Transcript Universal Health Insurance: Can We Get there from here?

Universal Healthcare:
Can We Get There?
California Physicians’ Alliance
Developed by Bree Johnston, Dorothy Rice, Jim
Kahn, Vishu Lingappa, Beth Capell, and others
We are Going to Discuss Today
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Problems with our current system
Potential solutions
Politics of change
The Health Care Crisis: Interconnections
• >13% of GDP (50% more than Canada)
• double digit inflation
• employers shifting costs to employees
• wasted resources in a fragmented system
• 1 in 4 health care dollars not for health care
• >40 million uninsured
• most underinsured
• pre-existing condition
exclusions
• deductibles and steep copays
• erosion of choice of providers
• provider no longer trusted to be
advocate
• bureaucratic intrusion
• worse health care outcomes
• distortion of clinical judgment
What is Right with our System?
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Excellent hospitals, equipment, and health
care facilities
Enough well trained professionals
Superb research
Sufficient spending
What is Wrong with our System?
We spend far more money than any other
country on health care...
…but get far fewer benefits, far worse
health outcomes, and far less patient
satisfaction.
What is Wrong with our System?
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Tens of millions of workers and others lack
decent health care
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Health outcomes are worse than other developed
nations due to gaps in health coverage
We spend more per capita on health care than
any other country … with worse access and
outcomes
38% of Americans report one or more problems
getting access to care in the past year (Kaiser
Commission, July 2002)
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US National Health Expenditures
Reached $1.3 Trillion in 2000
Billions of Dollars
$1300
$990
$696
$429
$246
$13
$18
$27
$41
1950
1955
1960
1965
Source: Centers for Medicare and Medicaid Services
$73
1970
$131
1975
1980
1985
1990
1995
2000
Per Capita National Health Spending
Reached $4,637 in 2000
$4637
$3637
$2690
$1733
$1052
$582
$82
$105
$141
$202
1950
1955
1960
1965
$341
1970
SOURCE: Centers for Medicare and Medicaid Services
1975
1980
1985
1990
1995
2000
US National Heath Spending as % of GDP
Increased Rapidly Over the Years
13.4%
13.2%
1995
2000
12.0%
10.3%
8.8%
8.0%
7.0%
5.1%
4.4%
4.4%
1950
1955
1960
5.7%
1965
SOURCE: Centers for Medicare and Medicaid Services
1970
1975
1980
1985
1990
US Spends More Than Any Other Nation
Per Capita Spending, U.S. Dollars, 1998
$4.178
United States
$2.794
Switzerland
Norway
$2.425
Germany
$2.424
$2.312
Canada
$2.133
Denmark
$2.077
France
$2.07
Netherlands
$2.043
Australia
$1.822
Japan
United Kingdom
New Zealand
$1.461
$1.424
Source: Anderson & Hussey, Health Affairs, May/June 2001.
Life Expectancy at Birth
MALES 1996
United States
72.7
75.7
Switzerland
73.6
Germany
Canada
75.4
France
74.1
Netherlands
Denmark
74.7
72.8
75.4
Norway
75.2
Australia
77
Japan
New Zealand
United Kingdom
74.3
74.4
Source: Anderson G F. & Poullier JP. Health Spending, , Access, &
Outcomes: Trends in Industrialized Countries. Health Affairs,
1999; 18(3):178-192.
Life Expectancy at Birth
FEMALES 1996
79.4
United States
81.9
Switzerland
79.9
Germany
81.5
Canada
82
France
80.4
Netherlands
Denmark
78
Norway
81.1
Australia
81.1
83.6
Japan
New Zealand
United Kingdom
79.8
79.3
Source: Anderson G & Poullier JP. Health Spending, Access, and Outcomes:
Trends in Industrialized Countries. Health Affairs, 1999; 18(3):178-192.
