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- 1. The Case for Universal Healthcare Kao-Ping Chua Jack Rutledge Fellow, 2005-2006 American Medical Student Association
- 2. What is Universal Health Care?
- 3. What is Universal Health Care? “No American should lack access to health care because he or she lacks the ability to pay for it when needed, and no American should suffer serious financial distress or personal bankruptcy as a result of unpaid medical bills.” Uwe Reinhardt, Princeton health economist
- 4. Countries with Universal Health Care … (South Africa) Industrialized countries without universal health care? only one …
- 6. The moral argument for UHC
- 7. The Central Moral Question Is it wrong to deny people healthcare based on the ability to pay?
- 8. Increases in Health Insurance Premiums Compared to Other Indicators, 1999-2004 16% 14% 12% 10% 8% 5 TIMES! 6% 4% 2% 0% 1998 1999 2000 2001 Health Insurance Premiums 2002 Inflation 2003 2004 2005 Average Weekly Earnings Source: KFF/HRET Survey of Employer-Sponsored Health Benefits: 1999 – 2004
- 10. Annual deaths by cause, age 25-64 Homicide 19700 HIV/AIDS 14100 Stroke 19000 Diabetes 17500 Uninsurance 18000 0 5000 10000 15000 20000 25000
- 11. The uninsured receive poor medical care Inability to fill prescription Lack of regular healthcare provider or institution Poor care of chronic disease The “unhappy triad” of uninsurance – Receive less preventive care – Diagnosed at more advanced disease stages – Once diagnosed, receive less therapeutic care
- 13. Real-life examples Statistics don’t tell the full story
- 14. Uninsured child
- 15. Uninsurance can affect ANYONE Hi, My name is ______, and I am extremely interested in participating in whatever small way I can to effect Healthcare Reform in Indiana. My husband is a [very sick patient], and we were informed last Wednesday that Anthem Blue Cross of Indiana is going to terminate his employer's group insurance coverage…[unfortunately], he cannot qualify for individual coverage due to his health. So we are between a rock and a hard place and I am being forced to close my daycare business which I have ran for 23 years in order to try to find a job with benefits so we can have insurance. My husband is also looking for a new job in the middle of this health crisis so he too can try to get insurance so we can try to hang on to the home where we raised our children. It is a living nightmare that I know is shared by millions of other Hoosiers. Please let me know what I can do to help with this initiative.
- 16. The Central Moral Question Is it wrong to deny people healthcare based on the ability to pay?
- 17. The economic argument for UHC
- 18. The central economic question Will we save money by achieving universal health care?
- 19. A 3 part question How much would it cost to cover everyone? How much does it cost to NOT cover everyone? Do the costs of UHC outweigh the benefits?
- 20. How much would it cost to cover everyone? The cost of universal healthcare to the government Additional healthcare that would be used by uninsured if they had insurance $34-69 billion per year Covering out-ofpocket costs for the uninsured Depends on generosity of benefits Reimbursing providers for uncompensated care Depends on generosity of benefits
- 21. How much would it cost to cover everyone? (Reinhardt, 2003) Assume $100 billion cost to government in the first year of a UHC program Assume increase of per capita health spending by 10%/year Total cost: $1.6 trillion over 10 years, or about $160 billion per year
- 22. Questions to ask How much would it cost to cover everyone? How much does it cost to NOT cover everyone? Do the costs of UHC outweigh the benefits?
- 23. How much does it cost NOT to cover everyone? IOM: $65-$130 billion in lost productivity per year
- 24. How much does it cost NOT to cover everyone? “Job lock” (3.8 million jobs) Less preventive/chronic disease care costly High rate of medical bankruptcy Unnecessary use of the ER
- 25. How much does it cost NOT to cover everyone? Costs of keeping current employer-based system: – Loss of global competitiveness – Strain on businesses
- 26. Questions to ask How much would it cost to cover everyone? How much does it cost to NOT cover everyone? Do the costs of UHC outweigh the benefits?
