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