisely when families need it most. Private health insurance is a defective product, akin to an umbrella that melts in the rain." ... "Surprisingly, most of those bankrupted by medical problems had health insurance. More than three-quarters (77.9 percent) were insured at the start of the bankrupting illness, including 60.3 percent who had private coverage. Most of the medically bankrupt were solidly middle class before ﬁnancial disaster hit. Two-thirds were homeowners and three-ﬁfths had gone to college." See: http://economistsview.typepad.com/economistsview/2009/06/an-umbrellathat-melts-in-the-rain.html
National Health Spending: Per Person
$11,660 $10,339 $9,173
Per capita expenditures
$8,090 $7,129 $6,280 $4,257 $3,604 $3,910 $4,729 $5,485
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Source: Centers for Medicare & Medicaid Services
Health care costs are rising unabated. We spend far more on health care than other large, healthy, developed countries, yet we persistently lag in health outcomes and quality benchmarks. What this graph portrays is that by 2014 if you have a two people in your family, your total health care -related costs will be $24,000; a family of four - $48,000. These are real costs, whether you pay all these costs out of your pocket in the current year or not. Either you will pay them in one way or another or your children will pay them in the future if these are funded by borrowing (either private or government borrowing).
The big change from 1980 to today has been the relentless shift in the U.S. of community-based health care delivered as a service to institutional based health care delivered as a proﬁt-making business. Today, parts of health care are among the most proﬁtable businesses in America. Q: Is it even ethical or moral to proﬁt from someone elseʼs misfortune? Q: Is health care a privilege, or a right? Q: Are markets an appropriate mechanism to deliver health care and generate health results for a nation? Depending on how you answer these questions, which are theological/political questions, not merely economic or ideological questions, will determine what sort of health care you believe should be available for citizens of the U.S.
Breakout of health care expenditures In the U.S. by activities.
Shortages in pediatrics, internal medicine and family medicine. Decreased access to geriatricians and gynecologists. Low interest by medical students because of: high student loan debt malpractice insurance low starting salaries
Because of the high cost of medical training, medical students are increasingly going into the higher paying specialties of medicine in order to pay off school loan debt amounting to between $125,000 and $225,000.
Administration is the Fastest Growing job in Health Care
0% 1970 1975 1980 1985 1990 1995 2000
Source: Bureau of Labor Statistics and NCHS
The natural market behavior of private insurance companies in the U.S. unlike private insurance companies in Germany and Japan, for example, who are not allowed to make a proﬁt on basic health care insurance and are not allowed to turn away applicants for pre-existing conditions, is to compete to cover healthy, proﬁtable people while shunning anyone who actually needs care. To do this, they erect massive bureaucracies with no purpose other than to ﬁght claims, issue denials and screen out the sick. They consume care dollars, but their main output is paperwork headaches. In response, hospitals and doctorsʼ ofﬁces must employ armies of administrators to deal with the separate payment bureaucracies of hundreds of different insurance companies. U.S. businesses are saddled with the costly burden of administering their own health beneﬁts. Co-payment collection and processing, eligibility determinations, utilization reviews: the scope of the paperwork bloat is staggering.
