Transcript Econ and Health Disparity - University of South Carolina

Economics and Health Disparity in
the US
[email protected]
Department of Health Services Policy and Management
Arnold School of Public Health
University of South Carolina
Economics and health disparity:
1. Economic circumstances affect
environment and behavior,
which affect well-being
2. Economic circumstances affect
health care access, which
affects well-being
3. The health care financing
system affects economic
circumstances, which …
Some slides are courtesy of
PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
332 SOUTH MICHIGAN AVENUE
SUITE 500
CHICAGO, IL 60604
TEL: (312) 554-0382
WWW.PNHP.ORG
Economics and health disparity:
1. Economic circumstances affect
environment and behavior,
which affect well-being
2. Economic circumstances affect
health care access, which
affects well-being
3. The health care financing
system affects economic
circumstances, which …
Causes Of Excess Deaths Among
African Americans
Cardiovascular
39%
Source: Himmelstein & Woolhandler - Analysis of data from NCHS
Cardiovascular
25%
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
Deaths per 1000 Live Births
Infant Mortality by Race, South Carolina
White
Black
30
25
20
15
10
5
0
Infant Mortality by Race, South Carolina
White
Black
Difference
Ratio
30
2.5
20
2
15
1.5
10
1
2002
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
0
1980
0
1978
0.5
1976
5
1974
Deaths per 1000 Live Births
25
3
2002
35
2000
1998
1996
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
Percent of families in poverty
Poverty Rate
White
Black
30
25
20
15
10
5
0
Distribution of Wealth, 1976 & 1998
1998
1976
19%
51%
30%
35%
34%
Wealthiest 1%
Next 9%
Bottom 90%
31%
Despite Higher GDP, Most Americans
Have Less Disposable Income than Canadians
Source: Monthly Labor Review April, 1998
Note: Mean earnings in the U.S. were 15.5% higher than in Canada in 1995
Poverty Rates, 1997
U.S. and Other Industrialized Nations
Source: Luxembourg Income Study Working Papers
Note: U.S. figure for 1997, other nations most recent available year
Americans Lead the World in Hours Worked
Source: International Labor Organization, 1999
•
Science. 2004 Sep 17;305(5691):1736-9.
–
Inflammatory exposure and historical changes in human life-spans.
Finch CE, Crimmins EM.
Andrus Gerontology Center and Departments of Biological Sciences and of
Sociology, University of Southern California, Los Angeles, CA 90089, USA.
[email protected]
Most explanations of the increase in life expectancy at older ages over history
emphasize the importance of medical and public health factors of a particular
historical period. We propose that the reduction in lifetime exposure to infectious
diseases and other sources of inflammation--a cohort mechanism--has also
made an important contribution to the historical decline in old-age mortality.
Analysis of birth cohorts across the life-span since 1751 in Sweden reveals
strong associations between early-age mortality and subsequent mortality in the
same cohorts. We propose that a "cohort morbidity phenotype" represents
inflammatory processes that persist from early age into adult life.
– U.S. Civil War veterans who had infectious disease as young men were more
likely to have heart disease after age 50. Frequent diarrhea during infancy, a sign
of infection, is linked to cardiovascular disease in adulthood. Americans now in
their 50s are 15% more likely to have cardiovascular disease, and twice as likely
to have cancer, if they had a serious infectious disease in childhood.
•
Men who weighed less than 5.5 pounds at birth have, on average, a 50% greater
chance of dying of heart disease. Women – 23%. (Race effect? Which way?)
An aside on genetics
as a residual explanation
• Differences not attributable to the immediate
environment are attributed to genetic
differences
– E.g. cardiovascular disease race
differences
• Environment effects during development and
early childhood can affect adult health and
the next generation (e.g. hypertension and
pre-eclampsia).
Economics and health disparity:
1. Economic circumstances affect
environment and behavior,
which affect well-being
2. Economic circumstances affect
health care access, which
affects well-being
3. The health care financing
system affects economic
circumstances, which …
Uninsured Percentage, 2003
45 million
uninsured,
15.6% of
public,
in 2003
35%
30%
25%
20%
15%
10%
5%
0%
White
(nonHispanic)
Asian
Black
Hispanic
Number Uninsured/In Poverty 1967-1998
Source: Social Security Bul, HIAA, CPS
Who Are The Uninsured?
