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Universal Healthcare: Can We Get There? California Physicians’ Alliance Developed by Bree Johnston, Dorothy Rice, Jim Kahn, Vishu Lingappa, Beth Capell, and others We are Going to Discuss Today Problems with our current system Potential solutions Politics of change

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Universal Healthcare: Can We Get There?

California Physicians’ Alliance

Developed by Bree Johnston, Dorothy Rice, Jim Kahn, Vishu Lingappa, Beth Capell, and others


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We are Going to Discuss Today

  • Problems with our current system

  • Potential solutions

  • Politics of change


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The Health Care Crisis: Interconnections

• >13% of GDP (50% more than Canada)

• double digit inflation

• employers shifting costs to employees

• wasted resources in a fragmented system

• 1 in 4 health care dollars not for health care

• >40 million uninsured

• most underinsured

• pre-existing condition exclusions

• deductibles and steep co-pays

• erosion of choice of providers

• provider no longer trusted to be advocate

• bureaucratic intrusion

• worse health care outcomes

• distortion of clinical judgment


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What is Right with our System?

  • Excellent hospitals, equipment, and health care facilities

  • Enough well trained professionals

  • Superb research

  • Sufficient spending


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What is Wrong with our System?

We spend far more money than any other country on health care...

…but get far fewer benefits, far worse health outcomes, and far less patient satisfaction.


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What is Wrong with our System?

  • Tens of millions of workers and others lack decent health care

  • Health outcomes are worse than other developed nations due to gaps in health coverage

  • We spend more per capita on health care than any other country … with worse access and outcomes

  • 38% of Americans report one or more problems getting access to care in the past year (Kaiser Commission, July 2002)



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Access is a Huge Problem

  • 1 of 5 Americans postponed getting needed health care last year

  • 1 of 7 Americans had a problem paying for medical bills last year

  • 1 of 10 did not get a prescription drug they needed due to costKaiser Commission on Medicaid and the Uninsured, July 2002


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Access Problems Harm Health

  • The Institute of Medicine estimates 18,000 excess deaths per year due to lack of health coverage

  • People without health insurance:

    • Receive too little medical care too late

    • Are sicker and die sooner

    • Receive poorer care when they are in hospitals, even for acute situations like car accidents Care Without Coverage, Institute of Medicine, May 2002


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Illness is a Major Cause of Bankruptcy

  • Half of all bankruptcies involve a medical cause or debt

  • 326,441 families identified illness/injury as the main reason for bankruptcy in 1999

  • 299,757 more had large medical debts at time of bankruptcy

Source: Norton’s Bankruptcy Advisor, May 2000



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Why Should People with Health Insurance Care about the Uninsured?

  • With economic ups and downs, it could be you

  • Many people are tied to jobs that they don’t like due to health insurance

  • Working people age 50 to 65 are just as likely as younger workers to lose health insurance— just when they need it most

  • Fairness, humanity, and social obligation


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Why Should People with Health Insurance Care about How Insurance Works?

  • Health insurance premiums are rising, and this may worsen during economic decline

  • Risk is being shifted to patients through Medical Savings Accounts & Defined Contributions… so sick people pay more Fuchs NEJM, 2002

  • Insurance works best for patients if we are in one large risk pool


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Why Should People Insurance Works?with Health Insurance Care about How Insurance Works?

  • Health insurance premiums are rising, and in a down economy employers shift costs to employees

  • Medical Savings Accounts & Defined Contributions undermine the risk pool, seduce patients to gamble with their health, and threaten care for people with major disorders Fuchs NEJM, 2002

  • So more and more people have less access to care, and what care they do get is getting worse.


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Adverse Consequences of Investor Owned Health Care Insurance Works?

  • Bankruptcy in physicians groups due to inadequate payments

  • Erosion of provider-patient trust

  • Conflicts of interest

  • Worse quality and access in investor -owned health systems and nursing homes, especially among those in fair or poor health

    Thomas SGIM 2000 Woolhandler et al JAMA 1999

    Harrington AJPH 2001 Tu NEJM 2002


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Why is Health Care Different From Most Market Commodities? Insurance Works?

  • Health care is technically complex -- it’s hard to make choices that “maximize utility”

  • Health care is expensive, tempting HMOs to cheat (exclude the sick) rather than compete (profit by being efficient)

  • Poor choices cannotbereliably revisited

  • Providing it requires good clinical judgment

All industrialized democracies have removed health insurance from the market and provided citizens with a national health insurance … except USA


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Evidence of impact: Insurance Works?

