Health Care Reform • Issues of power and control, political expedience and emphasis on individualism • Only industrialized nation in the world without a comprehensive medical coverage plan (national health insurance) • Why?
Co-opting the middle class • This lack of comprehensive coverage affects all classes but worse for the middle class • 47 million people have no health coverage and another 29 million are under protected for even catastrophic illness: most of these have middle class incomes, occupations and education • 60% of all bankruptcies are caused by medical costs
Causes of the problem • Is it a problem—depends on your view of the role of government • Entrepreneurial Doctoring • Industrial and economic free will and opportunity • Large profits • Individual responsibility
Causes of Problem • We-they oppositional attitudes, blaming the victim • Volunteerism not a factor as medicine becomes more economically dominated • We will care for you if you can pay • Exceptions—Medicare, Medicaid, AFDC, and EMTALA
Who pays? • Type of Payment (1991) (% of dollars spent) • Out-of Pocket 22% (Higher now) • Private insurance 5% • Employer based insurance 27% • Government 43%
Who pays? • Source of Coverage (% of population) • Uninsured 19% (higher now) • Individual insurance 4% • Employment based insurance 48% • Government 29%
Managed Care • Cost limits mean care limits • Control by protocol and paperwork • Insurance power • Individual lack of power • Managed Care defined
Trends • Employers hit with higher bills are passing cost on to employees • Co-payments, higher deductibles • Less covered procedures and tests • More use of ER • More people going without care because of cost, worse health—presenting sicker and requiring more dollars spent (Public health issue)
Burdens • Individuals • Insurers • Employers • Government • Health institutions
Example • Uncompensated care rises for hospitals • Fewer dollars for new technologies and closing ERs and Hospitals • More people don’t pay • Worse credit ratings for those and worse economic stability • Less compensated care • Cost shifting
Out of Pocket expense • Affects those with lower incomes more • May impact where people go for care • ER as clinic and primary care giver • ER docs poorly trained to be primary care givers
Doctoring as Business • Professionalism and status a moral and social contract • We give you power and status and you give us care and compassion, etc. without regard to cost, payment • This contract is breached with medicine as business—Contract there is different
Why do you go into medicine? • Altruism • Compassion • Help people • Use your intellect • THEN income, status • What happens when the financial reward is not enough to continue the effort?
Problems • Pervasive anti-government mentality • Reliance on self-reliance and control • Market forces to control costs—why does that not work? • The market is one’s very existence and we do not use economic benefit/risk analysis alone for these decisions
Doctor as Businessman • Managed care decreased the autonomy of doctors • Dissolved the link between bill and payment • Took control over decisions with protocols and procedure denials for routine (non-emergent) procedures • Authorization process
Why should you care? • You will pay if you have insurance and others do not—cost shifting—not changed with new system • Government and industry will control your ability to get desired and needed services • Not a grocery store any more • Your physician has little power to change this • Both of us lose to creeping bureaucracy
New reform • Will the new reform make any difference?
What should you do? • Make more money • Invest in buffers such as medical emergency funds • Sacrifice other desires for coverage • PREVENT ILLNESS and disease that are preventable by good health practices, vaccines and less risk behaviors • Rationing and political protest