The shortcomings of the

ACA prove its time for a

single-payer healthcare
system
Anand Saha
Quillen Chapter of Physicians for a National Health
Program
ETSU Quillen College of Medicine
Physicians for a National
Health Program (PNHP)

Quillen College of Medicine founding chapter

o
President: Anand Saha, MS
o
Vice President: Annie !olari", MS
o
Secretary/Treasurer: #i$erty %oye, MS
o
Advisory Board Members: &&&&&&&&&&&&& and &&&&&&&&&&&&&, MS'

(ur partners
o
Chapters in East TN, Middle TN, and )est TN
o
UT College of Medicine Chapter starting in Septem$er
o
*ander$ilt and Meharry in the +or"s,

'-,.../ physicians and other professionals

nation+ide
Physicians for a National
Health Program (PNHP)
PNHP supports a single0payer, 12mpro3ed Medicare
for All4 health system +here medical care is
privately-delivered but publicly-funded, PNHP
$elie3es that access to high05uality health care is
a right of all people and should $e provided
equitably as a public service rather than $ought
and sold as a commodity,
What will NOT
be talked about
6emocrats7 and
8epu$licans7 3ie+s on
healthcare reform,
Anything from %o9 Ne+s,
MSN:C, CNN, or partisan
thin" tan"s,
Politics
%acts and e3idence from
peer-reviewed sources
only,
My opinion $ased on the
facts and e3idence on
+hy single0payer is the
ans+er,
What will be
talked about
E*26ENCE ; Politics
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
Kwas Rule of Threes
Overview
2, =lo$al models of healthcare systems,
22, )hat7s $ro"en in USA7s healthcare system>
222, )hy free mar"et healthcare +ith for0pro?t
insurance companies is not the ans+er,
2*, )hy single0payer is the ans+er,
*, Physicians for a National Health Program
proposal@ 12mpro3ed Medicare for All4
Part 2@ =lo$al models of
healthcare systems
Two components
of a healthcare system
Healthcare
Healthcare
6eli3ery
AHealthcare
pro3idersB
6eli3ery
AHealthcare
pro3idersB
%inancing
AHealth
2nsuranceB
%inancing
AHealth
2nsuranceB
TR Reids 4 models of healthcare

:e3eridge Model
o
!nsurance@ Public, pro3ided
and ?nanced $y go3ernment
through ta9,
o
"ealthcare@ Public, doctors
are employees of
go3ernment,

:ismarc" Model
o
!nsurance# Private, non-
proft companies pro3ide
insurance,
o
"ealthcare@ Private, doctors
run pri3ate $usinesses,

National Health
2nsurance
o
!nsurance@ Public, pro3ided and
?nanced $y go3ernment through
ta9,
o
"ealthcare@ Private, doctors run
pri3ate $usinesses,

(ut0of0poc"et
o
No formal system forC
anything,
o
8ich get healthcare
TR Reids 4 models
of healthcare
$everidge
%odel
$ismarc&
%odel
'ational
"ealth !nsurance
Out-of-
poc&et
!nsurance Pu$lic Pri3ate Pu$lic None
"ealthcare Pu$lic Pri3ate Pri3ate Pri3ate
E(amples
of
countries
:ritain,
2taly,
Scandina3ia
=ermany,
Dapan,
%rance
Canada,
Tai+an
African
countries, 2ndia, S
America
T.R. Reid's book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care
PNHP endorses single0payerE
Canadas Medicare is run by each
individual province
Credit: PNHP Shapiro PowerPoint
4 Requirements for
Province-operated Medicare
)*+niversal coverage that does not impeded,
either directly or indirectly, +hether $y charges or
other+ise, reasona$le access,
,*-ortability of bene.ts from pro3ince to
pro3ince
/*Coverage for all medically necessary
services
F,Pu$licly administered, non-pro.t program
Credit: PNHP Shapiro PowerPoint
Part 22@ )hat7s $ro"en in
USA7s healthcare system>
USA = patchwork of models

:e3eridge Model
o
!nsurance@ Public, pro3ided
and ?nanced $y go3ernment
through ta9,
o
"ealthcare@ Public, doctors
are employees of
go3ernment,

:ismarc" Model
o
!nsurance# Private, non-
proft companies pro3ide
insurance,
o
"ealthcare@ Private, doctors
run pri3ate $usinesses,

