Health and Wellbeing: Why does America Fare so Badly?

1. Health and Wellbeing: Why does America Fare so Badly? Steven A. Schroeder, MD Kinsman Ethics Conference April 11, 2013

2. Quick Poll • How many think U.S. has best medical system? • How many have family happy with their own medical care? • How many of you want your family to die in an ICU? • How many think that the 2010 Affordable Care Act was a good thing? A bad thing? Not sure?

3. NRC/IOM Report: Shorter Lives, Poorer Health* • Lack of universal health coverage • Weaker foundation in primary care • Poor care coordination • Greater obesity (though lower smoking rates) • Less likely to practice safe sex as teens • More car crashes, gun deaths • Greater income inequality • Highest rate of child poverty * Woolf and Aron. JAMA 2013; 309:771-72

4. Compared to Peer Countries, Americans do Worse:* • Infant mortality and low birth weight • Injuries and homicide • HIV and AIDS • Drug-related deaths • Obesity and diabetes • Heart disease • Chronic lung disease • Disability * IOM, U.S. Health in International Perspective, 2013

5. Why Are Americans so Unhealthy?* • Health systems (large # uninsured) • Social and economic conditions --higher poverty levels --higher: caloric intake, drug abuse, traffic accidents with alcohol, firearms violence --Poorer education --Weaker social safety net • Physical environments (automobile focused) * IOM, 2013

6. Five Iconic American Beliefs That Impair Population Health* • Individual freedom • Free enterprise • Self-reliance • Role of religion • Federalism * IOM 2013 report

7. Health Status: United States vs. 33 Other OECD Countries * White male/female values from 2004

8. Life Expectancy at Birth in Selected OECD Countries, 1960–2009. Fineberg HV. N Engl J Med 2012;366:1020-1027

9. Some Good News • US does much better for life expectancy after age 75 • Life expectancy data at all time high—77.6 years at birth, but ….. • Women: 80.1, men: 74.8 • White women>black women>white men>>>black men • Almost all the recent gains were in upper SES groups; (some declines in poor white women) • Much of those gains are from less use of tobacco

10. Proportions (Premature Mortality) (Premature Mortality) Determinants of Health Social15% • Genetic predisposition • Behavioral patterns • Environmental exposures • Social circumstances • Health care Genetic 30% Environment5% Health care 10% Behavior 40% Source: McGinnis JM, Russo PG, Knickman, JR. Health Affairs, April 2002.

11. * Also suffer frommental illness and/or substance abuse Behavioral Causes of Annual Deaths in the United States 435 Number of deaths (thousands) * * 112 Sexual Alcohol Motor Guns Drug Obesity/ Smoking Behavior Vehicle Induced Inactivity Source: Mokdad et al, JAMA 2004;291:1238-1245 Mokdad et al; JAMA. 2005; 293:293 Flegal KM, Graubard BI, Williamson DF, Gail, MH. Excess deaths associated with underweight, overweight, and obesity. JAMA 2005;293:1861-1867

12. Health Improves While Disparities Widen Health Time

13. Health Status—Summary • Doing better • Oregon is #13/50 states (2012) • But at bottom of developed world • We may not get enough credit for functional status improvements (new joints, etc.) • Major declines in heart disease (multiple reasons) • Major opportunities for improvement in tobacco and obesity • Can’t improve without more attention to the poor • Hard to improve through medical care alone

14. Costs of Medical Care: We’re Number One! • Up to 17.6% of GDP in 2010, $2.8 trillion; Netherlands 12%; others < • Poor health value for the dollar • Tendency to look for painless quick fixes (electronic medical record, pay for performance, comparative effectiveness) • Reluctance to take on the involved sectors (pharma, device and insurance industries, hospitals, doctors, unions)

15. Actual and Projected National Health Expenditures, Selected Years Source: Sean Keehan and others (2008). “Health Spending Projections Through 2017: The Baby-Boom Generation is Coming to Medicare.” Health Affairs Web Exclusive, Feb. 26, pp w146. (www.healthaffairs.org)

16. Health Expenditures as a Percentage of Gross Domestic Product (GDP) in Selected OECDCountries, 1960–2009. Fineberg HV. N Engl J Med 2012;366:1020-1027

17. 2010 Health Expenditures as a Share of GDP Source: OECD Health Data 2012

18. The U.S. Healthcare Value Shortfall Health Care Spending- Per Capita In $US PPP* Years - Estimated Average Life Expectancy Source: Harvard Business Review, p. 70, April 2010

