Number
Talks: Healthcare, we care
Chen
Wu and Xin Wu*
Wiess School of Natural
Sciences, Rice University, Houston, TX, and *College of Medicine, Texas
A&M Health Science Center, College Station, TX
Email:xinwumd@yahoo.com
Abstract
The World Health Organization (WHO) ranked
the U.S. health care system as the highest in cost and responsiveness, 37th in
overall performance, and 72nd in overall level of health among 191 member
nations in 2000. Overall health spending in the U.S. was $2.3 trillion for 85%
insured and 15% uninsured people in 2008. In the same time, the premiums,
copayment, deductions, donations, and portion of city, state and federal taxes collected
from us are around $2.4 trillion for health care. Medical waste spending,
including unnecessary treatment, administrative inefficiency, medical errors,
and for-profit ventures took up one-third of the nation's healthcare spending.
There is about $450 billion gap between what we paid $2.4 trillion in 2008 and
what we will pay with the new approved health reform if with a 15% savings
($1.9 trillion if based on 2008 spending data). In addition, in the current
health system, insurance companies can refuse to insure people because of
pre-existing conditions, chronic diseases, or unemployment. We are one illness
away from financial ruin. We will discuss the issues of current health system,
health care reform, doctors’ shortage and income, and possible non-profit
insurance companies and government control in the healthcare system. Based on current health spending data,
we can achieve the best affordable
health care for all from prevention, prediction, preemption, protection, and
personal treatments without a tax increase, with savings from reduced
administration cost and medical waste,
and eliminating the excess profit of for-profit insurance companies. A
physician shall always support access to medical care for all people.
Key words: Health care spending; Health care
reform; Physician shortage; Health insurance
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“For America must always
stand on the side of freedom and human dignity. Always.”
(Applause) “Well, I do not accept second place for the United States of America
(in the world)” (Applause) President Obama in his first State
of the Union address in 2010. However, can it be accepted as rank 37th
or worse?
Certainly, we are
number one in many fields such as Science and Technology. We are also the most
expensive health care in the world based on health expenditure per person and
on total expenditures as a percentage of gross domestic product
(GDP). Overall health spending reached $2.3 trillion ($7681/person) and was
equal to 16.2 percent of the U.S. GDP in 2008. The World Health Organization
(WHO) ranked the U.S. health care system as the highest in cost and
responsiveness. The United States now spends well over twice the median
expenditure of industrialized nations on universal health care system. However,
WHO also ranks US health care system as 37th in overall performance, and 72nd
by overall level of health among 191 member nations in 2000 and worst in rich
countries. As of September 23, 2010, the United States ranked 49th for both
male and female life expectancy combined while the risk profiles (e.g. smoking
and obesity) of Americans generally improved relative to those citizens from
other developed nations. The latter means poor US health outcomes are largely
due to health care but not the smoking and obesity.
The fact of current health
care (before 2014. Figure and table):
(1) We
paid $2.3 trillion in health care for 85% insured (office visits + emergency
visits + inpatient care) + 15% uninsured (limited office visits + emergency
visits + limited inpatient care) in 2008. Emergency care charge is 5 -10 times
more than regular office visits.
(2) We
paid $2.4 trillion from premiums, out-of pocket payment, portion of city, state
and federal taxes, Medicare and donations. It is around $100 billion more than
total health spending in 2008, for unsecured health care.
(3) 45.7
million Americans (about 15.3% of the total population) had no health insurance
coverage at some point during 2007. Most uninsured Americans are working-class
personals. They have limited or no preventive care. More than $200 billion from
local, state and federal governments (Table legend) were spent to support
uninsured people who are not covered by Medicare and Medicaid each year. There
is an additional $92 billion (close to 100 billion) from private funding to
cover unpaid medical expense.
(4) Indirect
health care costs 31% of all health care expenditures in the US (i.e. about 750
billion), including hundreds of health
insurance providers administrative costs, costs of billing, profits for the
insurance companies, and wasteful medical spending account. It only accounts
15-17% in single payer health care systems in other rich industrial countries
(e.g. Canada and UK). Wasteful medical spending in the US includes unnecessary
treatment (40% of the waste), fraud (19%), administrative inefficiency (17%),
and medical errors (12%), comprised one-third of the nation's healthcare spending.
The five biggest for-profit health insurers made a combined profit of $12.2
billion in 2009. There are hundreds more health insurance providers. Most
insurance companies run with profits.
(5) Private
insurance companies can refuse to insure us for pre-existing conditions. If we
lose our job or income, we lose our insurance even though you might pay
insurance for many years in the past. When we need them most, they drop us. We
are one illness away from financial ruin or bankruptcy.
(6) Almost
100,000 people, whether insured or uninsured, died in the United States each
year, because of lack of needed care or access to care duo to the issues of
copayment and deductions. It is three times the number of people who died of
AIDS. In the next 10 years (2010-2019). More than 275,000 adults across the
nation will die prematurely due to a lack of health coverage based on a
scientific report in 2005.
We should support any health reform that
is better than current health care. A good health care includes
prevention, prediction, preemption, protection and personal treatments (5Ps).
Health is one of the most basic human rights. We must have a healthy body and
mind to study, to work, and to support our family and ourselves.
