health care in the u.s. and the world

Martin DonohoeMartin Donohoe

Determinants of HealthDeterminants of Health EraEra Socioeconomic statusSocioeconomic status SexSex RaceRace LocationLocation EnvironmentEnvironment GeneticsGenetics Health HabitsHealth Habits Access to CareAccess to Care

The State of U.S. Health The State of U.S. Health CareCare

49 million uninsured49 million uninsured 48,000 deaths/year48,000 deaths/year

30 million more underinsured30 million more underinsuredRemain in dead-end jobsRemain in dead-end jobsGo without needed care Go without needed care and/or prescriptionsand/or prescriptions

MarryMarry

Reasons for No Health Insurance Reasons for No Health Insurance Coverage (2009)Coverage (2009)

The State of U.S. Health The State of U.S. Health CareCare

US ranks near the bottom US ranks near the bottom among westernized nations in among westernized nations in overall population health (#24), overall population health (#24), life expectancy (#42), infant life expectancy (#42), infant and maternal mortality, etc.and maternal mortality, etc.

15% of Americans live in 15% of Americans live in povertypoverty

22% of US children live in 22% of US children live in povertypoverty

Health Care Expenditures Health Care Expenditures per Capitaper Capita

U.S. = $8,233 (17.6% of U.S. = $8,233 (17.6% of GDP)GDP)

Canada, Australia, Japan, Canada, Australia, Japan, Europe: $3,000 to $6,000Europe: $3,000 to $6,000Average for low income Average for low income developing nations = $22-developing nations = $22-2525

Who Pays for Health Who Pays for Health Care?Care?

Government (federal, state, and local)Government (federal, state, and local) Medicare, Medicaid, VA, IHS, jails and Medicare, Medicaid, VA, IHS, jails and

prisonsprisons Private insurancePrivate insurance

Primarily employer-basedPrimarily employer-based Out-of-pocketOut-of-pocket Health care costs = 17.6% of GDP (1/2 of Health care costs = 17.6% of GDP (1/2 of

worldwide health care costs)worldwide health care costs)

Health Insurance Health Insurance IndustryIndustry

DelistingDelisting Cherry pickingCherry picking Pre-existing conditionsPre-existing conditions Charging uninsured 2-3X moreCharging uninsured 2-3X more Hiring debt collection agencies, Hiring debt collection agencies,

which sometimes hound patients which sometimes hound patients in the ER (in violation of EMTALA)in the ER (in violation of EMTALA)


High administrative costsHigh administrative costs 15-30% (vs. 2-3% for Medicare and 15-30% (vs. 2-3% for Medicare and

Medicaid)Medicaid) Average full-time physician spends Average full-time physician spends

over $85,000/yr on billing and over $85,000/yr on billing and insurance functionsinsurance functions

17,849 different billing codes (in 17,849 different billing codes (in 2012 increases to 141,058)2012 increases to 141,058)


Large profit marginsLarge profit margins

CorruptionCorruption

Loyalty: shareholders (not Loyalty: shareholders (not patients)patients)

Drug Companies’ Cost Drug Companies’ Cost StructureStructure

Innovation:Innovation:Published Research Leading to DrugsPublished Research Leading to Drugs

Premature Deaths in the Premature Deaths in the U.S.U.S.

10% due to inadequate 10% due to inadequate medical caremedical care

60% due to behaviors, social 60% due to behaviors, social circumstances, and circumstances, and environmental exposuresenvironmental exposures

Address Social Factors Address Social Factors Responsible for Illness and Responsible for Illness and

DeathDeath Deaths in 2000 attributable to:Deaths in 2000 attributable to:

Low education: 245,000Low education: 245,000Racial segregation: 176,000Racial segregation: 176,000Low social support: 162,000Low social support: 162,000 Individual-level poverty: Individual-level poverty:

133,000133,000 AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465



Income inequality: 119,000 Income inequality: 119,000 (population-attributable (population-attributable mortality – 5.1%)mortality – 5.1%)

Area-level poverty: 39,000 Area-level poverty: 39,000 (population-attributable (population-attributable mortality – 1.7%)mortality – 1.7%)

AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465



AMI – 193,000AMI – 193,000CVD – 168,000CVD – 168,000Lung CA – 156,000Lung CA – 156,000

AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465

Deaths per yearDeaths per year

Tobacco = 400,000 (+ 50,000 ETS)Tobacco = 400,000 (+ 50,000 ETS) Obesity = 300,000Obesity = 300,000 Alcohol = 100,000Alcohol = 100,000 Microbial agents = 90,000Microbial agents = 90,000 Toxic agents = 60,000 (likely higher)Toxic agents = 60,000 (likely higher) Firearms = 35,000Firearms = 35,000 Sexual behaviors = 30,000Sexual behaviors = 30,000 Motor vehicles = 25,000Motor vehicles = 25,000 Illicit drug use = 20,000Illicit drug use = 20,000

Major Contributors to Major Contributors to Illness and DeathIllness and Death

40% of US mortality due to tobacco, 40% of US mortality due to tobacco, poor diet, physical inactivity, and poor diet, physical inactivity, and misuse of alcoholmisuse of alcohol

Every $1 invested in programs Every $1 invested in programs covering above items saves $5.60 in covering above items saves $5.60 in health care costshealth care costs

Prevention: 2-4% of national health Prevention: 2-4% of national health care expenditurescare expenditures

NoncomplianceNoncompliance

Poverty and HungerPoverty and HungerUS: 15% of residents and 22% US: 15% of residents and 22% of children live in povertyof children live in poverty

Rates of poverty in Blacks and Rates of poverty in Blacks and Hispanics = 2X WhitesHispanics = 2X Whites

Poverty associated with worse Poverty associated with worse physical and mental healthphysical and mental health

Economic DisparitiesEconomic DisparitiesWomen 75 centsWomen 75 cents/$1 Men/$1 MenMedian income of black Median income of black

U.S. families as a percent U.S. families as a percent of white U.S. families of white U.S. families 62%62%60% in 196860% in 1968

63% for Hispanic families63% for Hispanic families

Educational ApartheidEducational Apartheid

High levels of de facto school High levels of de facto school segregation by race and SESsegregation by race and SES

Gross discrepancies in per-pupil Gross discrepancies in per-pupil spending and teacher salariesspending and teacher salaries

Achievement and graduation gaps Achievement and graduation gaps growinggrowing

Racial Disparities in Racial Disparities in Health Care CoverageHealth Care Coverage

Percent uninsured:Percent uninsured: Whites = 12%Whites = 12% Asians = 17%Asians = 17% African-Americans = 21%African-Americans = 21% Hispanics = 32%Hispanics = 32% Undocumented immigrants = 100% Undocumented immigrants = 100%

(emergency care exception)(emergency care exception) CA Proposition 189CA Proposition 189

Racial Disparities in Health Care:Racial Disparities in Health Care:African-AmericansAfrican-Americans

Higher maternal and infant Higher maternal and infant mortalitymortality

Higher death rates for most Higher death rates for most diseasesdiseases

Shorter life expectanciesShorter life expectanciesLess health insuranceLess health insuranceUndergo fewer diagnostic tests / Undergo fewer diagnostic tests / therapeutic procedurestherapeutic procedures

Racial Disparities in Health Racial Disparities in Health Care:Care:

African-AmericansAfrican-AmericansEqualizing the mortality rates Equalizing the mortality rates of whites and African-of whites and African-Americans would have averted Americans would have averted 686,202 deaths between 1991 686,202 deaths between 1991 and 2000and 2000Whereas medical advances Whereas medical advances averted 176,633 deathsaverted 176,633 deaths AJPH 2004;94:2078-2081AJPH 2004;94:2078-2081

Outside the USOutside the USOne billion people lack clean One billion people lack clean

drinking water and 3 billion lack drinking water and 3 billion lack sanitationsanitation13,000-15,000 deaths per day 13,000-15,000 deaths per day worldwide from water-related worldwide from water-related diseasesdiseases

Hunger kills as many individuals in Hunger kills as many individuals in eight days as died during the atomic eight days as died during the atomic bombing of Hiroshimabombing of Hiroshima