Some Comparisons
Per
Capita
costs,
1999 US
$
Infant % over
Mortali age 65
ty
Per
1000
Life
expect
ancy,
women
US
4400
8
12
79
Canada
2400
6
12
81
Germany 2400
5
17
80
Japan
1800
4
17
83
UK
1600
6
16
80
Access is a Huge Problem
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1 of 5 Americans postponed getting
needed health care last year
1 of 7 Americans had a problem paying
for medical bills last year
1 of 10 did not get a prescription drug they
needed due to cost
Kaiser Commission on Medicaid and the Uninsured, July 2002
Access Problems Harm Health
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The Institute of Medicine estimates
18,000 excess deaths per year
due to lack of health coverage
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People without health insurance:
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Receive too little medical care too late
Are sicker and die sooner
Receive poorer care when they are in hospitals, even
for acute situations like car accidents
Care Without Coverage, Institute of Medicine, May 2002
Illness is a Major Cause of Bankruptcy
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Half of all bankruptcies involve a medical cause
or debt
326,441 families identified illness/injury as the
main reason for bankruptcy in 1999
299,757 more had large medical debts at time of
bankruptcy
Source: Norton’s Bankruptcy Advisor, May 2000
Who are the Uninsured?
Not
working
10%
Full Time
44%
Selfemployed
16%
Part Year
17%
Part Time
13%
Why Should People with Health Insurance
Care about the Uninsured?
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With economic ups and downs, it could be you
Many people are tied to jobs that they don’t
like due to health insurance
Working people age 50 to 65 are just as likely
as younger workers to lose health insurance—
just when they need it most
Fairness, humanity, and social obligation
Why Should People with Health Insurance
Care about How Insurance Works?
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Health insurance premiums are rising, and this
may worsen during economic decline
Risk is being shifted to patients through Medical
Savings Accounts & Defined Contributions… so
sick people pay more
Fuchs NEJM, 2002
Insurance works best for patients if we are in
one large risk pool
Why Should People with Health Insurance
Care about How Insurance Works?
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Health insurance premiums are rising, and in a
down economy employers shift costs to employees
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Medical Savings Accounts & Defined Contributions
undermine the risk pool, seduce patients to gamble
with their health, and threaten care for people with
major disorders
Fuchs NEJM, 2002
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So more and more people have less access to care,
and what care they do get is getting worse.
Adverse Consequences of
Investor Owned Health Care
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Bankruptcy in physicians groups due to
inadequate payments
Erosion of provider-patient trust
Conflicts of interest
Worse quality and access in investor -owned
health systems and nursing homes, especially
among those in fair or poor health
Thomas SGIM 2000
Harrington AJPH 2001
Woolhandler et al JAMA 1999
Tu NEJM 2002
Why is Health Care Different From
Most Market Commodities?
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Health care is technically complex -- it’s hard to make
choices that “maximize utility”
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Health care is expensive, tempting HMOs to cheat (exclude
the sick) rather than compete (profit by being efficient)
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Poor choices cannot be reliably revisited
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Providing it requires good clinical judgment
All industrialized democracies have removed health insurance from the
market and provided citizens with a national health insurance … except USA
Evidence of impact:
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Negative impact on charity care JAMA 1999
Nurses report spending less time with
patients
 Higher acuity patients and worse staffing
 Less time to teach and comfort patients
AJN 1996
Has a Decade in the Marketplace
Improved Health Care?
• Access is worse
• Quality is eroding
• Choice has substantially diminished
• Trust in health care providers has been undermined
• Once again, COSTS ARE SKYROCKETING
Are we paying for care?
Or overhead?