  • Negative impact on charity care JAMA 1999

  • Nurses report spending less time with patients

    • Higher acuity patients and worse staffing

    • Less time to teach and comfort patients AJN 1996


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Has a Decade in the Marketplace Improved Health Care? Insurance Works?

  • Access is worse

  • Quality is eroding

  • Choice has substantially diminished

  • Trust in health care providers has been undermined

  • Once again, COSTS ARE SKYROCKETING


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Are we paying for care? Insurance Works? Or overhead?

  • Huge inefficiencies to operate a complex system with multiple private insurers plus Medicare, Medi-Cal, and other public programs

  • For-profit HMOs and hospitals where profits are “earned” by stockholders, not reinvested in the health care system

  • Administrative costs of $309 billion nationally, twice what is needed


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Overhead & Profit Insurance Works?As Percent of Premium


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Growth of Physicians, RNs & Administrators 1970-1998 Insurance Works?

Percentage Growth

Bureau of Labor Statistics, NCHS


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Nurse Staffing Improves Care Insurance Works?

  • Increased hours of nursing care is associated with better care of hospitalized patients

    Needleman et al NEJM 2002


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Do you want your health care dollars spent Insurance Works?

Here or

Here?


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The Case for Insurance Works? National Health Insurance

  • Fairness – everyone should have the health care they need when they need it

  • Efficiency – we could pay for comprehensive care for everyone and spend less money than now

  • We would spend more money on direct care

  • The current experiment with market driven health care has not worked … for patients, physicians, nurses, or society


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Health Care Options Project (HCOP) Provides insights into Health Reform

  • Convened by California Health and Human Services Agency, based on Senate Bill 480 signed by Governor Davis in 1999.

  • Examined options for extending health care coverage in California

  • Nine reform option papers

  • Analyzed and compared by consultants from The Lewin Group and AZA Consulting


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The Nine HCOP Proposals Health Reform

  • Six partial proposals

    • Three take steps back, reducing coverage or access

    • Two take modest steps forward, expanding existing programs

    • One is nearly universal, combining expansions of existing public programs with “pay or play” for employers (we will discuss)

  • Three “universal coverage” proposals

    • Two “single payer”

      • We will discuss the Kahn proposal

    • One “health service”


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Steps Forward, Almost Universal Health Reform

  • Healthy California (Brown and Kronick)

    • Stage One: Covers Low Income Adults

    • Stage Two: Pay or Play

    • Covers 6 million more Californians, to 33 million

    • BUT: As with Single payer, costs to state government are high and assumptions about federal funding optimistic.


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Pay or Play Health Reform

Pay Tax

Offer Insurance

Employers Choose

Employees Choose

Workers Covered Under Public Program

Employer Plan



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Universal Health Care Proposals or Play

  • California Single Payer Plan (Jim Kahn and CaPA colleagues)

  • Cal Care (Judy Spelman and Health Care for All)

  • California Health Service Plan (CHSP) (Ellen Shaffer)


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How does it work? or Play

  • Universal coverage for residents of California

  • Comprehensive benefits, including long term care

  • Public administration


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The power of single payer: or Play

Highly equitable, highly efficient.

A rare combination.


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What is Single-Payer Health Care? or Play

Health insurance with these features:

  • Public financing -- one public payer

  • Universal -- covers everybody

  • Comprehensive -- covers all medical needs

  • Private delivery-- private & some public providers

  • Controls costs-- through global budgets and bulk purchasing, not clinical micromanagement

  • Portable -- retained with move, change or loss of job

  • Accountable -- to participants


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What do we get from Single-Payer? or Play

  • Administrativeefficiency via simplified reimbursement.

  • Patient freedom to choose/change health care providers, without paying more.

  • Provider freedom to choose mode of practice (fee-for-service, capitation, or salary).

  • Fairer financing (lower cost to sick, poor/middle-income).

  • Explicitness in priorities (e.g., prevention) and financing (e.g., risk adjustment)

  • Shared dedication to success, via universal participation.


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Benefits Under Single-Payer or Play

  • All medically necessary health care services as determined by the patient’s chosen provider

  • Full mental health, prescription drug, and long-term care coverage

  • No exclusion of “pre-existing conditions”

  • No deductibles or life-time cap in benefits

  • Modest co-payments, if any

  • Choice of any willing licensed health care provider


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How Does Single-Payer Do It? or Play

  • Just collects money and pays bills without needing to intrude into individual doctor-patient relationships to make a profit.


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How Does Single-Payer Do It? or Play

  • Just collects money and pays bills without needing to intrude into individual doctor-patient relationships to make a profit.

  • Global budgeting controls costs while leaving clinical decisions in the hands of the patient’s chosen health care professional.


