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Universal Health Universal Health Insurance Insurance
Coverage in the Coverage in the United StatesUnited States
Brian Wells, MPHBrian Wells, MPH
University of FloridaUniversity of Florida
May 18, 2004May 18, 2004
OverviewOverview
Today’s Health Care SystemToday’s Health Care System Health Care Statistics Health Care Statistics Research studiesResearch studies Implementing a Universal SystemImplementing a Universal System Health Care System Around the Health Care System Around the
WorldWorld Concluding ThoughtsConcluding Thoughts
““Of all the forms of Of all the forms of inequality, injustice in inequality, injustice in health care is the most health care is the most
shocking and inhumane.”shocking and inhumane.”- Martin Luther King, Jr.- Martin Luther King, Jr.
Today’s Health Care Today’s Health Care SystemSystem
It’s not a systemIt’s not a system It is a “kaleidoscope of financing, It is a “kaleidoscope of financing,
insurance, delivery, and payment insurance, delivery, and payment mechanisms that remain unstandardized mechanisms that remain unstandardized and loosely coordinated”and loosely coordinated”
Major part of the system in private handsMajor part of the system in private hands Market driven economy invites the Market driven economy invites the
participation of numerous private entities participation of numerous private entities to serve these functionsto serve these functions
Source: Lecture, Dr. Robert Garrigues, Ph.D.
Today’s Health Care Today’s Health Care SystemSystem
This blend of public and private This blend of public and private involvement in health care delivery has involvement in health care delivery has resulted in:resulted in: A multiplicity of arrangement which enable A multiplicity of arrangement which enable
individuals to receive health care servicesindividuals to receive health care services Numerous insurance providers using Numerous insurance providers using
various mechanisms to insure against riskvarious mechanisms to insure against risk Multiple payers that make their own Multiple payers that make their own
determinations as to what to cover and determinations as to what to cover and how much to payhow much to pay
Source: Lecture, Dr. Robert Garrigues, Ph.D.
Today’s Health Care Today’s Health Care SystemSystem
Types of Managed CareTypes of Managed Care IPAIPA
Single Specialty, Multi-specialtySingle Specialty, Multi-specialty HMOHMO
Staff, Group, NetworkStaff, Group, Network PPOPPO POSPOS
Types of reimbursementTypes of reimbursement Discounted fee-for-serviceDiscounted fee-for-service CapitationCapitation
Source: Shortell, Stephen and Kaluzny, Arnold. Health Care Management: Organization Design and Behavior 4th Edition
Today’s Health Care SystemToday’s Health Care SystemInvestor Owned v. NFP Investor Owned v. NFP
HMOsHMOs Compared with not-for-profit HMOs,
investor-owned plans had lower rates for 14 HEDIS quality-of-care indicators.
If all women in the United States were covered in investor owned HMOs rather than non-profit plans, there would be an estimated 5925 additional deaths per year from breast cancer alone.
Epo and XigrisSource: Himmelstein, D. et al. Quality of Care in Investor-Owned vs. Not-for-Profit HMOs. JAMA. 7 / 14 / 99. Vol. 282 No. 2.
Today’s Health Care Today’s Health Care SystemSystem
Accounts for 15.5% of GDPAccounts for 15.5% of GDP Approximately $1.8 trillion Approximately $1.8 trillion $6,167 per capita (2004 projected amount)$6,167 per capita (2004 projected amount) Projected to reach 18.4% GDP, $3.3 trillion, Projected to reach 18.4% GDP, $3.3 trillion,
and $10,709 per capita in 2013and $10,709 per capita in 2013 Higher per capita expenditures than any Higher per capita expenditures than any
other countryother country Reason?Reason?
High technology, number of uninsured, multiple High technology, number of uninsured, multiple payers, medical liability, charity care, etc.payers, medical liability, charity care, etc.
Source: Centers for Medicare and Medicaid Services - http://www.cms.hhs.gov/statistics/nhe/projections-2003/ National Center for Health Statistics - http://www.cdc.gov/nchs/
StatisticsStatistics
Health Insurance Coverage of the Health Insurance Coverage of the U.S. Population, 2002U.S. Population, 2002
Uninsured17%
Other Private5%
Employer54%
Medicare12%
Medicaid/Other Public
13%
Total = 285 millionNote: Data do not total 100% due to rounding. SOURCE: Urban Institute and Kaiser Commission estimates based on March 2002 Current Population Survey.