National Health 2nsurance

o
!nsurance@ Public, pro3ided and
?nanced $y go3ernment through
ta9,
o
"ealthcare@ Private, doctors run
pri3ate $usinesses,

(ut0of0poc"et
o
No formal system forC
anything,
o
8ich get healthcare
Credit: PNHP California
Why so complicated?
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
US Spending per capita
US Spending per Capita
6ata are for .'.
Sources@ (EC6 .'G Health AHairs .. 'AFBII
J0
J,...
JF,...
JK,...
JI,...
J'.,...
JL,.F.
JL,FL.
JL,MK.
JL,-M.
JF,LF.
JF,FF.
JN,-.
J,-F.
Total US Pu$lic US Pri3ate

.
'
.

h
e
a
l
t
h
c
a
r
e

s
p
e
n
d
i
n
g

p
e
r

c
a
p
i
t
a
+SA0s public spending
e(ceeds everyone0s total
spending1
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
USA is 1 of 3 developed countries
that do not guarantee healthcare
Uninsured Americans
N.
FN
F.
LN
L.
N
.
M
i
l
l
i
o
n
s

o
f

U
n
i
n
s
u
r
e
d

A
m
e
r
i
c
a
n
'-MK '-I. '-IN '--. '--N ... ..N .'
'
Source@ Himmelstein, )oolhandler O Carras5uilo,
Ta$ulation from CPS O NH2S data
Why uninsured?
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
Nolte O Mc!ee, Measuring The Health Of Nations,
Health AHairs, Dan0%e$ ..I
Decline in Preventable
Mortality 1998-2002
USA Dapan Canada%rance 2taly Australia U!
0.,.N
.
.,.N
.,'
.,'N
.,
.,N
.,L
FP
'LP
'FP 'FP
'MP
'P
P
D
e
c
l
i
n
e

i
n

P
r
e
v
e
n
t
a
b
l
e

M
a
l
e

D
e
a
t
h
s

p
e
r

1
0
0
,
0
0
0
Credit: Steve Kemble, MD
Note@ 6ata are for .'' or most recent year a3aila$le
Source@ (EC6, .'L
Infant Mortality: Deaths in 1
st Year of Life Per
1,000 Live Births
.
'

L
F
N
K
M
K,'
F,-
L,I
L,K
L,N
L,F
,'
Credit: Steve Kemble, MD
Note@ 6ata are for .'' or most recent year a3aila$le
Source@ (EC6, .'L
Physician Visits per Capita
USA 6enmar" U! Australia%rance Canada Dapan
.

F
K
I
'.
'
'F
F,'
F,K
N,.
K,K
K,M
M,F
'L,'
Credit: Steve Kemble, MD
World Health
Organization Ranking
2,*)3 of all ban&ruptcies in ,445 6ere
medicalG -P of these medical de$tors had
medical de$ts o3er JN..., or '.P of preta9 family
income,,, Most medical de$tors +ere +ell educated,
o+ned homes, and had middle0class occupations,
Three quarters had health insurance* Q
QHimmelstein, et,al, Am D Med, August, ..-
Ultimate Cost =
Personal Bankruptcy
Source@ Himmelstein et al, Am D Med@ August, ..-
*A R Military
P
Medicare
'.P
Medicaid
NP
Uninsured
P
Pri3ate 2nsurance
K'P
And most had insurance!
(Harvard) Ultimate Cost = 45,000 annual deaths
State
-ercent
+ninsured
E(cess
7eaths
California L,-P N,L.
Te9as -,MP F,KMN
%lorida K,.P L,-N
Ne+ Sor" 'M,NP ,NF
=eorgia L,KP ',IF'
USA 'N,LP FF,M-I
Source@ )ilper et al, Am D Pu$lic Health ..-,
State ta$ulations $y author
My interpretation@
2nTustice in American
healthcare is a human rights
issueC not a political one,
Part 222@ )hy the free
mar"et, for0pro?t insurance
companies, and the ACA are
not the ans+er,
2 options for reform
6ou$le do+n on current system +ith for0pro?t
insurance companies and the free mar&et,
(8
Esta$lish single-payer 12mpro3ed Medicare for All,4
This really is a
1Patient :ill of 8ights4
The Afordable Care Act:
a step towards justice
Many
many
more
things
Ne+
2nsurance
8egulations
Ne+
2nsurance
8egulations

6ependents
co3ered to age
K

No one is
1uninsura$le4

No
cancellations
for $eing too
sic"

