1 National Health Insurance Kenneth Brummel-Smith, M.D. Charlotte Edwards Maguire Professor & Chair, Department of Geriatrics Florida State University College of Medicine

2 Current “System”  1000 insurers (over 4000 different policies)  Rationing happens here Wait times for elective surgeries Preventive care for uninsured and some insured Chronic care for uninsured  Higher dissatisfaction by patients and Drs  Huge profit margins of insurance companies

3 Billing Clerks  We have 900 billing clerks at Duke (900 bed hospital). I’m not sure we have a nurse per bed, but we have a billing clerk per bed. It’s obscene. Dr. Uwe Reinhardt, hearing on healthcare reform, US Senate Finance Committee, November 19, 2008  This is how we do “market-based” care 30% of the health care dollar goes to administration  Canadian hospitals average 2 billing clerks

4 Definitions  Universal coverage – everybody has some form of insurance coverage  Socialized medicine – medical care system is owned and managed by the government Drs are employed by government Hospitals are owned by the government  Single payer national health insurance – there is one insurance program for all

5 Many Models Single PayerSocializedRegulated Insurance Mixed CanadaEnglandGermanyUS DenmarkSpainFrance NorwayNetherlands Australia Taiwan Sweden

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7 18,314 Adult Deaths Annually Due to Uninsurance

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11 Half of Americans Live Where Population Is Too Low for Competition Source: NEJM 1993;328:148 A town’s only hospital will not compete with itself

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14 “Mandate” Model - Problems  Absent cost controls, expanded coverage unaffordable  Computers, care management, prevention not shown to cut costs  Adds administrative complexity and cost; retains wasteful private insurers  Impeccable political logic, economic nonsense

15 We Are Partly There!  We already have single payer Medicare  We already have socialized medicine Department of Defense Veterans Administration  We already have regulated insurance Federal Employees Health Benefits  We spend more than anyone else

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17 Funding For National Health Insurance  Income Source Medicare $ Medicaid $ DOD, VA $ Personal income tax – top 5% Payroll tax similar to current health payments Small tax on stock & bond transactions  Expenditures Hospitals (operating) Hospitals (capital) Fee-for-service providers Home care agencies Long term care providers HMOs Malpractice subsidy? Education subsidy?