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Huge inefficiencies to operate a complex system
with multiple private insurers plus Medicare,
Medi-Cal, and other public programs
For-profit HMOs and hospitals where profits are
“earned” by stockholders, not reinvested in the
health care system
Administrative costs of $309 billion nationally,
twice what is needed
Overhead & Profit
As Percent of Premium
35 Cigna
30
RC
25
AetnaWellpoint
20
United
HumanaPacific
15
10
5
Medicare
Pacific
Humana
United
Wellpoint
Aetna
RC
Cigna
0
Medicare
Growth of Physicians, RNs &
Administrators 1970-1998
2500
Percentage Growth
2000
Administrators
RNs
Physicians
1500
1000
500
0
1970
1975
1980
1985
1990
1998
Bureau of Labor Statistics, NCHS
Nurse Staffing Improves Care
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Increased hours of nursing care is associated
with better care of hospitalized patients
Needleman et al NEJM 2002
Administrators
2500
RNs
2000
Physicians
1500
Do you
want your
health care
dollars
spent
1000
500
0
1970
1975
1980
1985
1990
1995
Here or
Here?
The Case for
National Health Insurance
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Fairness – everyone should have the health care
they need when they need it
Efficiency – we could pay for comprehensive care
for everyone and spend less money than now
We would spend more money on direct care
The current experiment with market driven health
care has not worked … for patients, physicians,
nurses, or society
Health Care Options Project
(HCOP) Provides insights into
Health Reform
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Convened by California Health and Human Services
Agency, based on Senate Bill 480 signed by
Governor Davis in 1999.
Examined options for extending health care coverage
in California
Nine reform option papers
Analyzed and compared by consultants from The
Lewin Group and AZA Consulting
The Nine HCOP Proposals
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Six partial proposals
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Three take steps back, reducing coverage or access
Two take modest steps forward, expanding existing
programs
One is nearly universal, combining expansions of
existing public programs with “pay or play” for
employers (we will discuss)
Three “universal coverage” proposals
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Two “single payer”
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We will discuss the Kahn proposal
One “health service”
Steps Forward, Almost Universal
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Healthy California (Brown and Kronick)
 Stage One: Covers Low Income Adults
 Stage Two: Pay or Play
 Covers 6 million more Californians, to 33
million
 BUT: As with Single payer, costs to state
government are high and assumptions about
federal funding optimistic.
Pay or Play
Pay Tax
Offer
Insurance
Employers Choose
Employees
Choose
Workers Covered Under
Public Program
Employer
Plan
Net Change in Spending for Employers
and Families Under Pay or Play
$1,500
$1,000
CHOICE
$500
Healthy Families
$0
($500)
Co
ve
r
No
ag
e
Co
ve
r
ag
e
Fa
m
ilie
s
Universal Health Care Proposals
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California Single Payer Plan (Jim Kahn and
CaPA colleagues)
Cal Care (Judy Spelman and Health Care for
All)
California Health Service Plan (CHSP) (Ellen
Shaffer)
How does it work?
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Universal coverage for residents of California
Comprehensive benefits, including long term
care
Public administration
The power of single payer:
Highly equitable, highly efficient.
A rare combination.
What is Single-Payer Health Care?
Health insurance with these features:
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Public financing -- one public payer
Universal -- covers everybody
Comprehensive -- covers all medical needs
Private delivery -- private & some public providers
Controls costs -- through global budgets and bulk
purchasing, not clinical micromanagement
Portable -- retained with move, change or loss of job
Accountable -- to participants
What do we get from Single-Payer?
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Administrative efficiency via simplified reimbursement.
Patient freedom to choose/change health care providers,
without paying more.
Provider freedom to choose mode of practice (fee-forservice, capitation, or salary).
Fairer financing (lower cost to sick, poor/middle-income).
Explicitness in priorities (e.g., prevention) and financing
(e.g., risk adjustment)
Shared dedication to success, via universal participation.
Benefits Under Single-Payer
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All medically necessary health care services as
determined by the patient’s chosen provider
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Full mental health, prescription drug, and long-term
care coverage
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No exclusion of “pre-existing conditions”
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No deductibles or life-time cap in benefits
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Modest co-payments, if any
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Choice of any willing licensed health care provider
How Does Single-Payer Do It?
