Open Classroom Series Fall 2013: Policy for a Healthy America

1. Open Classroom Series Fall 2013: Policy for a Healthy America • Every Wednesday, 6pm – 8pm • September 4 through December 4 • West Village F, Room 20

2. This Week (September 4, 2013) “The US Health Care System: The Best and Worst in the World” Timothy Hoff Associate Professor of Management, Healthcare Systems, and Healthy Policy, Northeastern University, School of Public Policy and Urban Affairs & D’Amore–McKim School of Business Wendy Parmet Associate Dean for Academic Affairs and George J. and Kathleen Waters Matthews Distinguished University Professor of Law, Northeastern University, School of Law School of Public Policy & Urban Affairs | Northeastern University

4. U.S. Health Care:The Good, the Bad, and the Ugly Timothy Hoff, Ph.D. D’Amore-McKim School of Business School of Public Policy and Urban Affairs

5. US Spends More Source: OECD (2010), “OECD Health Data”, OECD Health Statistics

7. Source: UC Atlas of Global Inequality, at http://ucatlas.ucsc.edu/index.php.

8. The US Compared to Others • Compared to peer countries, US fares worse (infant mortality, violent deaths, HIV/AIDS, substance abuse, chronic disease) • Better survival after age 75 • Higher cancer survival, lower smoking rates, better control of high blood pressure and cholesterol

9. What’s the Deal? • We do not get value for the dollars spent • e.g. high quality of care, patient satisfaction, life quality • Emphasis on curative, not on preventive • A primary care system dying on the vine • Fragmented delivery system • 38 specialties, 124 subspecialties in US • Customers removed from costs of care • Promotes unhealthy behaviors, moral hazard

10. Alarming Realities • 48.6 million (16.7%) of Americans are uninsured • Health care prices are out of control • Persons covered by employer-sponsored insurance down 11.5 million from 2000-11 • Living longer, but not healthier • Depression, obesity, diabetes

11. Sociological Explanations • Sociological Explanations: • Societal norms: rugged individualism • Infrastructures not amenable to health • “Immediate gratification” culture • Poverty, inequality, and ill health • Lack of social mobility worse than ever

12. Economic Explanations • An advanced consumption-driven economy • Fast food, the car culture, selling unhealthy lifestyles • A fragmented health care marketplace • Rise of insurance, health care as a fringe benefit, separation of public health from medicine

13. What Should We Build On? • Medicare is a successful program • Life spans have lengthened for everyone • Insurance produces longer, better lives • We have an exceptional acute care system • We are starting to focus on new definitions of value

14. What Must Happen • Financing must shift to prevention and basic care • Prices must come down for all specialty services • Health insurance must be given to all • People must take greater responsibility for their health • System integration needed • Health care must be depoliticized

16. The U.S. Health Care System: The Best & The Worst in the World Wendy E. Parmet, JD Associate Dean for Academic Affairs, Northeastern Univ. School of Law

17. Doctor–Patient Relationship and Communication Base: Has a regular doctor/place of care. Source: 2011 Commonwealth Fund International Health Policy Survey of Sicker Adults in Eleven Countries.

18. Deaths Due to Surgical or Medical Mishaps per 100,000 Population, 2006 * 2005 **2004 Source: OECD Health Data 2008, “June 2008.”

19. Overall Ranking Note: * Estimate. Expenditures shown in $US PPP (purchasing power parity). Source: Calculated by The Commonwealth Fund based on 2007 International Health Policy Survey; 2008 International Health Policy Survey of Sicker Adults; 2009 International Health Policy Survey of Primary Care Physicians; Commonwealth Fund Commission on a High Performance Health System National Scorecard; and Organization for Economic Cooperation and Development, OECD Health Data, 2009 (Paris: OECD, Nov. 2009).

20. Quality of CareUS v. OECD Nations Above Average Below Average Access to Primary Care Management of diabetes Mortality for diabetes Post-discharge admissions Medical errors Childhood immunizations • Access to Specialists • Screening Tests • Use of cholesterol-lowering drugs • Mortality for MCI • Mortality for ischemic stroke • Adult immunizations

21. Mortality Amenable to Health Care Deaths per 100,000 population* * Countries’ age-standardized death rates before age 75; including ischemic heart disease, diabetes, stroke, and bacterial infections. See report Appendix B for list of all conditions considered amenable to health care in the analysis. Data: E. Nolte and C. M. McKee, London School of Hygiene and Tropical Medicine analysis of World Health Organization mortality files (Nolte and McKee 2008). Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

22. In 2012, Nearly Half of Adults Were Uninsured During the Year or Were Underinsured Uninsured during the year* 30% 55 million Insured all year, not underinsured^ 54% 100 million Insured all year, underinsured^ 16% 30 million 184 million adults ages 19–64 Note: Numbers may not sum to indicated total because of rounding. * Combines “Insured now, time uninsured in past year” and “Uninsured now.” ^ Underinsured defined as insured all year but experienced one of the following: out-of-pocket expenses equaled 10% or more of income; out-of-pocket expenses equaled 5% or more of income if low income (<200% of poverty); or deductibles equaled 5% or more of income. Source: The Commonwealth Fund Biennial Health Insurance Survey (2012).

