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