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Just collects money and pays bills without needing to
intrude into individual doctor-patient relationships to
make a profit.
How Does Single-Payer Do It?
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Just collects money and pays bills without needing to
intrude into individual doctor-patient relationships to
make a profit.
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Global budgeting controls costs while leaving
clinical decisions in the hands of the patient’s
chosen health care professional.
Ineffective and intrusive
micromanagement by insurance
companies (current system) involving
an army of bureaucrats
Global budgeting (under
single-payer) makes cost
control administratively
simple and unintrusive
How Does Single-Payer Do It?
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Just collects money and pays bills without needing
to intrude into individual doctor-patient relationships
to make a profit.
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Global Budgeting controls costs while leaving
clinical decisions in the hands of the patient’s
chosen health care professional.
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Enrollees are the shareholders in a health care system
motivated to provide the best possible care while
controlling costs.
Two Equal and Opposite forces:
Desire to control costs
(spent on someone else)
Desire for the best possible
care for loved ones
• Today, enrollees are not the shareholders, so these forces are out of balance:
HMOs cheat rather than compete, to increase profits and increase stock price.
• Under single-payer costs must be controlled by eliminating waste and
preventing disease, not by denying care to the sick to maximize profits.
How Does Single-Payer Do It?
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Just collects money and pays bills without needing to
intrude into individual doctor-patient relationships to
make a profit.
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Global Budgeting controls costs while leaving
clinical decisions in the hands of the patient’s
chosen health care professional.
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Enrollees are the shareholders in a health care
system motivated to provide the best possible
care while controlling costs.
• Eliminates hidden sources of waste
How Many Kinds of Waste can YOU Find in
Health Care Today?
• Unnecessary and wasteful bureaucracies
• Inadequate primary care ... increased utilization of
expensive ER services
• Inadequate mental health coverage manifests as somatic
complaints
• Inadequate resources for public health, prevention, and
research
• Legal costs related to lack of health insurance
• Hidden costs (e.g. workers compensation and liability
insurance partly pay for the lack of universal healthcare)
CA Single Payer Plan
Ownership
Private
Services Covered
All
Includes Long Term Care
Copays
$5 outpt, prescriptions
Provider payment
FFS or integrated delivery system
Hospital global budgets
Taxes
Payroll 8% firms earning > $75,000
$1 tobacco
income tax 1.6% for all and additional
those making > $250,000
Universal Health Care Proposals:
Bottom line
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Universal coverage, broad benefits
Expanded benefits for those with insurance!
Increased government spending but ...
Lower total spending than now
Less spending on administration, overhead, and
profits
More spending on direct care
California Single Payer SB 921
Eligibility
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All state residents eligible.
Individuals lacking legal immigration status (i.e.,
“undocumented”) included if they document residence.
Non-SB 921 Option: After 3-month waiting period; longer
residency for certain services (e.g., long-term care 3
years). Emergency care covered during waiting period.
California Single Payer SB 921
Delivery system
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Private and county.
Fee-for-service and capitated (integrated health
delivery systems). Providers and participants choose
one.
California Single Payer SB 921
Administration
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Elected commissioner
Health Care Agency
Statewide boards/offices: Health Policy; Consumer
Advocacy; Medical Practice Standards.
… responsible for financial management of the system;
establishing eligibility and benefits; negotiating
reimbursement.
California Single Payer SB 921
Benefits
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Comprehensive.
Specifically, all medical care deemed medically
appropriate by the patient's licensed provider: inpatient,
outpatient, tests, prescription drugs, durable equipment,
podiatry, chiropractic, transport, rehab, disease
management, language, prevention, mental health,
dental and vision, long-term care (home-based, day
treatment, 100 days institutional).
Medical Practice Standards - cosmetic excluded, Board
may remove some services.
California Single Payer SB 921
Cost-sharing
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No cost sharing for 2 years.
After 2 years, cost-sharing option with limits of $250
per person/$500 per family per year.