»Children
»25%
»Employed
»50%
»Unemployed
»5%
»*Out of labor
»force
»20%
*Students>18, Homemakers,
Disabled, Early retirees
Source: Himmelstein & Woolhandler - Tabulation from 1999 CPS
Blacks’ and Hispanics’ Full Time Jobs
Provide Less Insurance
Source: Commonwealth Fund, 3/2000
Are Emily and Brendan More
Employable than Lakisha and
Jamal?
Former Welfare Recipients:
Jobs May Not Bring Coverage
Uninsured Forego Care for Serious Symptoms
Source: Arch Int Med 2000; 1269 - analysis of RWJ Foundation Survey
Serious Sx = loss of consciousness, breast lump, chest pain > 1 minute, etc.
Potentially Serious Sx = Difficulty urinating, productive cough with fever etc.
Health care foregone
Un- and underinsurance costs
money and lives
Later diagnosis of cancers
Uninsured get less heart care
Uninsured get less trauma care
Uninsurance 6th Leading Cause of
Death among persons under 65
• http://www.iom.edu/IOM/IOMHome.nsf/
Pages/Consequences+of+Uninsurance
• Primary prevention and screening
• Cancer care
• Chronic disease care: diabetes,
cardiovascular disease, end-stage renal
disease, HIV, mental illness
Uninsurance as Cause of Death
continued
• Acute care for cardiovascular disease,
trauma
• “Surprisingly, provider response to traumatic
injury can be influenced by insurance status.
Uninsured trauma victims are less likely to be
admitted to a hospital, receive fewer services
when admitted, and are more likely to die than are
insured trauma victims.”
Patients Refused Authorization for
ER Care
• 8% to 12% of HMO patients presenting
to 2 ERs were denied authorization
• Authorization delayed care by 20 to 150
•
minutes
One HMO member’s story:
• Refused at private hospital ER
because didn’t have insurance card
• Admitted to public hospital
• Then, the HMO insisted on transfer to
the private hospital
Patients Refused Authorization for
ER Care
• Of those denied:
47% had unstable vital signs or other high
risk indicators
40% of children were not seen in f/u by
primary MD
Eventual diagnoses included: meningococcemia
(2), ruptured ectopic (2),shock due to
hemorrhage (2), septic hip, PE, MI (2),
ruptured AAA, pancreatitis, peritonsillar
abscess, small bowel obstruction, unstable
angina, pneumothorax, appendicitis,
meningitis(3)
Sick HMO Patients: Barriers to Care
Source: Consumer Reports 7/2000:41 - based on survey of 52,000 readers
»% of CABG* Patients Using High»Mortality Hospitals
Tradeoff Savings for Outcome:
HMOs Push Heart Surgery Patients
to High-Mortality Hospitals
»60%
»40%
»20%
»45%
»49%
»Private
»FFS
»Medicare
»FFS
»59%
»64%
»Private
»HMO
»Medicare
»HMO
»0%
Source: JAMA 2000; 283:1976
*CABG = coronary artery bypass graft surgery
Milliman & Robertson
Pediatric Length of Stay Guidelines
•
•
•
1 Day for Diabetic Coma
2 Days for Osteomyelitis
3 Days for Bacterial Meningitis
“They're outrageous. They’re dangerous. Kids
could die because of these guidelines.”
Thomas Cleary, M.D. Prof. of Pediatrics, U. Texas, Houston
Listed as "Contributing Author" in M&R manual
Source: Modern Healthcare May 8, 2000:34
Milliman & Robertson
“We do not base our guidelines on any
randomized clinical trials or other
controlled studies, nor do we study
outcomes before sharing the evidence
of most efficient practices with
colleagues.”