WaterWaterAmount of money needed each Amount of money needed each year (in addition to current year (in addition to current expenditures) to provide water expenditures) to provide water and sanitation for all people in and sanitation for all people in developing nations = $9 billiondeveloping nations = $9 billion

Amount of money spent annually Amount of money spent annually on cosmetics in the U.S. = $8 on cosmetics in the U.S. = $8 billionbillion

OverpopulationOverpopulationWorld population - exponential World population - exponential

growthgrowth1 billion in 18001 billion in 18002.5 billion in 19502.5 billion in 19506 billion in 20006 billion in 20007 billion in 20117 billion in 2011est. 8-10 billion by 2050est. 8-10 billion by 2050

Status of WomenStatus of Women

Women do 67% of the Women do 67% of the world’s workworld’s work

Receive 10% of global Receive 10% of global incomeincome

Own 1% of all propertyOwn 1% of all property

Worldwide, every minuteWorldwide, every minute 380 women become pregnant (190 380 women become pregnant (190

unplanned or unwanted)unplanned or unwanted) 110 women experience pregnancy-related 110 women experience pregnancy-related

complicationscomplications 40 women have unsafe abortions40 women have unsafe abortions 1 woman dies from childbirth or unsafe 1 woman dies from childbirth or unsafe

abortionabortion

Reason: Lack of access to reproductive Reason: Lack of access to reproductive health serviceshealth services

Deaths in WarDeaths in War1818thth Century = 19/million population Century = 19/million population1919thth Century = 11/million population Century = 11/million population2020thth Century = 183/million Century = 183/million populationpopulation

Civilian Casualties:Civilian Casualties:10% late 1910% late 19thth Century Century85-90% in 2085-90% in 20thth Century Century

Inverse Care LawInverse Care Law

Those countries that Those countries that need the most health need the most health care resources are care resources are getting the leastgetting the least

The Medical Brain DrainThe Medical Brain Drain

U.S. is largest consumer of U.S. is largest consumer of health care personnelhealth care personnel

Five times as many migrating Five times as many migrating doctors flow from developing to doctors flow from developing to developed nations than in the developed nations than in the opposite directionopposite direction Even greater imbalance for nursesEven greater imbalance for nurses


2011: WHO estimates 2011: WHO estimates developing world shortage of 4.3 developing world shortage of 4.3 million health professionalsmillion health professionalsUS: 280 physicians/100K US: 280 physicians/100K

populationpopulation India: 60/100KIndia: 60/100KSub-Saharan Africa: 18/100K Sub-Saharan Africa: 18/100K


Example of “inverse care law”:Example of “inverse care law”:Those countries that need the most Those countries that need the most

health care resources are getting health care resources are getting the leastthe least

Voluntary WHO Global Code of Voluntary WHO Global Code of Practice on the International Practice on the International Recruitment of Health Care Personnel Recruitment of Health Care Personnel (adopted 2010)(adopted 2010)U.S. working on implementingU.S. working on implementing

Tobacco – Weapon of Mass Tobacco – Weapon of Mass DestructionDestruction

Direct medical costs = $100 Direct medical costs = $100 billion/yr billion/yr

Lost productivity = $97 billion/yrLost productivity = $97 billion/yr Medical care and lost Medical care and lost

productivity due to tobacco use productivity due to tobacco use costs each U.S. citizen costs each U.S. citizen approximately $600/yrapproximately $600/yr

Consequences of Environmental Consequences of Environmental DestructionDestruction

Global warming: 160,000 Global warming: 160,000 deaths and 5.5 million deaths and 5.5 million disability-adjusted life years disability-adjusted life years lost per year (will double by lost per year (will double by 2020)2020)

Air pollution: 60,000 - 75,000 Air pollution: 60,000 - 75,000 premature deaths/yr. (U.S.); premature deaths/yr. (U.S.); 1.8 million worldwide1.8 million worldwide

Consequences of Consequences of Environmental Environmental

DestructionDestruction Pesticides in food Pesticides in food → → 1,000,000 1,000,000

deaths over the last 6 years; 1 deaths over the last 6 years; 1 million cancers in current generation million cancers in current generation of Americansof Americans

Lead and mercury exposure multi-Lead and mercury exposure multi-billion dollar problemsbillion dollar problems