23. Uninsured Rates Among Nonelderly by State, 2007-2008 NH VT WA ME MT ND MN MA OR NY WI SD ID RI MI CT WY PA NJ IA NE OH NV IN IL DE UT WV VA MD CO CA KS MO KY DC NC TN OK SC AR AZ NM GA AL MS AK TX LA FL HI <14% Uninsured (18 states & DC) National Average = 17% 14 to 18% Uninsured (18 states) >18% Uninsured (14 states) SOURCE: Kaiser Commission on Medicaid and the Uninsured/Urban Institute analysis of 2008 and 2009 ASEC Supplements to the CPS., two-year pooled data.

24. Medical Bill Problems or Medical Debt Percent of adults (ages 19–64) with any medical bill problem or outstanding debt* By Income and Insurance Status, 2007 National Average * Problems paying or unable to pay medical bills, contacted by a collection agency for medical bills, had to change way of life to pay bills, or has medical debt being paid off over time. Data: 2005 and 2007 Commonwealth Fund Biennial Health Insurance Survey. Source: Commonwealth Fund National Scorecard on U.S. Health System Performance, 2008

25. Diagnosis of Late-Stage CancerUninsured vs. Privately Insured Ratio of probability of diagnosis of late vs. early stage cancer, Uninsured/private insurance Equal likelihood between Uninsured and Insured NOTE: Odds ratios were adjusted for age, sex, race/ethnicity, facility type, region, and income and education on basis of postal code. They represent the odds of being diagnosed with stage III or state IV cancer vs. stage I cancer. Analysis based on cases occurring between 1998-2004. SOURCE: Kaiser Family Foundation, based on Halpern MT et al, Association of insurance status and ethnicity with cancer stage at diagnosis for 12 cancer sites: a retrospective analysis." The Lancet Oncology. March 2008.

26. It’s Not Just (Or Mostly) Health Care “But health care systems and the health services they deliver are not the only influences on population health.” - National Research Council & Institute of Medicine, 2013

27. Obesity (BMI>30) Prevalence Among Adult Population, 2007 Percent * 2006 ** 2005 Note: BMI = body mass index. For most countries, BMI estimates are based on national health interview surveys (self-reported data). However, the estimates for the US, UK, and New Zealand are based on actual measurements of weight and height, and estimates based on actual measurements are usually significantly higher than those based on self-report. Source: OECD Health Data 2009 (June 2009).

28. Adult Population Smoking Daily2009 - OECD

29. Birthrate per 1,000 Women, ages 15-19, 2000-2009

30. 10 Great Public Health Achievements • Immunizations • Motor Vehicle Safety • Workplace Safety • Control of Infectious Disease • Declines in Deaths from Heart Disease & Strokes • Safer and Healthier Foods • Healthy Mothers & Babies • Family Planning • Fluoridation of Water • Tobacco Control

31. Barriers to a Healthier U.S. • Economics, Culture, Politics, & Law • Income & racial inequality • Risk-taking culture • An aversion to regulation • Our political & legal systems

33. Open Classroom Series Fall 2013: Policy for a Healthy America September 4, 2013 - “The US Health Care System: The Best and Worst in the World” Any Questions? Timothy Hoff Associate Professor of Management, Healthcare Systems, and Healthy Policy, Northeastern University, School of Public Policy and Urban Affairs & D’Amore–McKim School of Business Wendy Parmet Associate Dean for Academic Affairs and George J. and Kathleen Waters Matthews Distinguished University Professor of Law, Northeastern University, School of Law School of Public Policy & Urban Affairs | Northeastern University

34. Next Week (September 11, 2013) “Promises and Pitfalls of ‘Obamacare’” John Auerbach Distinguished Professor of Practice and Director of the Institute on Urban Health Research, Northeastern University; former Commissioner of Public Health in Massachusetts (2007 – 2012) John McDonough Professor of the Practice of Public Health and Director of the Center for Public Health Leadership, Harvard School of Public Health, Department of Health Policy and Management, Division of Policy Translation & Leadership Development School of Public Policy & Urban Affairs | Northeastern University