Wall Street Journal 7/1/98
Racial Disparity in Access to Kidney
Transplants
Pharmacies in Minority Neighborhoods
Fail to Stock Opioids
Source: N Engl J Med 2000; 242:1023
Minority Physicians Provide
More Care for the Disadvantaged
Ethnicity of Physician
Source: AJPH 1997;87:817
Economics and health disparity:
1. Economic circumstances affect
environment and behavior,
which affect well-being
2. Economic circumstances affect
health care access, which
affects well-being
3. The health care financing
system affects economic
circumstances, which …
Health Care Relative to US GDP, 2002, of $10.45 trillion
Health care $1.55
trillion
14.8%
$5440 per person
Everything else we
make
85.2%
Health Spending, 1990 & 1998:
U.S. Costs Rose More Than Other Nations’
Source: Health Affairs 2000; 19(3):150
Elderly as Percent of Total Population, 2000
Source: Health Affairs 2000; 19(3):192
Risky People Charged More
Firms Shift Health Insurance
Costs to Workers
Source: Int J Health Serv 1999;29:498
Rising Out-of-Pocket Costs for Seniors
Voucher/Premium Support Proposals Would Worsen
Percent of Income
Source: Senate Select Committee on Aging; AARP 4/95 & 3/98; and Commonwealth Fund
May, 1999 projections (adjusted to include nursing home costs)
Federal Tax Subsidies for
Private Health Spending, 1998
Note: Total federal tax subsidy = $111.2 billion
Source: Health Affairs 1999; 18(2):176
Who Pays for Healthcare?
Government
Amount in 1998
(billions)
$736.8
Medicare
$216.2
Medicaid
$170.6
Premiums for public employees
$67.3
Tax subsidy for private insurance
$124.8
Other*
$157.9
Percent
64.1%
Private employers
$216.5
18.8%
Individuals (excludes tax subsidy)
$195.8
17.0%
Total
$1149.1
100%
Source: Himmelstein & Woolhandler - Unpublished analysis of NCHS data, Health Affairs 1999;18(2):176
* Includes VA, NIH, subsidy for public hospitals, worker's comp, health departments etc.
Who Pays for Health Care,
US DHHS version (2002)
Behind Who Pays, 1998
Individuals (after
tax subsidy)
17%
Private employer
premiums
19%
Medicare
18%
Medicaid
15%
Premiums for
public employees
6%
Other public
14%
Tax subsidy
11%
Source: Himmelstein & Woolhandler - Unpublished analysis of NCHS data, Health Affairs 1999;18(2):176
* Includes VA, NIH, subsidy for public hospitals, worker's comp, health departments etc.
U.S. Public Spending Per Capita for Health
is Greater than Total Spending in Other Nations
Note: Public includes benefit costs for govt. employees & tax subsidy for private insurance
Source: NEJM 1999; 340:109; Health Aff 2000; 19(3):150
Who Pays For Health Care?
Regressivity Of U.S. Health Financing
Source: Oxford Rev Econ Pol 1989;5(1):89
Many Americans Can't Afford the Basics
Percent of Insured and Uninsured with Unmet Needs
Source: Census Bureau - "Extended Measures of Well-Being: Meeting Basic Needs"
Financial consequences
U.S. Seniors Paying More for Ten
Top Selling Drugs*
Source: U.S. GAO – www.house.gov/bernie/legislation/pharmbill/international.html
*Zocor, Ticlid, Prilosec, Relafen, Procardia XL, Zoloft, Vasotec, Norvasc, Fosamax, Cardizem CD
Financial Suffering at the End of Life
Source: Ann Int Med 2000; 132:451 - SUPPORT Study of 988 terminally ill patients
* Out-of-pocket medical costs > 10% of household income
** Patient or family sold assets, took out mortgage, used savings or took extra job
Illness and Medical Costs,
A Major Cause of Bankruptcy
•
45.6% of all bankruptcies involve a medical reason or large
medical debt
•
326,441 families identified illness/injury as the main reason
for bankruptcy in 1999
•
An additional 269,757 had large medical debts at time of
bankruptcy
•
7 per 1000 single women, and 5 per 1000 men suffered
medical-related bankruptcy in 1999
Source: Norton's Bankruptcy Advisor, May, 2000
35
Rate of abortions per 1,000 women aged
15–44 in the United States and in South
Carolina, 1973–2000
30
25
20
15
10
5
0
1973
1975
1977
1979
1981
1983
1985
1987
1989
1991
1993
Occurring in:
South Carolina
United States
Guttmacher Institute
1995
1997
1999
2001
Induced Abortions in the US
1,800,000
1,600,000
1,400,000
1,200,000
1,000,000
800,000
600,000
400,000
200,000
0
1990
Guttmacher Institute data.
