2. The greatest enemy of the truth is very often
not the lie--deliberate, contrived, and
dishonest, but the myth -- persistent,
persuasive, and unrealistic.
Belief in myths allows the comfort of opinion
without the discomfort of thought.
John F. Kennedy
4. National Story:
Healthcare Spending Crisis
• “Health spending will hit $2.5 trillion this year
• “devouring 17.6 percent of the economy
• “The United States spends more on healthcare
than any other country
• “but its system is widely considered inefficient
and it lags many other nations in key quality
measures”
Reuters, Feb 24, 2009
5. Oregon Story:
57 Y F in extremis
• ED: lethargy, high pCO2, large pleural effusion
• ICU: Stabilized, improved, extubated
• able to provide Past History:
• Noted breast lump months before
• Spouse lost job, waited for insurance
• Seen in clinic, mammogram ordered
• Dx: Malignant effusion,
Metastatic breast cancer
6. Myth Number 10
We have the best health
care system in the world.
7. 1
Japan
75
3
Sweden
73.3
4
Switzerland
73.2
7
Italy
72.7
8
Australia
72.6
9
Spain
72.6
11
Canada
72
12
France
72
13
Norway
72
Health Adjusted 14
16
Germany
Austria
71.8
71.4
Life Expectancy 17
19
Israel
Netherlands
71.4
71.2
2002 WHO data 20
Belgium
71.1
22
Greece
71
23
New Zealand
70.8
24
United Kingdom
70.6
26
Denmark
69.8
27
Ireland
69.8
28
Slovenia
69.5
29
United States of America
69.3
32
Cuba
68.3
33
Republic of Korea
67.8
10. Myth Number 9
It’s their fault -
Uninsured are different from you & me.
11. “They” Are You and Me,
Typical Americans
• 50 million Americans
• 1 in 6 Oregonians
• ages 19-30
• ~10 M children
• 80% employed
• $20,000 - $60,000/yr
• self employed, service
sector, small business
• outsourced middle
aged couples
12. Myth Number 9 b
It’s our fault
Our lifestyle and diversity are the problem
13. Not smoking, obesity, homicide, diversity
or statistical artifact
Exhibit 1
Per Capita Health Spending And 15-Year Survival For 45-Year-Old Women, United States And 12 Comparison Countries,
1975 And 2005
US
Thousands of dollars
Switzerland
Belgium
Canada Austria
Netherlands
France Sweden Australia
UK Japan
US Switzerland
Canada Australia Sweden
Austria France Netherlands
UK Belgium Japan
SOURCE Authors’ analysis based on data from the sources described in the text. NOTES The dashed line separates 1975 values (blue
circles) and 2005 values (red squares). Values are presented for the percentage of forty-five-year-old women surviving fifteen years.
14. Myth Number 8
Safety Net Care
Equal access to quality care for
people without insurance
15. No Prenatal Care for 11%
Why not?
31%
No money or insurance
47%
Unable to get appointment
Other reason
22%
MMWR 5/12/2000; 49:393
16. More Deaths Among
Uninsured With Trauma
• 174,921 kids National Trauma Data Bank
• Controlled for injury, severity, age, race,
type of hospital
• Uninsured kids: 2.97 times higher deaths
• Medicaid kids: 1.19 times higher deaths
17. No Insurance Means Poor
Outcomes
• up to 1.25x higher mortality overall
• up to 3.2 x higher in-hospital mortality
• delays in Dx of colon cancer, melanoma
• poorer outcomes for breast cancer
• avoidable admissions for asthma, bleeding
ulcers, diabetes, etc.
• up to 3x more likely to have adverse
outcomes
18. Some Major Public Health
Problems
Diabetes 72449
Influenza, pneumonia 56326
Colon cancer 50610
Second hand smoke ~50000
No insurance 44840
Breast cancer 40470
Traffic deaths 37261
Prostate cancer 26328
22. Choice?
Employer
Health
Benefit
Plans
Offered
Kaiser/HRET
Survey
of
Employer-‐Sponsored
Health
Benefits,
2008. slide: PNHP IN/Rob Stone
23. “Consumer Choice” in U.S.