Health Insurance Coverage of Health Insurance Coverage of Children and Nonelderly Adults, Children and Nonelderly Adults,
20022002
Uninsured12%
Medicaid23%
Other6%
Employer59%
Uninsured20%
Medicaid7%
Other8%Employer
65%
Total: 77.3 million Total: 173.6 million
SOURCE: Kaiser Commission on Medicaid and the Uninsured (KCMU) and Urban Institute analysis of the March 2003 Current Population Survey.
Children Adults under 65
Barriers to Health Care by Barriers to Health Care by Insurance Status, 2002Insurance Status, 2002
8%
15%
10%
18%
31%
47%
27%
41%
Contacted by CollectionAgency about Medical Bills
Had problem paying medicalbill
Needed Prescription but didnot get it
Postponed Seeking Care
Uninsured
Insured
Source: NPR/Kaiser Family Foundation/Kennedy School of Government
Health Care Survey, May, 2002.
Research demonstrates that the uninsured:Research demonstrates that the uninsured:
• Use fewer preventive and screening servicesUse fewer preventive and screening services
• Are sicker when diagnosedAre sicker when diagnosed
• Receive fewer therapeutic servicesReceive fewer therapeutic services
• Have poorer health outcomes (higher Have poorer health outcomes (higher mortality and disability rates) andmortality and disability rates) and
• Have lower annual earnings because of Have lower annual earnings because of poorer healthpoorer health
The Consequences of Being The Consequences of Being UninsuredUninsured
ChildrenUnder 19
21%
Adults55-648%
Adults35-5431%
Adults19-3440%
Characteristics of the Uninsured, Characteristics of the Uninsured, 20022002
300% FPLand Above
19%
200-299% FPL16%
100-199% FPL28%
<100% FPL36%
Income Work Status
Total = 43.3 million uninsured
Age
Note: Percentages may not total 100% due to rounding.SOURCE: KCMU and Urban Institute analysis of the March 2003 Current Population Survey.
1 Full-TimeWorker56%
No Workers19%
Part-TimeWorkers12%
2 or MoreFull-TimeWorkers
14%
The Nonelderly Uninsured by Race, The Nonelderly Uninsured by Race, 20022002
Two or More Races
1%
Asian5%
American Indian
1%
White48%
Hispanic29%
Black16%
Total = 43 Million
Distribution by Race/Ethnicity Risk of Being Uninsured
12%
14%
29%
20%
34%
22%
0% 20% 40%
Two or More
Am. Indian
Asian
Hispanic
Black
White
National Average17.3%
Note: Asian group includes Pacific Islanders; American Indian group includes Aleutian Eskimos.SOURCE: KCMU and Urban Institute analysis of the March 2003 Current Population Survey.
37%28%
38%
20%
15%
42%
68%86%
10% 10% 6%
18%17% 7%
7%13%
2%
66%
5% 8%
0%
25%
50%
75%
100%
U.S. Total Poor (<100%FPL)
Near Poor(100-199%
FPL)
Moderate(200-299%
FPL)
High (300%+FPL)
Health Insurance CoverageHealth Insurance Coverageby Poverty Level, 2002by Poverty Level, 2002
Employer
Medicaid
Uninsured
Notes: The federal poverty level was $14,348 for a family of three in 2002. Percentages may not total 100% due to rounding.SOURCE: Urban Institute and Kaiser Commission on Medicaid and the Uninsured, analysis of the 2003 Current Population Survey.
Other
285 million 52 million 54 million 51 million 128 million
Uninsured Rates Among the Nonelderly by State, 2001-2002
<13% Uninsured (19 states)
13 to <17% Uninsured (13 states & DC)
>17% Uninsured (18 states)
National Average = 17%
SOURCE: KCMU and Urban Institute analysis of the March Current Population Survey, 2002 and 2003, two-year pooled data.