- 27. Do the costs of UHC outweigh the benefits? Lost productivity Loss of entrepreneurship $160 billion per year Less preventive care Unnecessary use of ER Less global competitiveness* Strain on business*
- 28. UHC coupled with cost controls would save money Scenario 1: employer mandate Scenario 2: expansion of public insurance programs Scenario 3: creation of new programs for the uninsured Scenario 4: single-payer system
- 29. "The issue of universal coverage is not a matter of economics. Little more than 1% of GDP assigned to health could cover all. It is a matter of soul." - Uwe Reinhardt
- 30. The cultural argument for UHC
- 31. The central cultural question Is universal health care consistent with American values?
- 32. What does the American Dream mean to you? (The Feldman Group, 2005)
- 33. What are the main threats to the American Dream? (The Feldman Group, 2005)
- 34. UHC and American values Do we believe in: Equality and equal opportunity?
- 35. UHC and American values Do we believe in: Life, liberty, and the pursuit of happiness?
- 36. UHC and American values Do we believe in: Getting good value for our money?
- 37. US Spending on Health Care, 2002 U. K. Japan France Total health care costs comprise 14% of GDP! Canada Germany Switzerland $1.7 trillion U. S. $- $1,000 $ Per Capita $2,000 Public $3,000 Private Source: OECD Health Data 2002, Health Affairs 2002 21:88-99 $4,000 $5,000
- 38. Best Health Care in the world? (WHO Rankings 2000) 1. France 2. Italy 3. San Marino 4. Andorra 5. Malta 6. Singapore 7. Spain 8. Oman 9. Austria 10. Japan 11. Norway 12. Portugal 13. Monaco 14. Greece 15. Iceland 16. Luxembourg 17. Netherlands 18. United Kingdom 19. Ireland 20. Switzerland 21. Belgium 22. Colombia 23. Sweden 24. Cyprus 25. Germany 26. Saudi Arabia 27. United Arab Emirates 28. Israel 29. Morocco 30. Canada 31. Finland 32. Australia 33. Chile 34. Denmark 35. Dominica 36. Costa Rica 37. United States of America 38. Slovenia 39. Cuba 40. Brunei Darussalam Source: World Health Organization, Health Systems: Improving Performance, 2000
- 39. Infant Mortality, 2000 Deaths/100,000 Births 8 7 6 5 4 3 2 1 0 U. S. Canada Source: OECD, 2003 Australia France Italy Germany Sweden
- 40. Life Expectancy, 2000 80 79.5 79 Year s 78.5 78 77.5 77 76.5 76 75.5 75 U. S. Germany Source: OECD Health Data 2003 U.K. France Italy Canada Sweden
- 41. The 3 Big Questions Is it wrong to deny people healthcare based on the ability to pay? Will we save money by achieving universal health care? Is universal health care consistent with American values?
- 42. Benefits for providers UHC will… Allow you to more successfully treat patients Allow you to be your patient’s doctor, not their financial counselor/social worker. Allow you to base your decisions on medical care on best practices, not on your patient’s ability to pay
- 43. How can you get involved? Educate yourself and question your assumptions: http://www.amsa.org/uhc Get involved in a state or national campaign: http://www.amsa.org/uhc JOIN AMSA!
- 44. Parting thoughts “The Americans will always do the right thing…after they’ve exhausted all the alternatives.” - Winston Churchill
Notas del editor
- Today, we’re going to talk about the case for universal health care. The purpose of this presentation is to raise awareness and generate support for the idea of universal health care. This talk is not going to advocate for any specific way of achieving universal health care – the point is just to objectively present the facts about the problem in our health care system so you can decide for yourself how you feel.
- To start off, let’s define the term universal health care. This is a term that’s thrown around a lot by politicians, the lay media, and the advocacy world. But the term means different things to different people. To some people, universal health care implies a nationally coordinated public insurance system. To others, it means having some sort of basic level of health care access – some people argue we already have universal health care because technically, no one can be denied medical screening and stabilization in the ER by law.
- The definition of universal health care used in this presentation is a little bit different. It comes from Uwe Reinhardt, a world-famous Princeton health economist. He defines universal health care as a system in which “No American should lack access to health care because he or she lacks the ability to pay for it when needed, and no American should suffer serious financial distress or personal bankruptcy as a result of unpaid medical bills.” In other words, universal health care refers to a society in which there are minimal financial barriers to health care and in which you don’t go bankrupt once you do access the health care system.
