Introduction: We Need Reform; It’s Up To Us! Health Care Costs Lack of Insurance We Have to Cover Everyone to Control Costs! Politics of Reform Obstacles to Reform Reform Proposals: What’s On the Table Single Payer: Keep Fighting Keep Fighting: For Affordability, Abortion, Access

1. The Truth About Health Reform: It’s Up To Us Ellen R. Shaffer PhD MPH Joe Brenner MA EQUAL/Center for Policy Analysis www.centerforpolicyanalysis.org 415-922-6204 [email_address] February, 2010 February, 2010 EQUAL/ Center for Policy Analysis

5. Many are Misinformed Many are Uninformed February, 2010 EQUAL/ Center for Policy Analysis

8. What Is EQUAL? February, 2010 EQUAL/ Center for Policy Analysis

11. The Truth About Health Reform Executive Summary February, 2010 EQUAL/ Center for Policy Analysis

15. Losing Primary Care: February, 2010 EQUAL/ Center for Policy Analysis Shortages in pediatrics, internal medicine and family medicine. Decreased access to geriatricians and gynecologists.

20. Health Care Costs Too Much February, 2010 EQUAL/ Center for Policy Analysis

21. Health Care is Big Business $2.5 Trillion A Year February, 2010 EQUAL/ Center for Policy Analysis

22. Distribution of National Health Expenditures, by Type of Service, 2008 February, 2010 EQUAL/ Center for Policy Analysis Note: Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http:// www.cms.hhs.gov/NationalHealthExpendData / (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2008; file nhe2008.zip).

23. Relative Contributions of Different Types of Health Services to Total Growth in National Health Expenditures, 1998-2008 February, 2010 EQUAL/ Center for Policy Analysis Notes: Percentages may not total 100% due to rounding. Other Personal Health Care includes, for example, dental and other professional health services, durable medical equipment, etc. Other Health Spending includes, for example, administration and net cost of private health insurance, public health activity, research, and structures and equipment, etc. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http:// www.cms.hhs.gov/NationalHealthExpendData / (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2008; file nhe2008.zip).

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25. Total Health Expenditures Per Capita, U.S. and Selected Countries, 2003 February, 2010 EQUAL/ Center for Policy Analysis

26. * 2008 and 2009 NHE projections. .Source: K. Davis, Why Health Reform Must Counter the Rising Costs of Health Insurance Premiums, (New York: The Commonwealth Fund, Aug. 2009). Insurance Premiums Rising Faster Than Workers’ Earnings 2000–2009 Percent 108% 32% 24%

27. Premium as % of Median Family Income, 2008–2020 February, 2010 EQUAL/ Center for Policy Analysis Percent Projected

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29. Health and Welfare Expenditures, General Fund, All K-12 Districts and County Offices of Education, California 1999 – 2008 February, 2010 EQUAL/ Center for Policy Analysis

30. February, 2010 EQUAL/ Center for Policy Analysis Notes: Percentages may not total 100% due to rounding. Source: Kaiser Family Foundation calculations using NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http:// www.cms.hhs.gov/NationalHealthExpendData / (see Historical; National Health Expenditures by type of service and source of funds, CY 1960-2008; file nhe2008.zip). Distribution of National Prescription Drug Expenditures by Source of Payment, 1998-2008 Private Insurance Consumer Out-of-Pocket Payments Public Funds

31. Private Health Insurance Administrative Costs per Person Covered, 1986-2008 February, 2010 EQUAL/ Center for Policy Analysis Notes: These data show the net cost of private health insurance per private enrollee (including Blue Cross/Blue Shield, commercial insurance, HMOs, and self-insured plans), as calculated by the Centers for Medicare and Medicaid Services. Net cost of insurance is the difference between premiums earned and benefits incurred, and includes insurers’ costs of paying bills, advertising, sales commissions, and other administrative costs; net additions/subtractions from reserves; rate credits and dividends; premium taxes; and profits or losses. Private enrollment is estimated by CMS using the National Health Insurance Survey and the Current Population Survey. Source: Kaiser Family Foundation calculations NHE data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, at http:// www.cms.hhs.gov/NationalHealthExpendData / (see Historical; National Expenditures by type of service and source of funds, CY1960-2008, file nhe2008.zip, Admin.& Net Cost of Priv. Hlth Insurance, Pvt Health Insurance); and private health insurance enrollment data from Centers for Medicare and Medicaid Services, Office of the Actuary, National Health Statistics Group, Table 4 at http://www.cms.hhs.gov/NationalHealthExpendData/downloads/bhg08.pdf .

32. Number of Uninsured Growing February, 2010 EQUAL/ Center for Policy Analysis

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34. February, 2010 EQUAL/ Center for Policy Analysis New York Times

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37. Quality of Care: People Suffer and Die Because of Our Cruel and Unfair System February, 2010 EQUAL/ Center for Policy Analysis

38. Uninsured: Dying from a Toothache in the U.S. February, 2010 EQUAL/ Center for Policy Analysis A man in his early 20s with a worsening dental infection was unable to afford a dentist. He finally saw a physician who prescribed an antibiotic, but the patient was unable to pay for the prescription. He came to our clinic when the infection had spread to his chest. He died soon after admission. The egregious is commonplace in our non-system. JAMAVol. 286 No. 20, November 28, 2001"Within the System of No-System," Robert L. Ferrer, MD, MPH

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43. Potential Years of Life Lost Due to Diabetes per 100,000 Population, 2006 February, 2010 EQUAL/ Center for Policy Analysis *2005 **2004 Data: OECD Health Data 2008 (June 2008).

