1. Dr. Woolhandler has no financial conflicts of interest to report

9. Being Uninsured Increases The Risk of Dying by Between 3% and 41%

14. Many Specialists Won’t See Kids With Medicaid
Figure 2 Clinics Scheduling Specialty Care Appointments for Children, According to Type of Insurance. Public insurance was reported by callers as the Illinois Medicaid–Children's Health Insurance Program (CHIP) umbrella program; private insurance was reported by callers as Blue Cross Blue Shield. Each of the 273 clinics was called twice (for a total of 546 calls) by the same caller, with only insurance coverage varying between the two calls: once reporting Medicaid–CHIP coverage and once reporting private coverage. Calls were made 1 month apart, and the order of the reported insurance status was randomly assigned. Asthma clinics included 38 allergy–immunology clinics and 6 pulmonary disease clinics.
Bisgaier J, Rhodes KV. N Engl J Med 2011;364:

19. Rationing One third of Americans are uninsured or underinsured
They are often denied care
They are sicker and die younger than the affluent and well insured

20. Unnecessary Procedures20

21. How Market Force Shaped Which Hospitals Opened New Invasive Cardiology Programs Between 1996 and 2014
A competing hospital opening a program was a strong predictor of opening a new program.
For-profit ownership was a strong predictor.
Being a non-profit in a market dominated by for-profits was also a predictor.
Lack of service availability in the community was a weak predictor.
Source: NBER Working Paper W June, 2017 – N = ~315

24. Rationing a Surplus 100s of 1000s of unnecessary procedures
Excess capacity (for well-reimbursed services)
Excess high-tech equipment
Ubiquitous low-value/no-value care

33. 33

48. Medicare Privatization Increases Inequality, Costs and Profiteering

53. Despite Medicare’s Lower Overhead and Broader Network, Medicare Advantage Plans Outcompete Traditional Medicare By Cherry Picking, Upcoding and Lobbying for Overpayment

59. Center for American Progress:Medicare Extra for All

60. Medicare Extra
Mainstream Democratic Party’s response to momentum of Medicare-for-All
Major improvement over Hillary’s proposal, “public option” since enrollment in public plan is automatic
Voodoo economics: Foregoes single payer’s administrative savings by including multiple private insurers (employer plans and Medicare Advantage)
Medicare becomes a de facto high risk pool – which also raises costs

61. ACOs Warmed-over HMOs

62. HMO and ACO Similarities
Diagnosis: FFS and “fragmentation”
Rx: Invert FFS incentives
Shift insurance risk to providers
Protect” patients with P4P
Consolidate providers into entities large enough to be “held accountable” for cost (via capitation)

63. HMO and ACO Differences
More ACOs are provider-based (so far)
Patients not restricted to ACO (so far), and mostly unaware they’re in an ACO

65. 65

66. Do ACOs Pay Doctors to Deny Care? We Asked, Few Would Tell
Medicare requires Medicare Advantage plans but NOT ACOs to disclose physician incentives.
We surveyed all 426 Medicare ACOs’ CEO or “public contact” regarding physician payment policies – (3 s + 1 snail mail).
Only 9.2% responded
>1/3 of responding ACOs penalized docs based on their patients’ utilization of care.
42% “shared risk” with docs.
Source: Mansour M. et al, AJPH 2017;107:1251

70. “Mandate” Model for Reform
Expanded Medicaid-like program
Free for poor
Subsidies for low income
Buy-in without subsidy for others
Employer Mandate +/- Individuals
Insurance Exchanges 70

72. Medicare’s “Software” 18.9 Million Seniors Enrolled Within11 Months

75. Trump’s Health Financing Actions So Far
Skinny ACA repeal in tax law– ends individual mandate penalties
Allow “association”, “short term” and other junk insurance – undermines risk pools; and raises cost for sicker people.
Let employers deny coverage for birth control.
Obstruct ACA enrollment.
Allow states to implement punitive Medicaid changes – premiums, copays, workfare, time limits.

76. Canada-style Medicare for all

77. 77

86. Single Payer Transition: For Patients
Every U.S. resident gets an insurance card.
Coverage for all medically necessary care, no copays, deductibles.
Drug formulary, with alternatives covered when medically indicated.
Free choice of doctor or hospital.

87. Single Payer Transition: For Doctors
All patients fully covered.
Simplified FFS billing OR salaried practice in institutions paid global budgets/capitation.
Participating doctors couldn’t charge anyone for a covered service
Less time (and money) wasted on billing, coding etc. - resources redirected to increase clinical support/staffing.
Single formulary
Physicians take-home incomes little changed.

88. Single Payer Transition: For Hospitals
Global operating budgets
Separate grants for new capital purchases – Ban on using operating surplus to purchase new capital.
No per-patient billing or cost tracking
Charting and coding for clinical, not financial purposes.
Administrative savings redirected to clinical units.
Special funding to retrain displaced clerical and financial personnel to participate in clinical care.

89. Single Payer Transition: For Insurers and Drug Firms
Ban on private insurance duplicating single payer coverage, as well as Medicare Advantage plans. (Essential for administrative savings).
Drug prices negotiated with single payer -formulary inclusion used as leverage.
Break patents (e.g. “march in”) for price gouging.

94. All of the Senators Who Supported Single Payer in 2016

95. 2017 - 16 Senators Sponsor Single Payer Bill