- By that definition, the United States is the only industrialized country in the entire world that does not have universal health care. Every other country has decided that universal health care is not just morally correct, but economically feasible as well.
- So with that background, here’s the outline for this talk. There are three major arguments for universal health care: a moral argument, an economic argument, and a cultural, values-based argument.
- Let’s start with the moral argument for universal health care.
- The moral argument for universal health care boils down to one central question: is it wrong to deny people health care based on the ability to pay? Can you treat health care like a commodity or a privilege like a VCR, or should you treat health care as a basic need? In this country, we have decided to treat health care as a privilege. Let’s examine the consequences of this for Americans.
- This is arguably the most important slide in the entire presentation. From 1999-2004, health care premiums rose about 10% per year, which is 5 times the rate of inflation. Inflation, you can see, went up about 2-3% per year, and average weekly earnings for workers increased by a comparable amount. When health care premiums outpace growths in earnings, that means that Americans are taking home less and less salary – employers aren’t increasing wages because they have to pay for increasing health care premiums.
- Because health care costs are spiraling out of control, more and more people are unable to afford health insurance. In 2003, there were 45 million underinsured people, and there were at least that many people who are underinsured (they have insurance but wouldn’t be protected from catastrophic medical costs). These aren’t lazy people – 8 out of 10 uninsured individuals work or come from working families. The uninsured aren’t just poor people either – a growing sector of the middle class is losing insurance as more and more employers drop benefits. In fact, from 2000 to 2005, the percentage of employers who offered insurance dropped almost 10 percentage points.
- So why is it a problem if you’re uninsured? According to the Institute of Medicine, the uninsured have about a 15% excess mortality rate each year compared to the insured, even after you control for things like socioeconomic class, race, etc. Among people from age 25-64, this translates into 18,000 premature deaths each year because of uninsurance, which is of a comparable magnitude to homicide, HIV/AIDS, stroke, and diabetes. Now, we don’t HEAR about these deaths in the media, because the deaths are subtle, quiet, and not as obvious as, say, a homicide. But clearly, uninsurance is a significant cause of death.
- Why are the uninsured dying prematurely? This isn’t rocket science. When you’re uninsured, you’re less likely to be able to fill a prescription. An average statin drug like Lipitor costs about $95/month or more than $1,000/year, which is a lot of money regardless of what your income is. The uninsured are less likely to have a regular health care provider or institution and more likely to use the ER for care. Most people don’t know what an average doctor’s visit costs because they’re only responsible for the co-payment, but it costs a significant amount of money if you’re paying the full cost out-of-pocket. Also, many physicians and health care facilities refuse to see uninsured patients for financial reasons and because of bias. The uninsured receive poor care of chronic disease – diabetics are less likely to get the proper eye and foot care they need when they’re uninsured, resulting in debilitating and sometimes life-threatening complications. And finally, there’s the “unhappy triad” of uninsurance. Basically, if you’re uninsured, you’re less likely to get preventive care – you don’t get Pap smears, mammograms, colonoscopies, etc. Because you don’t get this preventive care, you are diagnosed at a more advance disease stage. And once you’re diagnosed, you receive less therapeutic care because you can’t afford it.
- This slide really sums up what was just said. In this study, the authors calculated how much more likely an uninsured person would be diagnosed with late stage cancer relative to an insured person. As you can see, the uninsured were 1.7 times more likely to be diagnosed with late-stage colorectal cancer; 2.6 more melanoma; 1.4 for breast cancer; and 1.5 for prostate cancer. They were also 1.7 more likely to die of colorectal cancer as well relative to the insured. Now,
- Now, all of these statistics are sobering, but statistics never tell the full story. They don’t capture the human dimension of this problem, so to illustrate, here are two real-life examples.
- This is a picture of a child who had a repair of a cleft palate and wasn’t able to afford the dental, orthodontic, and medical care that he needed after the operation because he was uninsured. Unfortunately, the results are that his jaw and teeth developed abnormally, which will have serious consequences for him for the rest of his life.