Determinants of health
Environmental Factors 20% Health Behaviors Genetics 50% 20% Access to Care 10%
Our current health care system incurs over $177 billion annually in mostly avoidable health care costs to treat adverse events from inappropriate medication use; Treatment of chronic disease costs the health care system over $1.3 trillion annually – diabetes alone is about $170 billion; About 1/3 of patients who begin a drug regimen never reﬁll the prescription. Victor A. Yanchick, Ph.D., Dean School of Pharmacy, Medical College of Virginia , Health Sciences Division, Virginia Commonwealth University, 2008-2009 AACP President
“The fundamental nature of medical risk in the United States has changed over the past 20 to 30 years— shifting away from random, infrequent, and catastrophic events driven by accidents, genetic predisposition, or contagious disease and toward behavior- and lifestyle-induced chronic conditions. Treating them, and the serious medical events they commonly induce, now costs more than treating the more random, catastrophic events that health insurance was originally designed to cover. Whatʼs more, the number of people afﬂicted by chronic conditions continues to grow at an alarming rate. “As the nature of risk has evolved, neither the funding mechanisms nor the forms of reimbursement for health care have adapted adequately, so the systemʼs supply and demand sides are both hugely distorted. Consumers are overinsured against some risks and underinsured against others; woefully short of the savings required to pay predictable, controllable expenses; and all too likely to be dealing with doctors who have big incentives to treat individual episodes of care rather than prevent illness and manage chronic conditions effectively.” Source: Ozgur Adigozel, Thomas M. Pellathy, and Shubham Singhal, “Why understanding medical risk is key to US health reform,” McKinsey & Co. study (June 2009)
Annual costs of chronic disease
•Heart disease and stroke $448B •Smoking and tobacco use $193B •Diabetes $174B •Obesity $117B •Cancer $89B •Arthritis $81B •Pregnancy complications $1B (pre-delivery) Total = $1.1Trillion
70% of all deaths in the United States. 75% of the nationʼs $2 trillion medical care costs. One-third of the years of potential life lost before age 65. Obesity - 127 million overweight or obese Obesity 33% of adult men 35% of adult women, 16% of children ages 2-19 Smoking – 47 million still smoke Alcohol (14 M) / drug abuse (16 M) Risky behaviors Sedentary, inactive TV? Video games? From: www.ama-assn.org/go/healthylifestyles
Obesity-related health care costs may presently be the #1 health care cost increase driver in the U.S. today.
This is why health care costs for children in the U.S. are more costly than for other developed nations. The U.S. has a poor safety net for children growing up in America compared with other developed countries.
Expensive! When one is sick or needs care it is almost always more expensive to neglect care in terms of lost productivity and to provide care when the health problem is worse due to neglect.
80% uses less than $1000 of care per year
Percent of health Care Expenditures
60 40 20
13% 0% 0% 0% 1% 1% 2% 4% 6%
1 1 1 1 1 1 1 1 1 0. 0. 0. 0. 0. 0. 0. 0. 0.
Source:Agency for Healthcare Research and Quality MEPS, 1999
In any one year, only 20% of the population accounts for ~80% of the health care costs for that year. However, in any one year, any one of us might potentially be in that high-use group.
What this chart shows is that about 3/4ths of health care costs in the U.S. are incurred by citizens over 65 years old and half of these costs by individuals over 80 years old. Today, its costs $100,000, on average, for a person to die of ʻold age.ʼ That is often because heroic measures were attempted to save someoneʼs life, when they were ready to die of natural causes anyway. This rescue from a natural death is not as prevalent in other developed countries.
Federal spending on Medicare and Medicaid is projected to grow from 5 percent of gross domestic product in 2009 to 12 percent by 2050.26 Federal spending on these programs will double in the next 10 years from $720 billion in 2009 to $1.4 trillion in 2019.27 According to the CBO, “rising costs for health care represent the single greatest challenge to balancing the federal budget.” As Peter Orszag, former director of the Congressional Budget Ofﬁce, explained: “health care reform is entitlement reform.”
Countries with universal care typically fund health care costs from current revenues. In the U.S., because of the split between private and public insurance, the government must account for its future liabilities for the ʻunfundedʼ portion of public insurance. What this number represents is the future taxes citizens must pay to provide Medicare beneﬁts to those citizens who have been promised these beneﬁts. However, if the same logic was applied to private insurance in the U.S., the amount of ʻunfundedʼ liabilities would be ~$673,000 per household plus Medicareʼs at $421,000. Each household would ʻoweʼ $1 million in future ʻunfundedʼ health care costs. Under the present system, some of these costs will be paid indirectly through lower pay and lower business proﬁts, some directly through deductions from income, and some directly through payroll taxes.
Even w/ Medicare, this does not relieve entirely problems of paying for health care for those over 65 years of age.
U.S. Health Care Spending
2018: $4.4 Trillion
2008: $2.4 Trillion
This is the potential growth in health care spending that the U.S. is expected to experience under the current way health care is provided in the U.S. If this would occur, the U.S. would essentially be uncompetitive in the global marketplace. It would have a hard time attracting necessary capital to innovate and invest in its future, it would be difﬁcult to attract the most skilled workers, and health care would costs consume more than a quarter of all our personal disposable income each year. In other words, this situation would be extremely onerous by any criterion we can imagine today.