Exemption for individuals who meet income rules, and for
prevention.
California Single Payer SB 921
Financing
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Current public health care spending -- public insurance
and service programs (e.g., Medi-Cal, Medicare, VA,
categorical programs, some county safety net funds).
Unspecified tax rates on: employers, employees,
unearned income, alcohol, tobacco.
Capture collateral sources, e.g., pension funding of
health care.
California Single Payer SB 921
Cost control
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Global budget overall -- current spending, grow at GDP
adjusted for population and other factors.
Global budget divisions -- (risk-adjusted) by region,
FFS/integrated, FFS hospitals, FFS provider types.
Negotiated rates -- FFS, global, capitation.
Administration cost -- for system, likely < 4%.
Bulk purchasing -- eg drugs at federal supply schedule.
Capital expenditures -- oversight/approval >$500,000.
If deficit anticipated -- cost-sharing, waiting period,
postponement of capital spending, other.
Fig 1 Changes in Health Spending, California Single-Payer Program in 2002
Amount in Millions
$151,776
Current Health Spending
Increases in Utilization
Utilization Change for Uninsured
Change for “Underinsured”
Reduction in Managed Care
Long-term Care
Nursing Home
$1,609
Home Health
$997
Spending Offsets
Bulk Purchasing
Prescription Drugs
($3,641)
Durable Medical Equip
($ 391)
Administrative Costs
Insurer Administration
($6,136)
Hospital Administration
($2,270)
Physician Administration ($4,752)
Total Before Global Budget Cap
Provider Payment Reductions
Net Change in Spending with Budget Cap
Net Change
$3,465
$2,793
$745
$2,606
($4,032)
($13,158)
N/A
($7,581)
Fig 6 Change in Family Health Spending by
Age of Family Head, After Wage Effects
$0
($300)
($600)
($440)
($351)
($570)
($900)
($708)
($1,200)
($1,500)
($1,545)
($1,800)
($1,637)
($2,100)
($2,400)
Under 24
25-34
35-44
45-54
55-64
65 (and over)
Fig 7 Change in Family Health Spending by
Income, After Wage Effects
$3,176
$3,500
$3,000
$2,500
$2,000
$1,500
$1,000
$421
$500
$0
($500)
($1,000)
($1,500)
($775)
($1,054) ($1,155)
($1,324)
($1,686)
($2,000)
($1,820) ($1,864)
Less than $10,000- $20,000$10,000
$19,999 $29,999
$30,000$39,999
$40,000- $50,000$49,999 $74,999
$75,000$99,999
100,000- $150,000
$149,999 or more
Single Payer:
Advantages for Providers
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Reduced administrative burden.
No micro-management by payers.
Consistent reimbursement across patients.
Consistent information requirements across patients.
Risk adjustment -- based on severity and perhaps
quality.
Attract patients based on quality.
Single Payer:
Challenges for Providers
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Reimbursement reduced to at least partly reflect lower
administrative burden and uncompensated care.
Must work within global budgets / capitation rate.
For large providers, likely reduced market power.
Approval for capital spending.
Quality visible and key -- for patients, possibly rates.
How do the HCOP Plans Compare?
Incremental
Example
Pay or Play
Example
Universal Care
Example
ITUP
Healthy CA II
CA Single Payer
Reduction in
Uninsured
2.6
5.7
6.6
Change in
Total Health
Spending
$1.4 billion
$3.0 billion
-($7.6) billion
Bottom Line
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Universal coverage proposals
 Universal coverage
 Improved benefits for those with insurance
 Lower total spending
Incremental and pay or play proposals
 Increased coverage, but not universal
 May be some steps backward
 Increased costs
Arguments against Single Payer
1. We can’t afford it
2. It would erode choice
3. It’s bad for business and the economy
4. The government can’t do anything as well as
the private system
5. It Will Lead to Rationing, like Canada and
Great Britain
6. Only incremental reform is feasible
Arguments against Single Payer
1.