- To illustrate the point that uninsurance can affect anyone, here’s an e-mail that AMSA received from a woman in Indiana. [Read the text]. This is not an isolated anecdote. This story is a variation on the stories of millions and millions of Americans – regular people who work hard, play by the rules, and still get punished by our system. The uninsured are no longer strangers to most people: they are our neighbors, our friends, and increasingly, our family members.
- And so we return to this central question of whether it’s wrong to deny people health care based on the ability to pay. Is it wrong that the child with cleft palate will have dental problems for the rest of his life? Is wrong that the woman had to close her daycare just so she could get health insurance for her sick husband? Most people would say that this absolutely is wrong.
- Now, let’s turn to the economic argument for universal health care, which is important. Clearly, there are many things that are morally wrong in our society, but if the solution is economically unfeasible, then the issue is really a political non-starter.
- The central economic question here is simply: will we save money by achieving universal health care?
- The answer to this question comes in three major parts. First, how much it would cost to cover everyone? Second, how much does it cost to NOT cover everyone? And finally, do the costs of universal health care outweigh the benefits?
- Let’s start with the cost of universal health care. There are four major components of the cost of universal health care. There’s the additional health care that would be used by the uninsured if they had insurance, which is estimated to be about $34-$69 billion per year, depending on whether benefits are as generous as Medicaid or private insurance. There’s covering the out-of-pocket costs for the uninsured. Right now, the uninsured pay a high percentage of their costs out-of-pocket, and presumably a universal health care system would help defray some of these out-of-pocket costs. Also, there’s reimbursing providers to uncompensated care. Right now, physicians spend anywhere from $6-8 billion per year in uncompensated care to the uninsured, which includes free care, charity care, etc.
- One reasonable estimate for the cost of UHC comes from the Princeton health economist Uwe Reinhardt, who was quoted before. He estimated that UHC might cost $100 billion in the first year. If you assume an increase in health spending of 10%/year, you end up with about $1.6 trillion over 10 years, or $160 billion per year. That’s not a small amount of money, of course. [Reinhardt, U. “Is there hoped for the uninsured?”, Health Affairs, 2003].
- The second question to answer is how much does it cost to not cover everyone. If UHC were just about spending money, obviously there wouldn’t be much of an economic argument for it. However, in reality, there are many costs that our society incurs right now because we don’t have UHC.
- The most obvious cost is loss of productivity. According to the Institute of Medicine, because the uninsured live shorter lives due to poorer health, they are able to contribute to the workforce for fewer years. The loss in productivity costs society $65-$130 billion each year!
- There are also a number of other costs associated with not moving towards a system of universal health care. There’s “job lock”, which refers to the idea that people stay with their jobs for the health insurance instead of starting their own business, which stimulates the economy because small business is where a lot of innovation occurs. Estimates vary, but as many as 3.8 million people would be self-employed if there were universal health care. Obviously, when you have less preventive and chronic disease care, you end up with advanced diseases and complications that are expensive to treat. There’s also a high rate of medical bankruptcy in our country. Experts estimate that 45% of all bankruptcies are related to medical causes – what’s more, about 2/3 of the people who declared bankruptcy for medical causes were insured. This is a cost obviously not just to individuals but also to society as well. Finally, there’s unnecessary use of the ER. Because the uninsured often cannot access basic primary care, they use the ER for conditions that could easily be treated in an outpatient setting. The problem with this is that it clogs up ERs and ends up being very costly, because the ER is one of the most expensive places to get treatment.
- Finally, there are a special subset of costs that are associated with our current employer-based system. First, American businesses are becoming less and less globally competitive because they have to shoulder the burden of health care and build skyrocketing health care costs into the prices of their products. The CEO of GM claims that $1,500 of the price of every GM car comes from health care costs, which is 2-3 times more than what Japanese and German automakers pay. As a result, GM starts off with a significant price disadvantage to other foreign automakers that don’t have to bear the full brunt of health care costs because there is government-assured health insurance. This represents a very significant cost to the American economy. The other cost of keeping the current employer-based system in place is related to the first: strain on businesses. American companies across the board are staggering under the weight of health care costs, contributing to decreased profitability. The CEO of Starbucks recently said that his company spends more on health care than on coffee! Now, it’s important to emphasize that these are costs that would only be saved if we dismantled the employer-based system. Not every way of achieving universal health care would do this, but comprehensive reforms such as single payer would.