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Ineffective and intrusive micromanagement by insurance companies (current system) involving an army of bureaucrats

Global budgeting (under single-payer) makes cost control administratively simple and unintrusive


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How Does Single-Payer Do It? companies (current system) involving an army of bureaucrats

  • Just collects money and pays bills without needing to intrude into individual doctor-patient relationships to make a profit.

  • Global Budgeting controls costs while leaving clinical decisions in the hands of the patient’s chosen health care professional.

  • Enrollees are the shareholders in a health care system motivated to provide the best possible care while controlling costs.


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Two Equal and Opposite forces: companies (current system) involving an army of bureaucrats

Desire to control costs (spent on someone else)

Desire for the best possible care for loved ones

  • Today, enrollees are not the shareholders, so these forces are out of balance: HMOs cheat rather than compete, to increase profits and increase stock price.

  • Under single-payer costs must be controlled by eliminating waste and preventing disease, not by denying care to the sick to maximize profits.


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How Does Single-Payer Do It? companies (current system) involving an army of bureaucrats

  • Just collects money and pays bills without needing to intrude into individual doctor-patient relationships to make a profit.

  • Global Budgeting controls costs while leaving clinical decisions in the hands of the patient’s chosen health care professional.

  • Enrollees are the shareholders in a health care system motivated to provide the best possible care while controlling costs.

  • Eliminates hidden sources of waste


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How Many Kinds of Waste can YOU Find in Health Care Today? companies (current system) involving an army of bureaucrats

  • Unnecessary and wasteful bureaucracies

  • Inadequate primary care ... increased utilization of expensive ER services

  • Inadequate mental health coverage manifests as somatic complaints

  • Inadequate resources for public health, prevention, and research

  • Legal costs related to lack of health insurance

  • Hidden costs (e.g. workers compensation and liability insurance partly pay for the lackof universal healthcare)


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FFS or integrated delivery system companies (current system) involving an army of bureaucrats

Hospital global budgets


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Universal Health Care Proposals: Bottom line companies (current system) involving an army of bureaucrats

  • Universal coverage, broad benefits

  • Expanded benefits for those with insurance!

  • Increased government spending but ...

    Lower total spending than now

  • Less spending on administration, overhead, and profits

  • More spending on direct care


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsEligibility

  • All state residents eligible.

  • Individuals lacking legal immigration status (i.e., “undocumented”) included if they document residence.

  • Non-SB 921 Option: After 3-month waiting period; longer residency for certain services (e.g., long-term care 3 years). Emergency care covered during waiting period.


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsDelivery system

  • Private and county.

  • Fee-for-service and capitated (integrated health delivery systems). Providers and participants choose one.


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsAdministration

  • Elected commissioner

  • Health Care Agency

  • Statewide boards/offices: Health Policy; Consumer Advocacy; Medical Practice Standards.

  • … responsible for financial management of the system; establishing eligibility and benefits; negotiating reimbursement.


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsBenefits

  • Comprehensive.

  • Specifically, all medical care deemed medically appropriate by the patient's licensed provider: inpatient, outpatient, tests, prescription drugs, durable equipment, podiatry, chiropractic, transport, rehab, disease management, language, prevention, mental health, dental and vision, long-term care (home-based, day treatment, 100 days institutional).

  • Medical Practice Standards - cosmetic excluded, Board may remove some services.


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsCost-sharing

  • No cost sharing for 2 years.

  • After 2 years, cost-sharing option with limits of $250 per person/$500 per family per year.

  • Exemptionfor individuals who meet income rules, and for prevention.


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsFinancing

  • Current public health care spending -- public insurance and service programs (e.g., Medi-Cal, Medicare, VA, categorical programs, some county safety net funds).

  • Unspecified tax rates on: employers, employees, unearned income, alcohol, tobacco.

  • Capture collateral sources, e.g., pension funding of health care.


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California Single Payer SB 921 companies (current system) involving an army of bureaucratsCost control

  • Global budget overall -- current spending, grow at GDP adjusted for population and other factors.

  • Global budget divisions -- (risk-adjusted) by region, FFS/integrated, FFS hospitals, FFS provider types.

  • Negotiated rates -- FFS, global, capitation.

  • Administration cost -- for system, likely < 4%.

  • Bulk purchasing -- eg drugs at federal supply schedule.

  • Capital expenditures -- oversight/approval >$500,000.

  • If deficit anticipated -- cost-sharing, waiting period, postponement of capital spending, other.




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Single Payer: EffectsAdvantages for Providers

  • Reduced administrative burden.

  • No micro-management by payers.

  • Consistent reimbursement across patients.

  • Consistent information requirements across patients.