Percent GDP 20.0 Percent of GDP 15.0 10.0 5.0 0 1960 1965 1975 1985 Year 1995 2005 2006 2007*
Source: Centers for Medicare and Medicaid Services, National Health Expenditures
*2007 number is a projection by CMS
The problem is that the present system is growing ever more expensive, year-byyear, consuming more and more of GDP each year, without commensurate improvements in the health of the nation or gains in productivity. This situation is making the U.S. businesses and its work force less competitive globally each year.
Blue are the countries that provide universal coverage (Canada, Brazil, Argentina, Chile, all of Europe, Russia, China, the Middle Eastern countries, Australia). Orange is Iraq and Afghanistan where the U.S. government provides universal coverage. Green are the countries that are planning on implementing universal coverage (South Africa, Mexico, Venezuela). Grey are the countries that have no universal coverage (U.S., African countries, India). Universal coverage means that every citizen is covered by either private or publicly-provided insurance. There are no exceptions. No one can be denied coverage for pre-existing conditions. There are no pools of uninsured as in the U.S. In the U.S. the best examples of universal coverage are the insurance programs for U.S. government employees, the U.S. military, and Medicare. Typically, in universal systems, governments set annual negotiated ﬁxed prices for all services, even if all services are privately provided. Also, private insurance companies are usually prohibited from making proﬁts on basic health care insurance. Instead, they compete on price and service to their customers. Some universal systems around the world also incorporate single payer. For example, even if there are many private suppliers of health care services, all bills are payed by one administrator. There are not many insurance companies competing to make proﬁts. In the U.S., Medicare is an example of a single payer system. This approach typically dramatically reduces the administrative cost of health care. For example, in Taiwan, insurance administrative costs may be 3% of premiums versus 20% for insurance companies in the U.S. Socialized health care means that the government owns the hospitals and directly employs the physicians and nurses. Great Britainʼs National Health Care Service is an example of a country w/ universal care where care is socialized. In the U.S., the U.S. VA military hospitals are an example of socialized health care.
This is the reason that so many countries have gone to universal coverage and publicly provided insurance, many with single payer administrators. Itʼs much less costly than private insurance programs that exclude people.
As you can see, almost all countries, even those with universal coverage have a mix of public and privately insured health care. Universal coverage usually pays for primary and preventative health care, as well as major medical and long-term care. Private insurance in those countries with universal care might cover elective surgery. Even in countries with socialized medicine, there may be private insurance and private hospitals and physicians working.
US vs. the World
Health Care Spending Per Capita in 2006
$3,371 $2,760 $2,448
United States Canada France Netherlands Germany United Kingdom New Zealand
Source: OECD Health Data, 2008
Each of these countries have universal care. Every citizen of their country has health insurance. No citizen goes bankrupt in these countries because of medical bills unlike the U.S. where even if you have insurance you can go bankrupt. Although, each country has a different way of implementing universal care, citizens rate their countryʼs health care system very favorably. And, they all cost about half of the U.S. way of managing health care. Yet, their health outcomes are generally better than what the U.S. achieves. Q: Does the U.S. have anything to learn about providing health care for its citizens from other countries?
Only 55% of patients receive recommended standard of care
---New England Journal of Medicine June 26, 2003
A recent Commonwealth Fund study found that across 37 indicators covering quality, access, efﬁciency, and equity, the United States achieves “an overall score of 65 out of a possible 100 when comparing national averages with benchmarks of best performance achieved internationally and within the United States.” Despite spending more than double the OECD median per person on health care, “quality of care is highly variable… opportunities are routinely missed to prevent disease, disability, hospitalization, and mortality,” and “the U.S. failed to keep pace with gains in health outcomes achieved by the leading countries.”
Health care expenditures vastly improve infant mortality and life expectancies between developed and developing nations e.g. U.S.. vs. Afghanistan.
What this chart shows is average life expectancy by a nationʼs expenditures on health care. Today, in developed nations, spending more on health care does not produce longer life expectancy. Life expectancy is almost negatively correlated with health care expenditures.
More Babies Die in the U.S. in the ﬁrst year of life
6 7.0 .9 5.3 5.3 4.7 4.1 3.5 4.1 3.9 3.1 1.8
U.S. Canada Australia Italy Germany France Sweden
Data are for 2004 or more recent year available
Even though the U.S. spends far more than other developed countries for health care, this does not mean that our babies have a greater probability of living during their ﬁrst year.