Toxic PollutantsToxic Pollutants

¼ US citizens live within 4 miles ¼ US citizens live within 4 miles of a Superfund siteof a Superfund site

Environmental RacismEnvironmental RacismWaste dumps/incinerators Waste dumps/incinerators more common in lower SES more common in lower SES neighborhoodsneighborhoods

Extinction/Species LossExtinction/Species Loss

Mass ExtinctionMass ExtinctionMore than 1/2 of the top 150 More than 1/2 of the top 150

prescription drugs from plants, prescription drugs from plants, other living organismsother living organisms

More than 250,000 known More than 250,000 known flowering speciesflowering species <0.5% surveyed for medicinal <0.5% surveyed for medicinal valuevalue

Overconsumption Overconsumption (“Affluenza”)(“Affluenza”)

U.S. = 6.3% of world’s populationU.S. = 6.3% of world’s populationOwns 50% of the world’s wealthOwns 50% of the world’s wealth

U.S. responsible for:U.S. responsible for:25% of world’s energy consumption25% of world’s energy consumption33% of paper use33% of paper use72% of hazardous waste production72% of hazardous waste production

But Are We Happier?But Are We Happier?

Average American works 200 Average American works 200 more hrs/yr than in 1960 (#1 more hrs/yr than in 1960 (#1 in world)in world)

Vacations shorterVacations shorterNo guaranteed paid sick leaveNo guaranteed paid sick leave8/10 Americans want a new job8/10 Americans want a new job

But Are We Happier?But Are We Happier?

Fewer close friendsFewer close friendsMore loneliness/depressionMore loneliness/depressionPharmaceutical fixesPharmaceutical fixes

US Charity Care SufferingUS Charity Care Suffering Public hospitals and ERs closingPublic hospitals and ERs closing

Long waits mean many leave before being seenLong waits mean many leave before being seen Free clinic demand increasing, more Free clinic demand increasing, more

patients being turned awaypatients being turned away Hospitals turning to lucrative initiatives to Hospitals turning to lucrative initiatives to

improve financial situationimprove financial situation Cosmetic surgery, luxury clinics, aggressive Cosmetic surgery, luxury clinics, aggressive

billing practices (including charging uninsured billing practices (including charging uninsured more than insured), recruiting wealthy foreign more than insured), recruiting wealthy foreign patientspatients

Maldistribution of WealthMaldistribution of WealthU.S: Richest 1% of the U.S: Richest 1% of the

population owns 50% of the population owns 50% of the country’s wealth country’s wealth -poorest 90% own 30%-poorest 90% own 30%-widest gap of any industrialized -widest gap of any industrialized nationnation

Maldistribution of Maldistribution of Wealth is DeadlyWealth is Deadly

880,000 deaths/yr in U.S. 880,000 deaths/yr in U.S. would be averted if the would be averted if the country had an income gap country had an income gap like Western European like Western European nations, with their stronger nations, with their stronger social safety netssocial safety nets

Maldistribution of wealthMaldistribution of wealth

Less than 4% of the combined Less than 4% of the combined

wealth of the 225 richest individuals wealth of the 225 richest individuals

in the world would pay for ongoing in the world would pay for ongoing

access to basic education, health access to basic education, health

care (including reproductive health care (including reproductive health

care), adequate food, safe water, care), adequate food, safe water,

and adequate sanitation for all and adequate sanitation for all

humanshumans

Health Requires EqualityHealth Requires Equality““All men are created equal”All men are created equal”

Declaration of IndependenceDeclaration of Independence

““Some people are more equal Some people are more equal than others”than others”George OrwellGeorge Orwell

Hudson River, 2009Hudson River, 2009

U.N. Declaration of Human U.N. Declaration of Human RightsRights

““Everyone has the right to Everyone has the right to a standard of living a standard of living adequate for the health and adequate for the health and well-being of himself and of well-being of himself and of his family, including food, his family, including food, clothing, housing and clothing, housing and medical care”medical care”

SolutionsSolutionsPay as you goPay as you goInsuranceInsuranceGovernment-run programGovernment-run program