  • Risk adjustment -- based on severity and perhaps quality.

  • Attract patients based on quality.


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Single Payer: EffectsChallenges for Providers

  • Reimbursement reduced to at least partly reflect lower administrative burden and uncompensated care.

  • Must work within global budgets / capitation rate.

  • For large providers, likely reduced market power.

  • Approval for capital spending.

  • Quality visible and key -- for patients, possibly rates.



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Bottom Line Effects

  • Universal coverage proposals

    • Universal coverage

    • Improved benefits for those with insurance

    • Lower total spending

  • Incremental and pay or play proposals

    • Increased coverage, but not universal

    • May be some steps backward

    • Increased costs


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Arguments against Single Payer Effects

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. It Will Lead to Rationing, like Canada and Great Britain

6. Only incremental reform is feasible


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Arguments against Single Payer Effects

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. It Will Lead to Rationing, like Canada and Great Britain

6. Only incremental reform is feasible


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1. We can’t afford it Effects

Response: We can afford it, we can’t afford our current system.


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The HCOP shows that Universal Publicly Funded Care Costs EffectsLess, not More

  • Incremental Reform

    • Many people still don’t have access to the care they need

    • Costs go up

  • Universal Coverage

    • Everybody gets health care, at a lower cost than currently


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Arguments against Single Payer Effects

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. It Will Lead to Rationing, like Canada and Great Britain

6. Only incremental reform is feasible


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2. It would erode choice Effects

  • Response: Would you rather have “choice” among a few insurance plans with limited benefits, or one health insurance policy with broad benefits that allows choice of providers?

  • Universal publicly-funded insurance gives consumers MORE choice of provider than almost all current plans


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Arguments against Single Payer Effects

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. It Will Lead to Rationing, like Canada and Great Britain

6. Only incremental reform is feasible


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3. It’s bad for business and the economy Effects

  • Response: A national health insurance program would be GOOD for the economy

    • Stop punishing people for changing jobs

    • Level the playing field among businesses that now do and don’t offer health insurance

    • Strengthen U.S. business position internationally

    • Reduce health care costs through large contracts(e.g., Rx drugs)

    • The transition requires careful planning to minimize disruption


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Small businesses can Effects’t afford the cost.

Actually, inaccessibility of health insurance is a major impediment to small business startup: you may have a great idea, but can’t start a company because you can’t attract employees – perhaps their current large employer is able to offer health benefits that you as a small employer can’t. Single-payer health care takes these shackles off entrepreneurship.

All competitors pay a fair share of health care benefits for employees – without need for a big benefits bureaucracy to keep track of who is covered by what, and when coverage starts, ends, or changes.


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Arguments against Single Payer Effects

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. Only incremental reform is feasible


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4. The government can’t do anything as well as the private system

  • Response: Public programs often work better than private programs.

    • Medicare is popular, the most efficient health insurance in the U.S. Beneficiaries choose physicians. It works for rich and poor.

    • Social Security, Fire and Police protection, roads, sewers, etc. are government programs with broad popular support, often evolved due to failure of private sector systems. They work and are popular perhaps because they benefit us ALL.


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Claims of Single-Payer Opponents system

  • Government programs are bad.

Response: What about Medicare, Social Security, Fire and Police protection, roads, sewers, etc. These are all government programs with broad popular support, that often evolved because of the failure of private sector alternatives to meet the needs of the people. These programs are popular perhaps because they benefit us ALL.


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Arguments against Single Payer system

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. It Will Lead to Rationing, like Canada and Great Britain

6. Only incremental reform is feasible


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5. It Will Lead to Rationing, like Canada and Great Britain

  • Response:

    • We have rationing now, according to who has insurance and who does not

    • We are talking about a system similar to Canada’s, not Great Britain’s

    • Canada has few significant waits for care

    • With sufficient spending (we will spend almost twice what Canada spends) there will be no need for rationing


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Arguments against Single Payer Britain

1. We can’t afford it

2. It would erode choice

3. It’s bad for business and the economy

4. The government can’t do anything as well as the private system

5. It Will Lead to Rationing, like Canada and Great Britain

6. Only incremental reform is feasible


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Although many health experts agree that universal publicly-funded insurance would solve many of our most pressing health care problems (access, under-insurance, waste, costs), the main argument against universal coverage is political infeasibility.


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Where would we be if we used the “political infeasibility” argument regarding the abolition of slavery, winning civil rights, or many other social and policy advances?


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Achieving Civil Rights took many steps and years infeasibility” argument regarding the abolition of slavery, winning civil rights, or many other social and policy advances?