We Do More Heart Transplants
8 5 3 3 5 5 5
U.K. France Germany Sweden Italy US
OECD, 2006 (2003 Data)
The extra amount of money the U.S. spends for health care each year is not explained by the type or amount of medical procedures it performs each year compared to those of other developed countries or by health outcomes.
We are Average in Number of Renal Transplants (2001/2002)
Transplants/million population 38 34 29 29 31 35 35 38
19 10 0 U.K. OECD, 2004 Australia U.S. Sweden Canada France
We Do Fewer Hip Replacements
Procedures per 100,000 population
150 125 106 100 126 133
Canada U.S. N.Z. Italy Australia U.K. Sweden
Source: OECD 2006 Data are for 2004 or most recent year available
How hard is it to get care?
% finding it difficult to get care
32 28 24 21 15 15 15
U.S. Canada New Zealand Australia U.K.
Commonwealth Fund Survey, 1998
The money isnʼt improving our outcomes. But, maybe it makes it easier to get care. Unfortunately, thatʼs not the case. All systems ration care. Rationing is an inescapable part of all economic life. It is the process of allocating scarce resources. Health care seems as if it should be different. But it isnʼt. No system has inﬁnite resources. So we ration. The choice is not between rationing and not rationing. Itʼs between rationing care rationally and rationing badly. Given the amount of money the U.S. spends for health care, and the results it achieves for this expenditure, itʼs hard to argue that we are now rationing very rationally. There are three main ways that the health care system already imposes rationing on us. Maybe the most important does not involve denying medical care to those who need it. It involves denying just about everything else. Our expensive, inefﬁcient health care system is eating up money that could otherwise pay for a mortgage, a car, a vacation or college tuition. Another kind of rationing involves the uninsured. The high cost of care means that some employers canʼt afford to offer health insurance and still pay a competitive wage. Those high costs mean that individuals canʼt buy insurance on their own. A ﬁnal form of rationing is the failure to provide certain types of care, even to people with health insurance. For example, in Australia, 81 percent of primary care doctors have set up a way for their patients to get after-hours care... In the United States, only 40 percent have. In ʻManaged Careʼ programs, the objective is to save health care costs by denying access to medical care, even if you are insured. Managed Care is comparable to a system that keeps kids from going to school in order to save the costs of education, even as the school buildings are kept open and all the teachers have been hired to teach the children. Source: Source: David Leonhardt, "Health Care Rationing Rhetoric Overlooks Reality," New York Times (June 17, 2009)
Cancer Survival Rate, All Cancers
70.0 52.5 35.0 17.5 0
St at la Sp s Ita ly w nd an er rla or er N itz et he d G ni te Sw K in gd m om nd es ay ai n y
Percent Survival Rate, Women Percent Survival Rate, Men
When asked who pays for health care in the United States, the usual answer is "employers, government, and individuals." Most Americans believe that employers pay the bulk of workers' premiums and that governments pay for Medicare, Medicaid, the State Children's Health Insurance Program (SCHIP), and other programs. However, this is incorrect. Employers do not bear the cost of employment-based insurance; workers and households pay for health insurance through lower wages and higher prices. Moreover, government has no source of funds other than taxes or borrowing to pay for health care. Failure to understand that individuals and households actually foot the entire health care bill perpetuates the idea that people can get great health beneﬁts paid for by someone else. It leads to perverse and counterproductive ideas regarding health care reform. Source: Victor R. Fuchs, “Who Really Pays for Health Care? The Myth of ʻShared Responsibility,ʼ” Journal of the American Medical Association, Vol. 299 no. 9, page(s) 1057-1059 (March 5, 2008)
Our Quality is Not the Best in the world Survival Rates for 5 Countries
Breast Cancer Colorectal Cancer Cervical Cancer Childhood Leukemia Kidney Transplant Liver Transplant Non-Hodgkin’s Lymphoma AMI, ages 20-84 Stroke, ages 20-84
Source: Health Affairs Vol 23:#3 , 2004
2nd 2nd best worst 2nd 2nd best best 2nd
4th 3rd 3rd best best best 4th worst best
worst worst worst 3rd 3rd worst worst NA NA
3rd best 4th 4th 3rd * 2nd 2nd
best 4th 2nd 2nd worst 3rd 3rd NA
The United States is often touted as having the best quality health care in the world. A claim not backed up by the evidence. This study published this year in Health Affairs compared 5 nations and found that we performed the best in only one category- breast cancer survival. We actually did the worst on kidney transplant survival. Canada, in contrast, did the best on 4 indicators. Source: Health Affairs Vol 23:#3 , 2004
Overall Ranking (2007) Quality Care Right Care Safe Care Coordinated Care Pt-Centered Care Access Efficiency Equity Healthy Lives
Expenditures per Capita,2004
4 5 4 3 3 3 4 2 1 $2,876
6 6 5 6 6 5 5 5 3 $3,165
2.5 3 1 4 2 1 3
2.5 4 3 2 1 2 2 3 4.5 $2,083
1 2 2 1 4 4 1 1 4.5 $2,546
5 1 6 5 5 6 6 6 6 $6,102
American College of Physicians, Ann Intern Med 2008;148:55-7
This chart is the result of a study on patient attitudes concerning health care in their countries. A 2008 report by the Commonwealth Fund ranked the United States last in the quality of health care among the 19 compared countries." Source: http://en.wikipedia.org/wiki/Health_care_in_the_United_States
We have it in our power to begin the world over again. A situation, similar to the present, hath not happened since the days of Noah until now. The birth-day of a new world is at hand.