Research StudiesResearch Studies
Research Studies- StatesResearch Studies- States
Missouri Foundation for HealthMissouri Foundation for Health Health care costs $29.4 billion annuallyHealth care costs $29.4 billion annually Switch to government- run program Switch to government- run program
could save $3 billion in administrative could save $3 billion in administrative costscosts
If state offered better benefits than 75% If state offered better benefits than 75% of Missourians now get through private of Missourians now get through private health insurance , state could save health insurance , state could save additional $1.3 billionadditional $1.3 billion
Research Studies-StatesResearch Studies-States 1992 Report of the State Health Care Access 1992 Report of the State Health Care Access
CommissionCommission Publicly financed and publicly administered Publicly financed and publicly administered
system would have saved Connecticut $2 billion in system would have saved Connecticut $2 billion in 19991999
Would cover entire population, cover all Would cover entire population, cover all necessary medical care, and provide dental necessary medical care, and provide dental coveragecoverage
Mainly done through cutting administration costs Mainly done through cutting administration costs and purchasing medicine in bulkand purchasing medicine in bulk
AMA of Massachusetts StudyAMA of Massachusetts Study Same Results as the Connecticut study, save as Same Results as the Connecticut study, save as
much as $2.7 billion in Massachusettsmuch as $2.7 billion in Massachusetts
Research Studies-Research Studies-NationalNational
New England Journal of Medicine- New England Journal of Medicine- Drs. Himmelstein and Woolhandler, Drs. Himmelstein and Woolhandler, Aug. 2003Aug. 2003 Compared spending on health care Compared spending on health care
administration in the U.S. and Canadaadministration in the U.S. and Canada U.S. spends $209 billion more than U.S. spends $209 billion more than
CanadaCanada Multiple insurers increase costs- 755 in Multiple insurers increase costs- 755 in
Seattle aloneSeattle alone
Research Studies-Research Studies-NationalNational
ABC News-Washington Post PollABC News-Washington Post Poll 8 out 10 respondents felt it was more important to 8 out 10 respondents felt it was more important to
provide coverage for all Americans, even if it means provide coverage for all Americans, even if it means higher taxeshigher taxes
53% of insured say they worry about losing insurance 53% of insured say they worry about losing insurance because of job lossbecause of job loss
Commonwealth Fund ReportCommonwealth Fund Report 32% of uninsured workers in 2001 employed by large 32% of uninsured workers in 2001 employed by large
companies as compared to 25% in 1987companies as compared to 25% in 1987 Center for Studying Health System Change Center for Studying Health System Change
ReportReport Uninsured people’s reliance on emergency care Uninsured people’s reliance on emergency care
indicates decreased access to other care, such as indicates decreased access to other care, such as physicians’ officesphysicians’ offices
Research Studies-Research Studies-NationalNational
Congressional Budget OfficeCongressional Budget Office Has repeatedly found a single payer, Has repeatedly found a single payer,
national health care system able to cover national health care system able to cover prescriptions, catastrophic care, and prescriptions, catastrophic care, and offer fair wages for less than current offer fair wages for less than current national spendingnational spending
PNHP Fact SheetPNHP Fact Sheet More than ½ of academic physicians More than ½ of academic physicians
endorse single payer systemsendorse single payer systems Most Americans favor some form of Most Americans favor some form of
national health insurancenational health insurance
Implementing a Implementing a Universal Health Universal Health
Care SystemCare System
Implementing a Implementing a Universal SystemUniversal System
Incremental ApproachIncremental Approach Expansion of the existing public/private,
pluralistic healthcare framework of Medicare, Medicaid, SCHIP (State Children’s Health Insurance Program), HMO’s (Health Maintenance Organizations), PPO’s (Preferred Provider Organizations), and POS’s (Point of Service Plans)
Single-Payer ApproachSingle-Payer Approach Fundamental restructuring of the
national/statewide healthcare system to wholly government-financed, universal, public health insurance
How do we pay for it?How do we pay for it?