  • Slavery first limited in the U.S. Constitution (1789)

  • Further constrained in Missouri Compromise

  • Eliminated in those states not under Union control (1864)

  • Banned by the Constitution (1865)

  • Voting Rights Act was not passed until 1965


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If we believe that a universal publicly funded health insurance is the best approach, let’s increase its political feasibility


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We Can Get There insurance is the best approach, let’s increase its political feasibility

  • From a recent Texas poll:

    52% favor - A national health plan, financed by taxpayers, in which all Americans would get their insurance from a single government plan

  • Other recent polls find similar results

  • This suggests that with a lot of education, work, and political organizing, a reasonable national health insurance proposal could win.

    University of Houston Center for Public Policy Texas Public Policy Survey Statewide Survey on Health Care Survey conducted June 20-29, 2002


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How can we “increase political feasibility”? insurance is the best approach, let’s increase its political feasibility

  • Expand coverage for the uninsured — this creates a constituency for coverage … imagine trying to take Medicare from seniors!

  • Grow the group of committed activists willing to educate the public about the advantages of universal health care

  • Put universal health care into the debate and onto the agenda at every opportunity

  • Build on key changes in public attitude, such as rising distrust of corporations due to accounting and profit-taking scandals

  • Use the HCOP as an educational tool


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What is CaPA? insurance is the best approach, let’s increase its political feasibility

  • The California Physicians Alliance, a chapter of Physicians for a National Health Program (PNHP)

  • CaPA’s primary goal is to:

    • Promote universal health access in California and the US

  • Secondary goals are to:

    • Protect the provider-patient relationship

    • Promote justice in health care

  • Basic assumptions are:

    • Health care is a human right

    • Equity in health care


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What can you do? insurance is the best approach, let’s increase its political feasibility

  • Join CaPA/PNHP

  • Recruit 10 of your friends to join CaPA/PNHP

  • Give this talk to a community group or at a house party

  • Write op-ed pieces and articles

If you aren’t part of the solution, you are part of the problem!


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In summary, for Single Payer insurance is the best approach, let’s increase its political feasibility

We can afford it, we would be spending our health care dollars better than now.

It is the right thing to do.

Coverage would be better for everyone.

It would not erode choice.

It would not be bad for business.

The government can do it.

We must make it feasible.


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Achieving Universal insurance is the best approach, let’s increase its political feasibilitycoverage will not happen overnight –Stay with the fight!


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Clinical Case Report: insurance is the best approach, let’s increase its political feasibilityThe U.S. Health Care System

  • Chief Complaint

  • History

  • Symptoms and Signs

  • Diagnosis

  • Treatment Options

  • Treatment Plan


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Chief Complaint insurance is the best approach, let’s increase its political feasibility


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“My patients can’t pay for care.” insurance is the best approach, let’s increase its political feasibilitySome are uninsured, and some have no insurance for medicines.


History l.jpg
History insurance is the best approach, let’s increase its political feasibility


Symptoms and signs l.jpg
Symptoms and Signs insurance is the best approach, let’s increase its political feasibility


Diagnosis l.jpg
Diagnosis insurance is the best approach, let’s increase its political feasibility


Treatment options l.jpg
Treatment Options insurance is the best approach, let’s increase its political feasibility


Treatment plan l.jpg
Treatment Plan insurance is the best approach, let’s increase its political feasibility


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MD disillusionment insurance is the best approach, let’s increase its political feasibility

  • Intrusive bureaucracy, managed care

  • Discontinuity of care

  • Compromised provider-patient relationship

  • Squeezed finances


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Unfairness insurance is the best approach, let’s increase its political feasibility

  • People without employer-based insurance pay premiums after taxes.

  • Younger people pay for Medicare but get no insurance themselves.

  • Renal disease is covered.


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What are the key structural features insurance is the best approach, let’s increase its political feasibilityof the ill health care system?

  • Private insurance linked to employment. Due to wage freeze + labor shortage in W W II.

  • Private insurers mainly for-profit due to conversions from non-profit.

  • Public insurance large but gaps. Medicaid and Medicare enacted in 1965 after debates since 1930s on national health insurance … Medicare fought by AMA as socialized medicine. Sporadic public program expansion.


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Number of uninsured, U.S. insurance is the best approach, let’s increase its political feasibility

40,000,000 = 15%

~ constant


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What are the options? insurance is the best approach, let’s increase its political feasibility

  • No intervention … observation only.

  • Reform health care market.

  • Expand public programs.

  • Improve the employer approach (pay or play).

  • Single payer.


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Diagnosis: insurance is the best approach, let’s increase its political feasibility

The U.S. health care system is haphazard, illogical, inefficient, and ineffective.

Drastic measures may be warranted.


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