Reason for Change in Health Plan
74%
Employer Change
Less Expensive
9% Better Care
17%
Health Affairs 2000; 19(3):158
24. Insurance
Premiums
•
Workers’
Earnings
•
InflaCon
1999-‐2008
150%
Health
Insurance
Premiums
Workers'
Earnings
Overall
InflaCon
113%
75%
38%
0%
1999 2000 2001 2002 2003 2004 2005 2006 2007 2008
Kaiser/HRET
Survey
of
Employer-‐Sponsored
Health
Benefits,
2000-‐2008.
Bureau
of
Labor
StaJsJcs,
Consumer
Price
Index slide: PNHP IN/Rob Stone
25. Medical Bankruptcy
62% of Personal Bankruptcies
Insurance at Onset of Illness
6%
8%
Medicare
Medicaid
24% Uninsured
61% Private
Health Affairs 2002
30. Strikes and Layoffs in Headlines
Pay, health care keep strike going
Santa Cruz Sentinel, CA …issues keeping the two sides from reaching a
deal, namely health care benefits ...
Strike looms, teachers consider pay, health benefits
BurlingtonFreePress.com,VT …Questions about health care costs and
coverage have emerged as a huge
TWU threatens strike over health care $
philly.com, PA ...ready to strike because the health plan
Machinists Union Strike for Pensions and Health ...
Emediawire WA Union members voted to strike ... Their vote
centered on issues of pensions, health care and job security. ...
35. Doctors Urged to Turn Away
the Very Sickest
“[We can] no longer tolerate patients
with complex and expensive-to-treat
conditions being encouraged to
transfer to our group.”
-letter to faculty from academic hospital chief
Source: Modern Healthcare, 9/21/95:172.
37. 37
Number of Practicing Physicians per 1,000 Population, 2007
4
3
2
1
0
NETH NOR SWITZ ITA SWE* GER FR OECD MedianAUS* UK US NZ CAN
THE
COMMONWEALTH
* 2006 FUND
Source: OECD Health Data 2009 (June 2009).
38. 38
Average Annual Number of Physician Visits per Capita, 2007
8
6
4
7.5
7.0
6.3 6.3 6.3
5.8 5.7
5.0
4.7
2 4.0 3.8
2.8
0
GER ITA** AUS FR OECD MedianCAN* NETH UK NZ SWITZ US* SWE*
* 2006 THE
COMMONWEALTH
** 2005 FUND
Source: OECD Health Data 2009 (June 2009).
39. 39
Hospital Discharges per 1,000 Population, 2007
300
225
150
75
0
FR GER NOR SWITZ SWEOECD MedianAUS* ITA* NZ US* UK NETH CAN*
THE
COMMONWEALTH
* 2006 FUND
Source: OECD Health Data 2009 (June 2009).
40. 40
Average Length of Hospital Stay for Acute Myocardial Infarction, 2007
Days
12
9
6
3
0
GER UK ITA* SWITZ NETH OECD Median CAN* FR AUS* US* SWE NOR
THE
COMMONWEALTH
* 2006 FUND
Source: OECD Health Data 2009 (June 2009).
41. 41
Hospital Spending per Discharge, 2007
Adjusted for Differences in Cost of Living
Dollars
18,000
16,000
14,000
12,000
10,000
8,000
6,000
4,000
2,000
0
US* CAN* NETH SWITZ NOR* SWE NZ OECD Median AUS* FR GER
THE
COMMONWEALTH
* 2006 FUND
Source: OECD Health Data 2009 (June 2009).
42.
43. NIH Clinical Research Grants
Fall in High Managed Care Areas
Managed Care Penetration
Low Medium High
Number of grants relative to 1986
1.300
1.175
1.050
0.925
0.800
1986 1988 1990 1992 1994
Source: Moy et al. JAMA 1997; 278:217
44. Innovation:
Published Research Leading to Drugs
15%
55% 30% Drug Companies
Foreign labs
NIH Funded Labs
Sources: Internal NIH document available from Public Citizen;
also Zinner, Health Affairs, Sept-Oct 2001; also Boston Globe 4/5/98
slide: PNHP/Marcia Angell
45.
