1. PHYSICIANS FOR A NATIONAL HEALTH PROGRAM 29 EAST MADISON SUITE 602 CHICAGO, IL 60602 TEL: (312) 782-6006 WWW.PNHP.ORG

2. The Uninsured

11. Financial Suffering Among the INSURED

18. Rising Economic Inequality

24. Persistent Racial Inequalities

30. Racial Disparity in Access to Kidney Transplants

32. Rationing Amidst a Surplus of Care

33. Unnecessary Procedures

34. Variation in Medicare Spending: Some Regions Already Spend at Canadian Level

37. 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

38. Profit-Driven HMOs: A Problem, Not a Solution

44. Medicare HMOs: A Cautionary Tale About Competition Between Public and Private Plans (AKA Public Plan Option)

46. Despite Medicare’s Lower Overhead, Enrollment of Medicare Patients in Private Plans Has Grown

48. Private Medicare Plans Have Prospered by Cherry Picking

56. Investor-Owned Care: Inflated Costs, Inferior Quality

59. For-Profit Hospitals’ Death Rates are 2% Higher Source: CMAJ 2002;166:1399

60. For-Profit Hospitals Cost 19% More Source: CMAJ 2004;170:1817

62. For-Profit Dialysis Clinics’ Death Rates are 9% Higher Source: JAMA 2002;288:2449

65. Drug Companies’ Cost Structure

67. High Deductible Insurance: Except for the Healthy and Wealthy, It’s Unwise

75. Mandate Model Reform: Keeping Private Insurers In Charge

76. “Mandate” Model for Reform Proposed by Richard Nixon in 1971 to block Edward Kennedy’s NHI proposal

77. “Mandate” Model for Reform Government uses its coercive power to make people buy private insurance.

78. “Mandate” Model for Reform 1.Expanded Medicaid-like program  Free for poor  Subsidies for low income  Buy-in without subsidy for others 2.Employer Mandate +/- Individuals 3.Managed Care / Care Management

80. “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

81. The Massachusetts Reform: Headed Towards Failure

82. Massachusetts Health Reform New Coverage < 150% Poverty - Medicaid HMO < 150% Poverty - Medicaid HMO 150% - 300% poverty - Partial subsidy 150% - 300% poverty - Partial subsidy > 300% poverty – Buy Your Own > 300% poverty – Buy Your Own

83. Massachusetts: Required Coverage (Income > $31k) Premium: $4,800 Annually (56 year old) Premium: $4,800 Annually (56 year old) $2000 deductible $2000 deductible 20% co-insurance AFTER deductible is reached 20% co-insurance AFTER deductible is reached

84. Crimes and Punishments in Massachusetts The Crime The Fine Violation of Child Labor Laws $50 Employers Failing to Partially Subsidize a Poor Health Plan for Workers $295 Illegal Sale of Firearms, First Offense $500 max. Driving Under the Influence, First Offense $500 min. Domestic Assault $1000 max. Cruelty to or Malicious Killing of Animals $1000 max. Communication of a Terrorist Threat $1000 min. Being Uninsured In Massachusetts $1068 $1068

85. How Many are Uninsured in Massachusetts? State and Blue Cross Surveys – 2.6% State and Blue Cross Surveys – 2.6% Phone survey, few non-english speakers Phone survey, few non-english speakers Census Bureau – 5.5% Census Bureau – 5.5% Door-to-door survey, all local languages Door-to-door survey, all local languages Mass. Department of Revenue – 5% Mass. Department of Revenue – 5% of taxpayers, as of 1/1/2008 – based on tax of taxpayers, as of 1/1/2008 – based on tax returns returns

90. Tried and Failed: State Experiments with Mandate Model and Other Incremental Reforms

91. Massachusetts 2006 “Every uninsured citizen in Massachusetts will soon have affordable health insurance and the costs of health care will be reduced. Gov. Romney.” Sources: Wall Street Journal 4/11/06 and New York Times 4/5/06. “The bill does what health experts say no other state has been able to do: provide a mechanism for all of its citizens to obtain health insurance.”