VA, IHSVA, IHSPPACAPPACASingle PayerSingle Payer

PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act

2014: 26 million uninsured adults 2014: 26 million uninsured adults with incomes under $29,327 will gain with incomes under $29,327 will gain coverage through Medicaid with little coverage through Medicaid with little or no premium or cost sharingor no premium or cost sharing

2014: Up to 17 million adults with 2014: Up to 17 million adults with incomes between $29,327 and incomes between $29,327 and $88,200 for a family of 4 will get tax $88,200 for a family of 4 will get tax credits to help purchase private credits to help purchase private health plans through new state health plans through new state insurance exchanges (sliding scale)insurance exchanges (sliding scale)


2014: No denial of coverage or higher 2014: No denial of coverage or higher premiums for preexisting conditionspremiums for preexisting conditions Up to ½ of AmericansUp to ½ of Americans

2010: Uninsured with preexisting 2010: Uninsured with preexisting conditions eligible for special insurance conditions eligible for special insurance plans after 6 months without insuranceplans after 6 months without insurance

2010: Young adults up to age 26 may 2010: Young adults up to age 26 may stay on parents’ health planstay on parents’ health plan


2010: Small business tax credits to 2010: Small business tax credits to offset costs of insuring employeesoffset costs of insuring employees

2010: Insurers cannot deny 2010: Insurers cannot deny coverage to children with coverage to children with preexisting conditionspreexisting conditions

2010: No lifetime benefit limits and 2010: No lifetime benefit limits and no rescisionsno rescisions


2010: Health plans must provide 2010: Health plans must provide preventive services without cost-sharingpreventive services without cost-sharing

50% cost-sharing discount for seniors in 50% cost-sharing discount for seniors in Medicare “donut hole”Medicare “donut hole”

Prevents hospitals from overbilling the Prevents hospitals from overbilling the uninsureduninsured

Creates public website listing payments Creates public website listing payments from drug, device, biological, and medical from drug, device, biological, and medical products companies to physiciansproducts companies to physicians


Problems:Problems:Complex, increases bureaucracyComplex, increases bureaucracyLeaves 23 – 40 million without Leaves 23 – 40 million without

insuranceinsurance40% of these eligible for, but not 40% of these eligible for, but not enrolled in, Medicaid or CHIPenrolled in, Medicaid or CHIP

22% undocumented immigrants22% undocumented immigrants


Problems:Problems:No effective cost control measuresNo effective cost control measuresWill not reduce medical Will not reduce medical

bankruptciesbankruptciesWill drain $billions from Medicare Will drain $billions from Medicare

payments to safety net clinics, payments to safety net clinics, threatening the remaining threatening the remaining uninsureduninsured


Unfair to women - segregation of Unfair to women - segregation of abortion funding, may affect abortion funding, may affect contraceptive coveragecontraceptive coverage

Poor likely to purchase less Poor likely to purchase less expensive plans with worse expensive plans with worse coverage and higher deductibles coverage and higher deductibles and copaymentsand copayments

?Penalties if poor do not buy ?Penalties if poor do not buy insurance?insurance?


Problems:Problems:Loopholes allow charges up to 3x Loopholes allow charges up to 3x

higher for elderly, higher charges higher for elderly, higher charges for large companies with for large companies with predominantly female workforcespredominantly female workforces

Benefits insurance companies, Benefits insurance companies, continues present inefficienciescontinues present inefficiencies


Problems: Pay for Performance likely to Pay for Performance likely to

backfire per behavioral economics backfire per behavioral economics research, incentivizes greedresearch, incentivizes greed

Electronic health records Electronic health records mandated, but no evidence of cost mandated, but no evidence of cost savings or better caresavings or better care


Inadequate numbers of primary care Inadequate numbers of primary care providersproviders Communities with a high number of PCPs per Communities with a high number of PCPs per

capita have lower medical costs and better capita have lower medical costs and better outcomesoutcomes

High levels of burnout and career dissatisfaction Over 1/3 of physicians are accepting no new Over 1/3 of physicians are accepting no new

Medicaid patients, and ¼ see no Medicaid Medicaid patients, and ¼ see no Medicaid patientspatients Due to low reimbursements, multiple social needsDue to low reimbursements, multiple social needs