A new study by Harvard Medical A new study by Harvard Medical School and Public Citizen School and Public Citizen National health insurance could save at National health insurance could save at
least $286 billion annually on paperwork.least $286 billion annually on paperwork. Funding will come from Funding will come from
Existing government health care Existing government health care spending (more than $1 trillion) spending (more than $1 trillion)
A phased-in tax on employers of 7.7% A phased-in tax on employers of 7.7% (almost $1 trillion)(almost $1 trillion)
General Accounting General Accounting OfficeOffice
The GAO has said: "If the US were to The GAO has said: "If the US were to shift to a system of universal shift to a system of universal coverage and a single payer, as in coverage and a single payer, as in Canada, the savings in Canada, the savings in administrative costs (10% to private administrative costs (10% to private insurers) would be more than insurers) would be more than enough to offset the expense of enough to offset the expense of universal coverage."universal coverage."
But, think about it for a But, think about it for a secondsecond
Employers who provide coverage are Employers who provide coverage are already paying 8.5%, on average. That already paying 8.5%, on average. That would raise about $920 billion.would raise about $920 billion.
In addition to that, there's already over a In addition to that, there's already over a trillion dollars being spent a year in trillion dollars being spent a year in local, state and federal dollars for health local, state and federal dollars for health care.care.
The American people are already paying The American people are already paying for universal health care; they're just not for universal health care; they're just not getting it.getting it.
Health Care Health Care System Around System Around
the Worldthe World
Health Care System Around Health Care System Around the Worldthe World
Universal healthcare action network - http://www.uhcan.org
Health Care System in UKHealth Care System in UKNHSNHS
Set up on 5Set up on 5thth July 1948 July 1948 Largest organisation in Largest organisation in
EuropeEurope One of the best health One of the best health
services in the world as per services in the world as per WHOWHO
Free appointment with GPFree appointment with GP NHS FundingNHS Funding
Mandatory salary contrib.Mandatory salary contrib. 7% of GDP7% of GDP
NHS StaffNHS StaffNHS in England - http://www.nhs.uk/england/
Health Care System in Health Care System in GermanyGermany
Self governance, decentralization, Self governance, decentralization, solidaritysolidarity
Independent of governmentIndependent of government Sickness fund – multiple non profit Sickness fund – multiple non profit
insurersinsurers 90% of population covered90% of population covered Free appointments with GPFree appointments with GP Low waiting listLow waiting list
Health Care System in Health Care System in JapanJapan
Similar to GermanSimilar to German Primary health care/Tertiary health carePrimary health care/Tertiary health care Multiple insurersMultiple insurers Mandatory enrollmentMandatory enrollment
Residence/employmentResidence/employment Premiums proportional to incomePremiums proportional to income Low risks/high income Low risks/high income low premiumslow premiums
7.3% of GDP – half of that in America7.3% of GDP – half of that in America Social factorsSocial factors
Less violenceLess violence Less drugsLess drugs Life expectancy/infant mortality rate higher than in Life expectancy/infant mortality rate higher than in
AmericaAmerica
Health Care System in Health Care System in CanadaCanada
Setup in 1947Setup in 1947 Mandatory insuranceMandatory insurance Free GP – any number of opinionsFree GP – any number of opinions FundingFunding
Graduated progressive income tax Graduated progressive income tax Sales tax/payroll taxesSales tax/payroll taxes Provincial health insurance Provincial health insurance
Federal govt. Federal govt. block grants to provincesblock grants to provinces Territorial health insurance Territorial health insurance
ConclusionConclusion
“…“…the Cubs will play the Red Sox in the the Cubs will play the Red Sox in the World Series long before this problem World Series long before this problem (uninsured Americans) is solved”- Neil (uninsured Americans) is solved”- Neil McLaughlin, Modern HealthcareMcLaughlin, Modern Healthcare
Perhaps the future is not quite that grimPerhaps the future is not quite that grim ““Their system was virtually identical to Their system was virtually identical to
ours.”- Dr. Steffie Woolhandler referring ours.”- Dr. Steffie Woolhandler referring to Canada’s system in place before to Canada’s system in place before national health insurancenational health insurance
SummarySummary
Today’s Health Care SystemToday’s Health Care System Health Care Statistics Health Care Statistics Research studiesResearch studies Implementing a Universal SystemImplementing a Universal System Health Care System Around the Health Care System Around the
WorldWorld