- So, we’ve talked about the cost of covering everyone and the cost of not covering everyone. Now let’s talk about whether the costs of UHC outweigh the benefits.
- And again, this sums up what we’ve said so far.
- Now a very important thing to understand here is that if universal health care simply expanded health care access, that would be a very expensive proposition. However, if you can couple universal health care with other significant cost controls, such as administrative simplification, error reduction, reduction of inappropriate usage of technology, etc., it is definitely possible to expand access to everyone and save money. In support of this notion, consider this recent 2005 study from the very non-partisan National Coalition for Health Care, which is made up of ideologically diverse entities such as business groups, labor unions, faith groups, and advocacy groups. This report assumed four different scenarios for achieving health care for all: an employer mandate (requiring employers to pay a certain percentage of health care costs for employees), expanding public insurance programs like Medicaid, creating a new program for the uninsured based on the federal employee health benefit program (the insurance that federal employees get), and a single-payer system like Medicare or what Canada has. Under all four of these scenarios, Thorpe found that the government would save hundreds of billions of dollars over 10 years. In particular, the first three scenarios saved at least $300 billion, whereas the single payer system saved $1.1 trillion because of administrative simplification.
- So that’s the economic argument for universal health care: UHC coupled with cost controls, will save money. In the end, regardless of whether you subscribe to this argument, consider the following quote from Reinhardt: “The issue of universal coverage is not a matter of economics. Little more than 1% of GDP assigned to health could cover all. It is a matter of soul.” In other words, even if you believed that UHC wouldn’t save any money and would cost $160 billion per year, that’s still not very much money in the grand scheme of America’s economy. In the end, we are the wealthiest nation in the world, and we absolutely could afford universal health care if we chose to do it.
- Let’s end with the cultural argument for universal health care.
- The cultural argument focuses on one central question: Is universal health care consistent with American values? Of course, the answer to this question depends on what you believe American values are. That’s obviously a complicated question, but it’s definitely possible to make some generalizations.
- Recently, the Feldman group in Washington DC released a survey that aimed to get at the problem of defining American values. They asked a representative sample of 1000 people who voted in the 2004 presidential elections a series of questions. One of them was, “What does the American Dream mean to you?” Respondents were read a series of statements and asked to rate them on a scale of 0 to 100, with 100 meaning that the statement reflected the respondent’s view of the American dream. In this survey, the top three rated responses were “having a close family”, “having freedom to make your own decisions about your life”, and “being able to provide for yourself and your family.”
- Now in a follow-up question, respondents were asked: what are the main threats to the American dream? Far and away, the highest rated response was “health insurance that is too expensive.” This was rated above the cost of college, concerns about public schools, and a loss of security in retirement. Now how can the cost of health insurance be a deterrent to the American dream? It’s not hard to figure out if you think about it. The highest-rated statement about the American dream was “having a close family.” High health care costs, the threat of uninsurance, and poor health because people can’t afford health care can obviously be significant family strains. The second-highest rated statement about the American dream was “having freedom to make your own decisions about your life.” When you’re bankrupt or suffering from huge medical debts, you obviously don’t have the freedom to determine how your life goes. Finally, the third-highest rated statement about the American dream was “being able to provide for yourself and your family.” Again, with skyrocketing health care costs, and with decreasing wages because employers have to pay higher premiums, it becomes a lot harder to afford health care. You can argue with the legitimacy of surveys all you want, but this is certainly not the only piece of evidence that suggests that people are really, really worried about health care in this country.
- Now, there are a number of other American values that are consistent with universal health care. First, we purport to believe in equality and equal opportunity – everyone should get a fair chance to make it in society. The problem is that health is distributed unequally according to genetics and environment, and if we were really serious about having a society of equality and equal opportunity, we would distribute health care equally to all people. We all know there are people who are born with genetic diseases or a familial predispositions towards diabetes, heart attacks, and other diseases – if we truly believed in equal opportunity, we would could everyone the health care they need to overcome these unavoidable problems. We would not punish these people for their genes by burdening them with high health care costs.