The Politics of Possibility
Thomas Paine, Common Sense published January 10, 1776 and spread quickly among literate colonists. Within three months, 120,000 copies are alleged to have been distributed throughout the colonies, which themselves totaled only two million free inhabitants, making it the best-selling work in 18th-century America, with the exception of the Bible. Its total sales in both America and Europe reached 500,000 copies. Aristotle called the free speech of citizens - truthful speech - parresia. In parresia, “one who speaks the truth is also one who is prepared to witness to the truth by living in service to the truth and in solidarity with others seeking the truth” (Northcott, 2007). Thomas Aquinas coined the term “affected ignorance” to describe individuals, and in this case maybe whole societies, as those who “choose not to know what can and should be known.” Maybe one of our roles today is to act with parresia towards those around us who exhibit affected ignorance.
Uniﬁed risk pool means everybody in, and nobody out. Everybody contributes to fund health care based on ability to pay. All medically necessary care is covered. Simpliﬁed administra9on saves money. Focused on preventa9ve and 9mely care. Transparency and Accountability to the public.
Affordable, universal health care = health security.
Nearly three-quarters of Americans (73%) say they are conﬁdent in doctors to recommend the right thing for reforming the U.S. healthcare system. That is signiﬁcantly higher than the public conﬁdence extended to President Barack Obama, as well as to six other entities that will be weighing in during the emerging healthcare reform debate. While the public trusts the views of doctors the most, more than 6 in 10 Americans are also conﬁdent in university professors or researchers who study healthcare policy (62%) and in hospitals (61%). At 58%, Obama fares better than congressional leaders on both sides of the aisle; however, the Democratic leaders in Congress have more credibility on healthcare reform than do the Republican leaders: 42% vs. 34%. In terms of the major private-sector healthcare debate participants, conﬁdence in what the pharmaceutical companies might advocate as the solution is only slightly higher than what health insurance companies might propose, 40% vs. 35%. Source: http://www.gallup.com/poll/120890/Healthcare-Americans-Trust-Physicians-Politicians.aspx
“It is my deep conviction that the only option is a change in the sphere of the spirit, in the sphere of human conscience. It’s not enough to invent new machines, new regulations, new institutions. We must develop a new understanding of the true purpose of our existence on this Earth. Only by making such a fundamental shift we will be able to create new models of behaviour and a new set of values for the planet”
Living in the Truth
The idea of “Living in Truth” rather than “living in the lie” was developed in the Eastern Bloc countries in the 1970s and ʻ80s and ultimately led to the nonviolent overthrow of Soviet power in those countries w/ the fall of the Berlin Wall in 1989. Combines non-violent, noncooperation of Ghandi/King w/ “truth” living teachings of Jesus. Best described by Vaclav Havel in his “Power and the Powerless” or by a close reading of the gospels in the NT and the prophets of the OT. Vaclav Havel, “Spirit of the Earth,” Resurgence, November-December 1998, 30.
American Health Care Reform American Medical Association California Nurses Association Cato Institute Center for American Progress
Gallup Poll Healthcare Now - Maryland New York Times Physicians for National Health Plan Deborah Richter, MD Harvey Rubin, MD, PhD
James S. Eadie, MD, FACEP
Margaret Flowers, MD
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