No
lifetimeRannual
ma9imums
Ne+
2nsurance
Mar"etplace
s
Ne+
2nsurance
Mar"etplace
s

Single door

1Ten Essential
:ene?ts4

Priced only $y
age, smo"ing
and location

K.0-.P 3alue

Na3igation
assistance
Stronger
Pu$lic
Programs
Stronger
Pu$lic
Programs

Medicare
sta$ili<ed and
strengthened

Medicaid
e9pansion
option
What about the
other 30 million?
TN not expanding Medicaid
Source: Commonwealth Fund website
Physicians vs Administrators
Source@ :ureau of #a$or StatisticsG NCHSG
HimmelsteinR)oolhandler analysis of CPS
Number of
administrators
per enrollee
Source: Woolhandler,
et al N Engl J Med
2003;349:768-75.
We Waste 31% of
Our Healthcare Dollar
Medical
o3erhead,
administration,
and insurance
pro?ts
Medical care
L'P
K-
P
)oolhandler, et al 1Costs of Health
Administration in the U,S, and Canada,4
NEDM LF-AIB Sept, ', ..L
J',L.. monthly premium U JF.. monthly
+aste
USA is the only developed country
with for-proft insurance companies
Antiquated rhetoric of choice
Name of planQ
$lueCross
$ron8e $4,S
$lueCross
Silver S45S
$lueCross
-latinum
-4,S
-lan type :ron<e Sil3er Platinum
%onthly
premium
J'N JF JLK.
7eductible JF... J'N.. J.
Annual cap JKLN. JKLN. J'N..
%inimum J'I'- JKIF JFL.
%a(imum JI'K- J-.LF JNI.
QActual health plans from TN Health e9change
Anands 2012 ACL surgery: $20,000 + Rehab 3x/week: $2,000
1The health0care reform process
e9poses ho+ corporate inVuence
renders the US =o3ernment
incapa$le of ma"ing policy on
the $asis of e3idence and the
pu$lic interest,4
1The health0care reform process
e9poses ho+ corporate inVuence
renders the US =o3ernment
incapa$le of ma"ing policy on
the $asis of e3idence and the
pu$lic interest,4
The Lancet put it
on their cover
Source@ #ancet 6ec N, ..-, Co3er of 3ol, LMF,
Part *@ )hy single0payer
is the ans+er
Two components
of a healthcare system
Healthcare
Healthcare
6eli3ery
AHealthcare
pro3idersB
6eli3ery
AHealthcare
pro3idersB
%inancing
AHealth
2nsuranceB
%inancing
AHealth
2nsuranceB
Revisiting TR Reids 4
models of healthcare
$everidge
%odel
$ismarc&
%odel
'ational
"ealth !nsurance
Out-of-
poc&et
!nsurance Pu$lic Pri3ate Pu$lic None
"ealthcare Pu$lic Pri3ate Pri3ate Pri3ate
E(amples
of
countries
:ritain,
2taly,
Scandina3ia
=ermany,
Dapan,
%rance
Canada,
Tai+an
African
countries, 2ndia, S
America
T.R. Reid's book The Healing of America: A Global Quest for Better, Cheaper, and Fairer Health Care
PNHP endorses single0payerE
%ederal
funds
State
funds
Employers
2ndi3iduals
Single0payer
pu$lic
insurance
fund
JJJ
Single-payer is simple
Credit: PNHP California chapter
Where would these
funds come from?
6ata are for .'.
Sources@ (EC6 .'G Health AHairs .. 'AFBII
J0
J,...
JF,...
JK,...
JI,...
J'.,...
JL,.F.
JL,FL.
JL,MK.
JL,-M.
JF,LF.
JF,FF.
JN,-.
J,-F.
Total US Pu$lic US Pri3ate

.
'
.