"If anyone...has a better approach "If anyone...has a better approach that will bring down premiums, bringthat will bring down premiums, bringdown the deficit, cover the uninsured, down the deficit, cover the uninsured, strengthen Medicare for seniors,strengthen Medicare for seniors,and stop insurance company abuses, and stop insurance company abuses, let me know."let me know."-- President Obama, State of the -- President Obama, State of the Union, 1/27/10Union, 1/27/10

Single PayerSingle Payer Cradle to grave, portable insurance for Cradle to grave, portable insurance for

everyoneeveryone All medically-necessary services coveredAll medically-necessary services covered Free choice of doctor and hospitalFree choice of doctor and hospital Global and local budgeting determined by Global and local budgeting determined by

physicians, patients, other health physicians, patients, other health professionalsprofessionals

Cost savingCost saving Public accountabilityPublic accountability Broad supportBroad support

Paying for Health Care Paying for Health Care TodayToday

Federal Government

(existing Medicare,

Medicaid, other)

Out-of-pocket

State and Local Govt (existing

Medicaid, other)

Private Insurance

How We Pay for Health Care Today

Source: Health Affairs, Feb. 2008; data for 2006

How Single Payer Could Be Paid How Single Payer Could Be Paid For: For:

One Example from a Recent Study One Example from a Recent Study of a California Planof a California Plan

Federal Government

(existing Medicare,

Medicaid, other)

Business (self-employed) income tax

(12%)

State and Local Govt (existing

Medicaid, other)

Surcharge on income (1% above $200,000)

Employee Payroll Tax (4%)

Employer Payroll Tax (8%)

Investment income tax (4%)

Note: Payroll and income taxes between $7,000 and $200,000 only. Source: Health Care for All Californians Act: Cost and Economic Impacts Analysis, The Lewin Group, January 2005

Covering Everyone withCovering Everyone with No Additional Spending No Additional Spending

Additional costsAdditional costs

Covering the uninsured and poorly-insured Covering the uninsured and poorly-insured +6.4%+6.4%

Elimination of cost-sharing and co-pays Elimination of cost-sharing and co-pays +5.1%+5.1%

SavingsSavings

Reduced insurance administrative costs -5.3%Reduced insurance administrative costs -5.3%

Reduced hospital billing costs Reduced hospital billing costs -1.9% -1.9%

Reduced physician office costs -3.6%Reduced physician office costs -3.6%

Bulk purchasing of drugs & equipment -2.8%Bulk purchasing of drugs & equipment -2.8%

Primary care emphasis & reduce fraud Primary care emphasis & reduce fraud --2.2%2.2%

Source: Health Care for All Californians Plan, Lewin Group, January 2005

Total Costs +11.5%

Total Savings -15.8% Net Savings - 4.3%

Single PayerSingle PayerNot socialism any more than Not socialism any more than

having a police force and fire having a police force and fire department which serve department which serve everyone or offering free public everyone or offering free public education to children through education to children through grade twelve is socialismgrade twelve is socialismImagine if insurance companies Imagine if insurance companies ran the fire departmentran the fire department

What You Can DoWhat You Can Do Educate yourselves and othersEducate yourselves and others

““Information is the currency of Information is the currency of democracy” (Thomas Jefferson)democracy” (Thomas Jefferson)

Join groups working to improve Join groups working to improve health carehealth care

Act Now!Act Now!

"If you think you are too "If you think you are too small to have an impact, small to have an impact, try going to bed with a try going to bed with a mosquito in your tent“mosquito in your tent“

- African Proverb- African Proverb

Further Info/References/Contact Further Info/References/Contact InfoInfo

Public Health and Social Justice WebsitePublic Health and Social Justice Websitehttp://www.phsj.org

Physicians for a National Health PlanPhysicians for a National Health Planhttp://www.pnhp.org/

Kaiser Family FoundationKaiser Family Foundationhttp://www.kff.org/

Martin DonohoeMartin [email protected]

health care in the u.s. and the world

Documents

health care costsprevention

health insurance coverage

health care49

health careus

overall population health

insurance functions17

social circumstances

low social support