92. Massachusetts 1988 “I am very proud of the fact that Massachusetts will be the first state in the country to enact universal health insurance.” Gov. Dukakis` Sources: New York Times 4/14/88 and 4/26/88 “Massachusetts last week ventured where no state has gone before: it guaranteed health insurance for every resident.”

94. Sources:Washington Post 6/9/92 and 3/20/`93 Oregon 1992 “Today our dreams of providing effective and affordable health care to all Oregonians has come true.” Gov. Roberts “The most far-reaching health care reform in the nation.”

96. Sources: Federal & State Insurance Week 4/12/93; and NY Times 9/16/94 “The most radical health care plan in America.” “Tennessee will cover at least 95% of its citizens with health insurance by the end of 1994.” Gov. Ned McWherter Tennessee 1992

98. Vermont 1992 “This is an incredibly exciting moment that should make all Vermonters proud.” Gov. Dean Source: New York Times 4/12/92 “Governor Howard Dean, the only governor who is a doctor, signed a law here today that sets in motion a plan to give Vermont universal healthcare by 1995.”

100. Sources: New York Times 4/19/92; and Richard Reece, Medical World News 7/1/92. “Minnesota is enacting a program that will be the most sweeping effort yet to provide health insurance to people who lack it... the first complete reform proposal in the U.S.” “Minnesota is about to embark on a plan to solve the health- insurance crisis that could hold lessons for other states and the nation.” Minnesota 1992/1993

102. Washington 1993 Source: New York Times 5/2/93 Washington state “passed one of the most aggressive health care experiments in the nation, a program that would extend medical benefits to all 5.1 million residents of the state....”

104. Sources: AP Newswire 4/25/06 and Ellen Goodman, Washington Post Writers Group 7/7/03. “It’s bold and comprehensive, and it’s now the law of the state.” Gov. Baldacci Maine 2003 “Maine has just become the first state in the union to approve a plan to provide universal access to affordable health insurance.”

106. Public Plan Option: The Next Disappointment

107. In 1962 Republicans Jacob Javits and John Lindsay proposed a Public Plan Option (H.R. 11253 and S. 2664) as an alternative to a public Medicare plan

108. Public Plan Option Saves Little Even if Half of Privately-Insured Switch No savings on hospitals’ billing or internal cost tracking  Hospitals already use computerized uniform bill (UB-82)  Global budgeting could save $90 bil. annually No savings on NH/home care bureaucracy ($24 bil. saved with single payer) No savings on MD office bureaucracy  Single payer would save $85 bil. annually through simple, uniform fee schedule, eliminating prior-approval etc. Insurance overhead reduced $38 bil. v $131 bil. under single payer  Private insurers retain significant market share  Hospital/NH payment can’t be simplified without global budgets  Need to collect premiums, track enrollment disenrollment etc.

110. Public Plan Option Cannot Solve Cost Problems Achieves only a fraction (1/7 th ) of administrative savings possible through single payer – makes expanded coverage unaffordable Medicare HMO experience shows private plans undermine fair competition despite regulations – avoid expensively ill Public plan effectively serves as subsidy for private insurers, taking on many high cost patients and few profitable ones

111. Public Money, Private Control

113. The U.S. Trails Other Nations

127. Canada’s National Health Insurance Program

140. Quality of Care Slightly Better in Canada Than U.S. A Meta-Analysis of Patients Treated for Same Illnesses (U.S. Studies Included Mostly Insured Patients) Source: Guyatt et al, Open Medicine, April 19, 2007

149. A National Health Program for the U.S.

157. Phony vs. Real Reform Phony Choice of HMO/insurer Coverage = Copays, exclusions etc. Security = Lose it if you can’t work or can’t pay Savings = Less care Real Choice of doctor and hospital Coverage = First $, Comprehensive Security = For everyone, forever Savings >$400 bil on bureaucracy

158. Public Opinion Favors Single Payer National Health Insurance