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These are slides for a talk I gave at Apollo College of Nursing on 11.4.08 - Election Day. The topic of the two hour presentation was Health Care reform, the Archimedes movement, and leadership in health care. The slides are heavily modified from a basic version that many speakers from the Archimedes Movement use. This was my second talk at Apollo college. Thank you so much Jessica for inviting me, and to all you nursing students for listening so intently.cheersIsaac
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The Archimedes Movement
Isaac Holeman www.WeCanDoBetter.org [email protected]
We Can Do BetterA Project of the Archimedes Movement
www.WeCanDoBetter.org
Why are we here?
How did we get here? What do we really want? How do we get there?
Get ready for a demographic tidal wave
How did we get here? What do we really want? How do we get there?
The KEY to understanding the health care debate
• Financing– How we pay for care
• Delivery – What we are buying– How care is organized and
delivered– Return on investment in terms
of health
How did we get here? What do we really want? How do we get there?
Problems with our delivery system
• Archaic structure• We have failed to evolve to
meet changing demands• Political gridlock
How did we get here? What do we really want? How do we get there?
Infectious disease model not designed to treat chronic
disease
How did we get here? What do we really want? How do we get there?
Infectious disease model not designed to treat chronic
disease
How did we get here? What do we really want? How do we get there?
Infectious disease model not designed to treat chronic
disease
How did we get here? What do we really want? How do we get there?
Infectious disease model not designed to treat chronic
disease
How did we get here? What do we really want? How do we get there?
Chronic disease = dying
How did we get here? What do we really want? How do we get there?
Back when our health system was being created
Evolution of the System
• Conditions that were once fatal have become chronic
• Solo or small practice group practices working independently
• Lack of data
How did we get here? What do we really want? How do we get there?
Three outdated structures in our delivery system
• 1954 Preferential tax treatment to employer sponsored coverage
• 1965 Enactment of Medicare
• 1965 Enactment of Medicaid
How did we get here? What do we really want? How do we get there?
Employer Sponsored Coverage: an accident in
history
•Labor shortage WWII
•Wage and price controls
•Companies sought to offer a “non-monetary” benefit
How did we get here? What do we really want? How do we get there?
Employer Sponsored Coverage: bad for a mobile
economy
• Public subsidy >$200B per year
• Paid by all taxpayers, including those without coverage
How did we get here? What do we really want? How do we get there?
Medicare: hasn’t adjusted for demographic boom
•Elderly used to be poorest segment of society
•Financed by taxes on those who are working
•Does not cover long-term care services for an aging population
How did we get here? What do we really want? How do we get there?
Medicaid: categorical eligibility was a bad idea
• To improve financial access for certain categories of the poor
• Poor children
• Blind and disabled
• Elderly needing long term care
• Pregnant women
How did we get here? What do we really want? How do we get there?
MedicaidMedicare
Employment-based coverage
PrivatePublic50 millionAmerican
s
(You, your friends)
Coverage Gap
How did we get here? What do we really want? How do we get there?
ER
ChangeEligibility
Drop Coverag
e
Public Private
Cost Shift(shifting accountability)
How did we get here? What do we really want? How do we get there?
You, your friends
The Current Debate: we are barking up the wrong tree
• It’s not a financing problem
• Why do we ask how to give the uninsured access to the INFECTIOUS DISEASE FOCUSED system?
How did we get here? What do we really want? How do we get there?
Buying more hover crafts won’t help them drive on the freeway
How did we get here? What do we really want? How do we get there?
What can we do about it?
How did we get here? What do we really want? How do we get there?
The Greatest Generation
• Higher Education• Interstate Highway System• Transmission Grid• Went to the Moon (and back!)• Cured polio, eradicated
smallpox
How did we get here? What do we really want? How do we get there?
Agreeing on a Shared Vision
What is the purpose of our health care system?
How did we get here? What do we really want? How do we get there?
Agreeing on a Shared Vision
Without first agreeing on where we want to end up, there is no political pathway by which to get there.
How did we get here? What do we really want? How do we get there?
Institute for Healthcare Improvement:
Triple Aim
• Improve population health• Reduce per capita cost• Improve the patient experience• Outcomes• Safety• Satisfaction
How did we get here? What do we really want? How do we get there?