19. IOM Estimates of Sources of Excess Medical Costs* • Unnecessary services $210b • Inefficiently delivered services $130b • Excess administrative costs $190b • Prices that are too high $105b • Missed prevention opportunities $ 55 • Fraud $ 75 Total = $765b, or about 1/3 total expended * 2010 report, based on 2009 expenditures

20. Why Is U.S. Medical Care So Costly?* • Physician supply? No (but specialty % very high) • Fee for service payment valuations? Yes • Health worker incomes? Yes • Hospital supply/length of stay? No • Proportion intensive care beds? Yes • Rate of expensive procedures, and technology in general? Yes!! *Schroeder synthesis

21. Why Is U.S. Medical Care So Costly (Part 2)? • Administrative costs? Yes • Malpractice, including defensive medicine? (Yes, about $54 b/year; 80% on defensive medicine) • Aging population? Not really • Patient demand? Yes • Lack of cost competition? No, but may be a cost containment strategy • Low investment in IT? Maybe • Fraud and abuse? Yes

23. Why Does US Medical Cost Containment Fail? • Americans (those who are insured) resist limiting choices • Power of industries—device manufacturers and drug companies • Power of medical/hospital sectors • Strong patient demand for more (e.g., alternative medicine) • Surge of new technologies • Political hot potato, and lack of accountability focus

24. Time Magazine Criticizes Hospitals

25. Why Not Let Costs Keep Rising? • Opportunity costs • Schools • The environment • Jobs and overseas competition (see General Motors) • Other worthy causes • Business resistance • Operational costs • Retiree costs • Source of labor disputes • Pressure on public programs (Medicare, Medicaid, County Hospitals) • Increases the number of uninsured • Biggest cause of personal bankruptcies

26. Health Care Priorities* • We want the best • We want it right now • We want choices • We want someone else to pay for it • If we can’t get it, we will sue * Most countries pick 2. U.S. has all 5

27. Access to Health Care • “Best of systems, worst of systems” • Insurance coverage the major barrier; we are unique in large % uninsured. 50.7 million uninsured in 2009 (16.7% population) • Gradual decline in employer coverage • Shift of expenses to out of pocket • Geography, language, literacy, racial barriers also important

28. Why U.S. Tolerates Such a Large Number of Uninsured? Explanations, Rationales and Myths* 1. The numbers are exaggerated 2. Uninsurance is often temporary 3. Many choose to be uninsured 4. The uninsured get care anyway 5. We can’t afford to expand coverage 6. Government is untrustworthy 7. American political system prevents major reform 8. (Poor under-represented politically) *Schroeder SA., The medically uninsured—will they always be with us?, NEJM, 1996; 334:1130-1133.

29. Major Implementation Challenges for the ACA • Implementation details tricky and still in progress: --state health exchanges --how does IRS collect penalties? --states have latitude in defining benefits --funding for demonstration projects

30. Obstacles to ACA Implementation • Creating the state exchanges: to date only 25/51 states have opted in • The Medicaid expansion component: a moving target; to date 23 states have accepted; 13 uncertain; 14 refused • House Republican budget tries to undo much of the ACA • No funding for certain elements of cost savings—health care workforce task force, IPAB • Other Republican attempts to obstruct, in contrast with Medicare in 1965, SCHIP in 2000, Medicare Part D in 2003

31. Legal Challenge to ACA • 26 state attorneys general asked Supreme Court suit to overturn ACA on two grounds: --The individual mandate (first enacted in MA) is unconstitutional. “Can the government require you to eat broccoli?” Yes it can. --The Medicaid expansion is coercive. Yes it is

32. Making Sense of all this • In the U.S., entrepreneurialism trumps solidarity • Class is the underlying factor in disparities in health and health care. • But we tend to conceptualize class as race. Is this unduly divisive? Does it demean people of color to have the implicit equations: White=rich; color=poor?

33. Making Sense (2) • Two fundamental issues: (1) opportunity costs of overspending on health care, and (2) how to narrow the class gap in health? • Opportunity costs are huge: education, environment, infrastructure. Don’t yet have a safe way politically to even debate these issues, though OR does it better than most • Entrenched interests (18% of GDP) will fight all attempts to bend the cost curve

34. Making Sense (3) • Narrowing the health and healthcare gap will depend on structural reforms --political campaign finance reform --revitalize labor (more of a force in Europe, with many Labor Parties) --greater voter registration and turnout --reforms within public health and medicine