2.
3.
4.
We can’t afford it
It would erode choice
It’s bad for business and the economy
The government can’t do anything as well as
the private system
5. It Will Lead to Rationing, like Canada and
Great Britain
6. Only incremental reform is feasible
1. We can’t afford it
Response: We can afford it, we can’t afford
our current system.
The HCOP shows that Universal Publicly
Funded Care Costs Less, not More
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Incremental Reform
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Many people still don’t have access
to the care they need
Costs go up
Universal Coverage
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Everybody gets health care, at a lower cost
than currently
Arguments against Single Payer
We can’t afford it
It would erode choice
It’s bad for business and the economy
The government can’t do anything as well as
the private system
5. It Will Lead to Rationing, like Canada and Great
Britain
6. Only incremental reform is feasible
1.
2.
3.
4.
2. It would erode choice

Response: Would you rather have “choice” among
a few insurance plans with limited benefits, or one
health insurance policy with broad benefits that
allows choice of providers?

Universal publicly-funded insurance gives
consumers MORE choice of provider than almost
all current plans
Arguments against Single Payer
1.
2.
3.
4.
We can’t afford it
It would erode choice
It’s bad for business and the economy
The government can’t do anything as well as
the private system
5. It Will Lead to Rationing, like Canada and Great
Britain
6. Only incremental reform is feasible
3. It’s bad for business and the economy

Response: A national health insurance program
would be GOOD for the economy
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Stop punishing people for changing jobs
Level the playing field among businesses that now do
and don’t offer health insurance
Strengthen U.S. business position internationally
Reduce health care costs through large contracts(e.g.,
Rx drugs)
The transition requires careful planning to minimize
disruption
• Small businesses can’t afford the cost.
Actually, inaccessibility of health insurance is a major
impediment to small business startup: you may have a great idea,
but can’t start a company because you can’t attract employees –
perhaps their current large employer is able to offer health
benefits that you as a small employer can’t. Single-payer health
care takes these shackles off entrepreneurship.
All competitors pay a fair share of health care benefits for
employees – without need for a big benefits bureaucracy to keep
track of who is covered by what, and when coverage starts, ends,
or changes.
Arguments against Single Payer
1.
2.
3.
4.
We can’t afford it
It would erode choice
It’s bad for business and the economy
The government can’t do anything as well as
the private system
5. Only incremental reform is feasible
4. The government can’t do anything
as well as the private system

Response: Public programs often work better than
private programs.
 Medicare is popular, the most efficient health
insurance in the U.S. Beneficiaries choose
physicians. It works for rich and poor.
 Social Security, Fire and Police protection, roads,
sewers, etc. are government programs with broad
popular support, often evolved due to failure of
private sector systems. They work and are popular
perhaps because they benefit us ALL.
Claims of Single-Payer Opponents
• Government programs are bad.
Response: What about Medicare, Social Security, Fire and
Police protection, roads, sewers, etc. These are all
government programs with broad popular support, that
often evolved because of the failure of private sector
alternatives to meet the needs of the people. These
programs are popular perhaps because they benefit us
ALL.
Arguments against Single Payer
1.
2.
3.
4.
We can’t afford it
It would erode choice
It’s bad for business and the economy
The government can’t do anything as well as
the private system
5. It Will Lead to Rationing, like Canada and Great
Britain
6. Only incremental reform is feasible
5. It Will Lead to Rationing, like
Canada and Great Britain
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Response:
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We have rationing now, according to who has insurance
and who does not
We are talking about a system similar to Canada’s, not
Great Britain’s
Canada has few significant waits for care
With sufficient spending (we will spend almost twice
what Canada spends) there will be no need for rationing
Arguments against Single Payer
1.
2.
3.
4.