Chronic Care
How did we get here? What do we really want? How do we get there?
People with Chronic Conditions:Percent of Health Care Spending
1% of population 35%
5% of population 50%
10% of population 70%
George Halvorson, Health Reform Now
How did we get here? What do we really want? How do we get there?
Managing Chronic Disease
It requires:
– Early intervention
– Coordinated care teams
– Educated patients
– Rapid response
– Doing the right thing at the right time
George Halvorson, Health Reform Now
How did we get here? What do we really want? How do we get there?
In order to focus on the delivery system, we need…
Purpose of public health care $
• We all pay, we should all benefit
• Focus on health, not just billable health services
How did we get here? What do we really want? How do we get there?
• Focus on Public Resources• Maximize the Benefit• Categorical Eligibility• Public Education as a Model
Finding Solutions
How did we get here? What do we really want? How do we get there?
• Health professionals• Hospitals and other providers • Uninsured• Workers with good employer-sponsored
coverage• Seniors on Medicare• Those with disabilities and other special
needs• Employers• Insurers and health plans• Pharmaceutical manufacturers• Medical device manufacturers• Others…
How did we get here? What do we really want? How do we get there?
Economic Stakeholders
Politics & Economics
• 1:11 jobs in U.S. is in the health care sector
• 1:7 dollars in our economy is related to health care
• 16% of Americans have no health insurance
• 84% do have health insurance
How did we get here? What do we really want? How do we get there?
Barack Obama
• Expand public and private insurance
• Reduce premiums with small biz tax credit
• Fed subsidized insurance
How did we get here? What do we really want? How do we get there?
Barack Obama: expected results
• Long term increase premiums for young and healthy
• Reduce premiums for older sicker
• (near) Universal access to infectious disease model of care
How did we get here? What do we really want? How do we get there?
John McCain
• Increase private insurance only
• Tax credit instead of exempting employer coverage
• Save money by deregulating state insurance laws
• Guaranteed access pool (state level)
How did we get here? What do we really want? How do we get there?
John McCain: expected results
• Lower premiums for healthier
• Higher for older and sicker people
How did we get here? What do we really want? How do we get there?
John McCain
“Opening up the health insurance market to more vigorous nationwide competition, as we have done over the last decade in banking, would provide more choices of innovative products less burdened by the worst excesses of state-based regulation.”
John McCain, September 2008
How did we get here? What do we really want? How do we get there?
John McCain & Barack Obama
• Health coordination & disease management in medicare
• Health IT - medical records
• Don’t explain how to pay for it
• Cost containment an afterthought
• Not talking about Medicare
How did we get here? What do we really want? How do we get there?
John McCain & Barack Obama• What’s missing? A lot!
• It’s being defined as an insurance problem
• The real problem is finding a shared vision, changing our delivery system
• Find an accurate diagnosis of problem - financing and access are not biggest part
How did we get here? What do we really want? How do we get there?
How did we get here? What do we really want? How do we get there?
The questions need to be
What do we want the system to achieve?
What role should I play?
How did we get here? What do we really want? How do we get there?
Leadership Starts With Us
• What can you teach your friends, family, patients?
• Local dialogue vs national leadership
• Join our email list
• Attend a chapter meeting
• Join the movement
How did we get here? What do we really want? How do we get there?
“Thus a legitimate and necessary role for the nurse is to work to change the larger structure and process of society in ways that will promote the individual’s health and well-being”
-- Stuart & Laraia, Principles of Psychiatric Nursing
A role for nurses?
1.Financing and delivery are separate
2.We have an infectious disease system,
need a chronic disease system
3.Must agree on a vision - triple aim?
4.Leadership starts with you
Take Home Messages
Isaac Holeman www.WeCanDoBetter.org [email protected]
“The realization that our illogical, mistaken health care system can’t go on forever has dawned, and so it will end. The question now is what replaces it.”
-- Ezra Klein, Los Angeles Times, Dec. 26, 2006
Thank You!
The Archimedes Movement
Isaac Holeman www.WeCanDoBetter.org [email protected]