46. Managed Care Drives Out
Charity Care
HMO Penetration in Region Low Medium High
13
Hours of Charity Care/Month
11
9
7
5
3
0% 1-20% 21-40% 41-60% 61-84% >84%
% of Practice Revenue from Managed Care
48. Health
Care
Expenditures
Per
Capita,
Adjusted
for
Differences
in
Cost
of
Living
$7,000
Out-of-Pocket Spending
Private Spending
$6,000
Out-of-Pocket Spending
Public Spending
$5,000 $2,572
$4,000
$803
$3,000 $483 $444
$342
$354
$239 $906 $313
$472 $370 $148
$582 $28
$396
$2,000 $238 $389 $113
$359
$2,727
$2,475 $2,350
$2,210 $2,176
$1,000 $1,894 $1,940 $1,917 $1,832
$1,611
$0
United States Canada France Netherlands Germany AustraliaUnited Kingdom
OECD Median Japan New Zealand
Source: The Commonwealth Fund, calculated from OECD Health Data 2006.
slide: PNHP IN/Rob Stone
56. Myth Number 1
“It’s a Non Starter”
There’s No Support for a Single Payer
57. Public
Support
–
Single
Payer
☤ 49%
favor
coverage
from
a
single
govt.
plan1
☤ 59%
prefer
a
system
like
Medicare
for
all 2
☤ 59%
say
government
should
provide
na?onal
health
insurance 3
Polls
from
2009
1
April,
Kaiser
Family
FoundaJon
2
January,
Grove
Insight
Opinion
Research
3January,
New
York
Times/CBS
News
slide: PNHP IN/Rob Stone
58. “In principle, do you support or oppose government legislation
to establish national health insurance?”
Ann Intern Med 2008;148:566-567
59. Single-Payer: “Politically Feasible?”
Other “Politically Infeasible” Movements
Abolition of Human
Slavery
(1860s)
Women’s Suffrage
Movement
(1840-1920)
Civil Rights Act
(1964)
slide: PNHP Nick Skala
60. Expensive, Inefficient, Inequitable
• No system in the industrialized world is as
heavily commercialized, and none is as
expensive, inefficient, and inequitable
• In short, the U. S. experience has shown that
private markets and commercial competition
have made things worse, not better, for our
health care system.
Arnold S. Relman, MD
61. Goals
• Health care for every American
no exceptions, cradle to grave.
• Free choice of doctors and hospitals
like Medicare patients have
• Patients and doctors make care decisions
not in the backroom or the board room
• Health policy is public policy
with accountability and transparency.
• No one goes bankrupt because of illness
not patients, not businesses, not governments
62. Do we keep rearranging the
deck chairs on the Titanic?
63. "...the greatest tragedy of this period … was
not the strident clamor of the bad
but the appalling silence of the good people”
Dr. Martin Luther King Jr.
64. What can we do?
Nobody can do
everything,
but
everybody can
do something Gil Scott-Heron
65. Primary Care & PPACA
• Greater need • Workforce expansion
• 32 million new insured • fund residencies (favor track
• need for prevention, record primary care)
continuity, coordination • loans for 10 y promise
• Inadequate supply • Payment reform
• 30% of MDs (vs 50-60%) • RBRVS reform (10% increase)
• 30-60% lower salaries • Medicaid/Medicare increase
• greater workload • New models of care
• diminishing resources • Patient centered medical home
• Accountable care organization
66. Current bills like unecessary surgery
“We have to do something”
• Access? No. Millions still uninsured,
thousands will die because of no access
• Choice? No. Insurance companies choose
who you see, what you can get, how much
you pay
• Affordability: No. Billing and claims waste
unchanged. Prices still set to guarantee big
insurance profit. Bankruptcies persist for
individuals, businesses, governments
67. Current Bills Fail to Improve
• Portability?No. You still lose insurance
when you change jobs, get laid off, etc.
Discontinuity -> poor outcomes
• Accountability? No. Health policy set by
big insurance in private. No
accountability, no transparency, no recourse
• Quality? No. Continues tweaking system
that’s been failing for decades