We can’t afford it
It would erode choice
It’s bad for business and the economy
The government can’t do anything as well as
the private system
5. It Will Lead to Rationing, like Canada and Great
Britain
6. Only incremental reform is feasible
Although many health experts agree that
universal publicly-funded insurance would solve
many of our most pressing health care problems
(access, under-insurance, waste, costs), the
main argument against universal coverage is
political infeasibility.
Where would we be if we used
the “political infeasibility”
argument regarding the
abolition of slavery, winning
civil rights, or many other
social and policy advances?
Achieving Civil Rights took many
steps and years
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Slavery first limited in the U.S. Constitution
(1789)
Further constrained in Missouri Compromise
Eliminated in those states not under Union
control (1864)
Banned by the Constitution (1865)
Voting Rights Act was not passed until 1965
If we believe that a universal
publicly funded health
insurance is the best approach,
let’s increase its political
feasibility
We Can Get There
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From a recent Texas poll:
52% favor - A national health plan, financed by
taxpayers, in which all Americans would get their
insurance from a single government plan
Other recent polls find similar results
This suggests that with a lot of education, work,
and political organizing, a reasonable national
health insurance proposal could win.
University of Houston Center for Public Policy
Texas Public Policy Survey Statewide Survey on Health Care
Survey conducted June 20-29, 2002
How can we “increase political feasibility”?
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Expand coverage for the uninsured — this
creates a constituency for coverage … imagine
trying to take Medicare from seniors!
Grow the group of committed activists willing to
educate the public about the advantages of
universal health care
Put universal health care into the debate and onto
the agenda at every opportunity
Build on key changes in public attitude, such as
rising distrust of corporations due to accounting
and profit-taking scandals
Use the HCOP as an educational tool
What is CaPA?
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The California Physicians Alliance, a chapter of
Physicians for a National Health Program (PNHP)
CaPA’s primary goal is to:
 Promote universal health access in California
and the US
Secondary goals are to:
 Protect the provider-patient relationship
 Promote justice in health care
Basic assumptions are:
 Health care is a human right
 Equity in health care
What can you do?
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Join CaPA/PNHP
Recruit 10 of your friends to join
CaPA/PNHP
Give this talk to a community group or at a
house party
Write op-ed pieces and articles
If you aren’t part of the solution, you
are part of the problem!
In summary, for Single Payer
We can afford it, we would be spending our health
care dollars better than now.
It is the right thing to do.
Coverage would be better for everyone.
It would not erode choice.
It would not be bad for business.
The government can do it.
We must make it feasible.
Achieving Universal
coverage
will not happen overnight –
Stay with the fight!
Clinical Case Report:
The U.S. Health Care System
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Chief Complaint
History
Symptoms and Signs
Diagnosis
Treatment Options
Treatment Plan
Chief Complaint
“My patients can’t pay for care.”
Some are uninsured, and some have
no insurance for medicines.
History
Symptoms and Signs
Diagnosis
Treatment Options
Treatment Plan
MD disillusionment
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Intrusive bureaucracy, managed care
Discontinuity of care
Compromised provider-patient relationship
Squeezed finances
Unfairness
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People without employer-based insurance pay
premiums after taxes.
Younger people pay for Medicare but get no
insurance themselves.
Renal disease is covered.
What are the key structural features
of the ill health care system?
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Private insurance linked to employment. Due to
wage freeze + labor shortage in W W II.
Private insurers mainly for-profit due to
conversions from non-profit.
Public insurance large but gaps. Medicaid and
Medicare enacted in 1965 after debates since
1930s on national health insurance … Medicare
fought by AMA as socialized medicine. Sporadic
public program expansion.
Number of uninsured, U.S.
40,000,000 = 15%
~ constant
What are the options?
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No intervention … observation only.
Reform health care market.
Expand public programs.
Improve the employer approach (pay or play).
Single payer.
Diagnosis:
The U.S. health care system is haphazard,
illogical, inefficient, and ineffective.
Drastic measures may be warranted.