h
e
a
l
t
h
c
a
r
e

s
p
e
n
d
i
n
g

p
e
r

c
a
p
i
t
a
+SA0s public spending
e(ceeds everyone0s total
spending1
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
US Spending per capita
Health Costs as % of GDP
Source@ Statistics Canada, Canadian
2nstitute for Health 2nfo, and
NCHSRCommerce 6ept,
Health
costs P
of =6P
'M
P
'N
P
'L
P
''
P
-P
MP
NP
'-K. '-M. '-I. '--. ... .'.
Canada7
s NHP
Enacted
Canada7
s NHP
Enacted
NHP %ully
2mplemente
d
NHP %ully
2mplemente
d
Canad
a
Canad
a
USA
USA
1Uni5uely
American4
Credit: PNHP Shapiro
Source@ Himmelstein, )oolhandler O
Carras5uilo,
Ta$ulation from CPS O NH2S data
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
Number of uninsured
citizens
Canada USA with the AA
US Census :ureau, .'
L.
Millio
n
.
Credit: Drs. Himmelstein and Wooldhandler
Triple Aim of a Good
Healthcare System
CARE
2mpro3e
health
outcomes
CARE
2mpro3e
health
outcomes
COSTS
Minimi<e costs
COSTS
Minimi<e costs
COVERAE
2nsurance for
all
COVERAE
2nsurance for
all
How many forgo medical
care due to cost?
Canada USA
.' data
!aiser %amily %oundation, Sept, .'L
''K
Million
ALMP of
AmericansB
N
Million
A'LP of CanadiansB
Credit: Drs. Himmelstein and Wooldhandler
How many die per year
due to lack of healthcare
Canada USA
)ilper, et al 1Health 2nsurance and Mortality in
U,S, Adults,4 American Dournal of Pu$lic HealthG
*ol, --, 2ssue ', 6ec ..-
FN,..
.
.
Credit: Drs. Himmelstein and Wooldhandler
Part *2@ PNHP proposal@
12mpro3ed Medicare for
All4

:ill introduced in Congress in %e$ruary .'L $y 8ep

Dohn Conyers A60M2B +ith NF co0sponsors,

Saves 9:;,<444<444<444 annually +hile

covering all /4<444<444= uninsured
Americans, and impro3ing $ene?ts,
o
Cuts administrati3e costs $y JFMK,...,...,... annually
o
Cuts pharmaceutical costs to WEuropean le3els7 $y J''K,...,...,...
annually
o
Total sa3ings@ JN-,...,...,...E

2mpro3es 5uality, reduces cost, e9pands access

PNHP Proposal: Improved Medicare for All
(HR 66!
PNHP Proposal: Improved Medicare for All
(HR 66!
S"reamline paymen": s"op adminis"ra"ive #as"e
o
Nearly $%% &illion saved ann'ally(

Single ris) pool: s"op pro*" of s'+ering

,nly one plan: s"op mar)e"ing #as"e

-ollec"ive &argaining: s"op p.armace'"ical pro*"s
Increase preven"ive medicine: s"op e/pensive diseases
from s"ar"ing

0ree c.oice of providers: s"op ra"ioning of .eal". care

professional c.oice
Credit: PNHP California chapter
Single-payer HR 676 vs ACA
59%+ of physicians support a national health program.
..M detail of sur3eys of random samples of US
physicians,
Carroll and Ac"erman, Ann 2nt Med ..IG'FI@NKK
Psychiatry
Peds
Specialties
Emergency Med
=eneral Peds
=eneral 2nt, Med
Med Specialties
%amily Med
(:0=yn
=eneral
Surgery
Surg
Specialties
8adiology
. NP N.P MNP '..P
Percent supporting National Health 2nsurance
Source@ Canadian 2nstitute for Health
2nformation
Canadian Physicians Incomes (2010-
2011)
Specialty 2ncome
%amily
Medicine
JKN,II'
2nternal Med JLK',NN'
Pediatrics JM.,.ML
Psychiatry J'F,M.
6ermatology JL-I,F'.
Canadian physician a3erage@
JL.M,FI
Specialty 2ncome
(:0=SN JFF-,''
=eneral
Surgery
JF'',--N
Thoracic
Surgery
JN-,MI
(phthalmolog
y
JNML,NI
Source@ Canadian 2nstitute for Health
2nformation
1Sou can ha3e uni3ersal
co3erage and good 5uality
healthcare +hile still managing
to control costsC $ut you need
S2N=#E0PASE8 to do it,4
0Har3ard health economist 6r,
)illiam Hsiao, Ph6
Sign the TN petition!
+++,pnhp,orgRstatesRtennessee
%or more information on healthcare policyC
o
The Common+ealth %und@ +++,common+ealthfund,org
o
!aiser %amily %oundation@ +++,"H,org
o
Physicians for a National Health Program@ +++,PNHP,org
o
Senator :ernie Sanders@ +++,Sanders,Senate,go3