- Similarly, our Declaration of Independence holds it to be “self-evident” that every person has a fundamental right to life, liberty, and the pursuit of happiness. If we really believe in a right to life, then how can we deny lifesaving medications and treatments to people based on their ability to pay? If we believe in a right to the pursuit of happiness, how can we shackle millions of Americans with poor health and health care costs that are denying them the financial flexibility to pursue their dreams?
- And finally, we are a country that supposedly likes getting good value for our money. We value economic efficiency and hate waste. So the question becomes: are we getting good value for our money in health care?
- We know that the U.S. certainly spends the most money on health care in the world, both in absolute dollars and on a per capita basis. In 2002, we spent $1.7 trillion on health care, or about 1/7th of our GDP.
- What has that money gotten us? Well, for one thing, it got us a really crappy ranking according to the World Health Organization in 2000. Now, ranking health care systems is obviously controversial and difficult, but even if you look at the most important of the WHO’s criteria – level of health attainment - the U.S. comes in a mere 24th. This would suggest that we in fact do not necessarily have the best health care system in the world, despite the fact that we have the most expensive health care system in the world.
- Part of the reason we’re ranked so low is because our infant mortality rate is abysmal. Even after you control for differences in measuring infant mortality, we have a much higher infant mortality rate than most other industrialized countries.
- And similarly, our life expectancy lags behind that of other countries as well. Now, infant mortality and life expectancy aren’t solely a function of the health care system, but it doesn’t take a genius to figure out that part of the reason we do so poorly on these statistics is that 1 out of 7 Americans can’t access basic health care. Once you take these people out of the measurements, the U.S. does better on infant mortality and life expectancy, but it’s still not great. Again we live in the wealthiest country in the world, and we have the most expensive health care system in the world. Shouldn’t we be doing better? We certainly could be doing better, if the money we spent were used more efficiently.
- To summarize, here are the three big questions at the root of the issue of universal health care. First, is it wrong to deny people health care based on the ability to pay? Second, will we save money by achieving universal health care? Third, is universal health care consistent with American values? If you can say “yes” to any of these, it’s definitely worth researching this topic more to see whether you can support universal health care. If you can say ”no” to all three of these, then consider one more argument: an argument specifically for providers.
- Basically, a universal health care system will dramatically improve the quality of practice for providers. It will allow you to more successfully treat patients: your patients will be able to afford the tests and medications you prescribe, improving compliance and health outcomes. It will also allow you to be your patient’s doctor, not their financial counselor or social worker. So much of a doctor’s time these days are spent figuring out how to help a patient afford their prescriptions and tests. Finally, universal health care will allow you to base your decisions on medical care on best practices, not on your patient’s ability to pay. Instead of the cheapest care, you will be able to provide the best care.
- If you’re interested in becoming involved with issue, there are a number of things you can do. First, educate yourself and question your assumptions. This is an extraordinarily complicated issue, and the learning curve is pretty steep. AMSA has compiled a series of user-friendly primers and overviews to help you navigate through the complex maze of our health care system. The URL is www.amsa.org/uhc. Second, get involved in a state or national campaign. Right now, most of the action is at the level of the states, as the federal government is doing very little to address the health care system. Again, you can go to AMSA’s website to find out what’s happening in your state. Finally, join AMSA if you’re not already a member. As a member, you’ll have the opportunity to participate in our UHC leadership trainings, our study tours, our conventions, and other events that will expand your awareness of this issue.
- We’ll conclude this talk with a semi-cynical quote from Winston Churchill. He wrote that “The Americans will always do the right thing…after they’ve exhausted all the alternatives.” In many ways, this is true of our health care system. With millions of people losing insurance every year, and with high health care costs ruining lots of lives, the public is not going to tolerate the current situation for much longer. While there might be a couple of detours on the way, America will ultimately end up doing the right thing and achieving some form of universal health care.