2000
2002 projected from 16
states
Two-thirds of women who have abortions
cite "inability to afford a child" as their primary reason.
Physician Visits Per Capita
Source: OECD, 1999 - Data are for 1997 or most recent available year
U.S. Public Spending Per Capita for Health
is Greater than Total Spending in Other Nations
Note: Public includes benefit costs for govt. employees & tax subsidy for private insurance
Source: NEJM 1999; 340:109; Health Aff 2000; 19(3):150
Hospital Inpatient Days Per Capita, 1997
Source: OECD, 1999
Difficulties Getting Needed Care
Source: Commonwealth Fund Survey, 1998
Continuity of Care
Source: Commonwealth Fund Survey, 1998
Reasons for Changing Health Plans
Employer
changed*
74%
Less expensive
17%
Better care
9%
*Changed job, or employer changed plan offerings
Source: Health Affairs 2000; 19(3):158
Infant Mortality, 1997
Deaths In First Year Of Life/1000 Live Births
Source: OECD, 1999 & NCHS
Life Expectancy For Women, 1997
Source: OECD, 1999 & NCHS
Life Expectancy For Men, 1997
Source: OECD, 1999 & NCHS
Minimum Standards For Canada's
Provincial Programs
1. Universal coverage that does not impede, either
directly or indirectly, whether by charges or
otherwise, reasonable access.
2. Portability of benefits from province to province
3. Coverage for all medically necessary services
4. Publicly administered, non-profit program
Who Pays For Health Care?
Regressivity Of U.S. Health Financing
Source: Oxford Rev Econ Pol 1989;5(1):89
Who Pays For Canada's NHP?
Province Of Alberta
Source: Premier's Common Future Of Health, Excludes Out-of-Pocket Costs
Health Care Spending % Of GNP:
U.S. & Canada, 1960-2001
Percent of GDP
15%
10%
U.S.
Canada
5%
2000
1995
1990
1985
1980
1975
1970
1965
1960
0%
Source: Statistics Canada, Canadian Inst. for Health Info., & NCHS/Commerce Dept
Number of Insurance Products
Hospital Billing & Administration
United States & Canada, 2000
Source: Woolhandler/Himmelstein NEJM 1991; 324:1253 & 1993; 329:400 (updated)
Physicians' Billing & Office Expenses
United States & Canada, 2000
Source:Woolhandler/Himmelstein NEJM 1991;324:1253 (updated)
Difference in Health Spending
Per Capita, U.S. vs. Canada, 2000
Bureaucracy
All Other
$1604
$857
Source: Woolhandler/Himmelstein NEJM 1991; 324:1253 & 1993; 329:400 (updated)
Infant Mortality
U.S. & Canada, 1955-1996
FIRST PROVINCE
IMPLEMENTS NHP
U.S.
CANADA
Source: OECD 1999, Statistics Canada & CDF
Infant Deaths by Income, Canada 1996
Even the Poor Do Better than U.S. Average
Homeless in Toronto
Death Rate Elevated, But Lower than In U.S.
Source: JAMA 2000; 283:2152
Physician Services For The Elderly:
Canadians Get More of Most Kinds of Care
Source: JAMA 1996; 275:1410
Growth in Spending 1970-1998:
Medicare vs. Private Insurers
Per Enrollee
Source: K. Levit, HCFA - Personal Communication - 3/1/00
NIH Clinical Research Grants (RO1)
Falling in High Managed Care Markets
Source: Moy et al. JAMA 1997; 278:217
Economics and health disparity:
1. Economic circumstances affect
environment and behavior, which
affect well-being
2. Economic circumstances affect health
care access, which affects well-being
3. The health care financing system
affects economic circumstances,
which feeds back to 1. and 2.
[email protected]
“It doesn’t have to be that way. We can do better!”