44. Mortality Amenable to Health Care: U.S. Failing to Keep Pace with Other Countries Deaths per 100,000 population* * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee, Health Affairs 2008). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008. Exhibit 2

46. 66% of personal bankruptcies are due to medical debt February, 2010 EQUAL/ Center for Policy Analysis

47. February, 2010 EQUAL/ Center for Policy Analysis Copyright ©2008 American Cancer Society From Ward, E. et al. CA Cancer J Clin 2008;58:9-31. FIGURE 10 Cancer Survival by Insurance Status*

48. February, 2010 EQUAL/ Center for Policy Analysis Copyright ©2008 American Cancer Society From Ward, E. et al. CA Cancer J Clin 2008;58:9-31. Uninsured Rates Among Adults Aged 19 to 64 Years by Income Level, 2001 to 2005 LOW INCOME MORE LIKELY UNINSURED

49. Race, Class, Insurance and Health February, 2010 EQUAL/ Center for Policy Analysis

50. February, 2010 EQUAL/ Center for Policy Analysis Copyright ©2008 American Cancer Society From Ward, E. et al. CA Cancer J Clin 2008;58:9-31. Breast Cancer: Blacks and Hispanics Diagnosed Later, More Likely Uninsured

51. February, 2010 EQUAL/ Center for Policy Analysis Copyright ©2008 American Cancer Society From Ward, E. et al. CA Cancer J Clin 2008;58:9-31. Colorectal Cancer Stage Distribution by Race and Insurance Status

52. February, 2010 EQUAL/ Center for Policy Analysis Copyright restrictions may apply. Haider, A. H. et al. Arch Surg 2008;143:945-949. Adjusted odds of mortality by race and insurance status (n = 311 503 )

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56. Amazing Fact #1 We Must Cover Everyone To Control Costs (Huh?)

62. New York Times

63. Amazing Fact #1 We Must Cover Everyone To Control Costs (Oh!)

65. Private Insurance Has Failed Government Plans are More Successful February, 2010 EQUAL/ Center for Policy Analysis

74. Health Reform Is A Political Challenge February, 2010 EQUAL/ Center for Policy Analysis

75. Tough Road February, 2010 EQUAL/ Center for Policy Analysis

77. $2.5 Trillion: Spending or Income ? Industry Opposes Income Constraints February, 2010 EQUAL/ Center for Policy Analysis Spending Income Individuals Insurance Industry Employers Pharmaceutical Co.s Governments Hospitals, Physicians

79. Politics in 2008: Auspicious February, 2010 EQUAL/ Center for Policy Analysis

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81. Politics in 2010: Challenging February, 2010 EQUAL/ Center for Policy Analysis

82. Economic Collapse – But Corporations Still In Charge February, 2010 EQUAL/ Center for Policy Analysis

83. Social institutions weakened: labor, women, civil society - ++Faith Community, online networks growing ++ February, 2010 EQUAL/ Center for Policy Analysis

84. Corporate media February, 2010 EQUAL/ Center for Policy Analysis

86. What Health Reform Bills Do February, 2010 EQUAL/ Center for Policy Analysis

95. Now: Women Can Pay More Example: Kaiser Permanente monthly premiums 2010 February, 2010 EQUAL/ Center for Policy Analysis Age Male Female Difference 19-24 $260 $273 5.0% 25-29 $292 $306 4.8% 30-34 326 342 4.9% 40-44 354 372 5.1% 45-49 418 439 5.0% 50-54 476 499 4.8% 55-59 559 559 0 60-64 628 598 -4.8%

96. Gender Discrimination In Premium Rates Would Be Prohibited February, 2010 EQUAL/ Center for Policy Analysis

97. Oldest Compared to Youngest: 215% Example: Kaiser Monthly Premium 2010 February, 2010 EQUAL/ Center for Policy Analysis Age Male Female Difference 19-24 $260 273 25-29 292 306 30-34 326 342 40-44 354 372 45-49 418 439 50-54 476 499 55-59 559 $559 +215% (2:1)

99. What is it going to cost? February, 2010 EQUAL/ Center for Policy Analysis

101. New: Insurance Exchange -- House Bill Example: 4-person family at 200% FPL ($44,000) February, 2010 EQUAL/ Center for Policy Analysis House Senate Premiums $2400 $2772 % Income 5.5% 6.3% OOP Cap $2000 $4100 Max OOP $4400 $6872 Max % Income 10% 15%

102. Estimates by House TriCommittee Staff February, 2010 EQUAL/ Center for Policy Analysis

105. What Happens to Medicare? February, 2010 EQUAL/ Center for Policy Analysis

107. Reconciling House and Senate Bills February, 2010 EQUAL/ Center for Policy Analysis

111. How can we get a single payer plan in our state? February, 2010 EQUAL/ Center for Policy Analysis

113. $2.5 Trillion: Spending or Income ? February, 2010 EQUAL/ Center for Policy Analysis Spending Income Individuals Insurance Industry Employers Pharmaceutical Co.s Governments Hospitals, Physicians

123. What We Can Do February, 2010 EQUAL/ Center for Policy Analysis