We
can achieve the best affordable health care system without a tax increase based
on current health spending data, by reducing administration
costs and wasteful medical spending,
and eliminating excess profit by for-profit insurance companies. The system
should be as follows:
(1) Non-profit
insurance companies or a single insurance system to care for everyone.
(2) No
out-of-pocket payments because copayments and deductibles are barriers to
access to care for many people. The out-of-pocket spending by us is $345
billion in 2008. It is possible to get health care without worrying about how much
money you have to pay. If we cut non-health care costs by 15%, we will save
$350 billion based on spending (2.3 trillion) in 2008 or $450 billion based on
we paid (2.4 trillion) in 2008 (Table and Figure). The saving could cover all
out-of-pocket spending.
(3) Free
choice of providers: Patients should be free to seek care from any licensed
health care provider.
Based on the table,
healthcare costs for every 10% of the insured population are $200 billion if combining
paid by out-of-pocket, private insurance company, Medicaid and Medicare (i.e. total
2.3 trillion - $200 billion from governments for uninsured people - $100
billion from other private funding = total $200 trillion for insured population.
Table legend), or $160 billion per 10% if indirect health
care cost cut 15% (about 1.9 trillion. Figure and
Table).
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Figure. The fact of current health care
(billion).
Table:
The fact of current health care (billion).
|
|
CDC 2005 report |
2008 spending |
as
new health law proposed (15% saving in admin cost) |
If deduct all administration cost (-31%) as
current level |
We paid in 2008 |
|
Out-of-pocket |
15% |
345 |
293.25 |
240 |
345* |
|
Private
health insurance |
36% |
828 |
703.8 |
576 |
870** |
|
Government |
45% |
1035 |
879.75 |
720 |
1035*** |
|
Other
private funds |
4% |
92 |
78.2 |
64 |
92**** |
|
Medicare
paid (1.45%
of income) |
|
|
|
|
114***** |
|
Total |
100% |
2300 |
1955 |
1600 |
2456 |
*: The
15% of out-of pocket spending includes copayment and deductible payment.
**:
Private health insurance premium paid: Used average of (826+920)/2 =
$870 billion in the Figure. The data calculated based on 195 million people
paid premium of private insurance company in 2008. The annual premium for
single coverage averaged over $4,700 (195 million in private section: 195
million * 4700 = $920 billion). The annual premium for an employer health plan
covering a family averaged nearly $12,700 (if 3 people a family: (195 million
/3) * 127000 = 826 billion in 2008. It has been reported that is $137700 for
each family in 2010 (about $890 billion)). Our paid premium should be close to
high-end of $920 billion if combining $828 billion health spending by private
health insurance in 2008 plus companies’ profit as mentioned above.
***: $1035 billion from government (from Tax
dollar) paid in 2008. Spending on Medicare for the elderly and disabled was
$469.2 billion in 2008. Spending on Medicaid was $329.4 billion in 2008. There
are more than 200 billion differences after deducted spending of $1035 billion from
Medicare and Medicaid. In the $200 billions, $100 billion from federal
government and $100 billion from state and local governments were paid to
uncompensated care costs for uninsured and underinsured people to hospitals and
Clinics.
****:
Other private funds (close to 100 billion or 92 billion), i.e. charity care for
someone who cannot pay his health care spending, is sometimes available, and is
usually funded by non-profit foundations, religious orders, government
subsidies, or services donated by the employees.
***** based on Census report that 116,783,
000 householder with mean household income 67,609, and Medicare rate = 1.45%.
------------------------------------------------------------------------------------------------------
There is near
$300 billion (13% of 2.3 trillion spending) in uncompensated costs for
uninsured (ER visit + limited inpatient care) and underinsured (ER + limited
office visit + limited inpatient care) after combining federal ($100 billion),
state and local governments ($100 billion), and private funding (close to 100 billion).
The emergency room (ER) charge per visit is 5 -10 times than office visits.
Therefore, It should be enough to cover 15% uninsured people with $300 billion
for affordable 5Ps because regular office visits will decrease unnecessary
expensive ER visits. Our overall level of health will also get improved.
We have paid around $2.4
trillion for $2.3 trillion overall health spending in 2008. That is a $100
billion gap. It would be the profits for hundreds of private insurance
companies and drug companies. There is a $350 billion difference (potential saving)
between what we spent (2.3 trillion) and the new proposed health bill ($1.9
trillion) with a 15% savings (the percentage is similar to single insurance system)
from reduced administration costs, medical waste and possible profits. This
adds up to a $450 billion difference (potential saving) between what we paid
($2.4 trillion) and new proposed health bill ($1.9 trillion). It is possible
that we can get health care without worrying about how much money we have to
pay for copayments and deductions. It was $345 billion out-of-pocket in 2008.
However, we have $350 or $450 billion potential saving.
We can reduce the budget
after reducing administration costs and wasteful spending, and switching
for-profit insurance company for non-profit company. Overall health spending
can be reduced to around $1.6 – $1.9 trillion without adversely affecting the
quality of care or access to care if it is a single health insurance system. It
also suggests our country can provide health care for everyone without an
increase in tax or premium because what we and the government paid, including
premiums, tax and donations, already covers far more than enough for care for
everyone (2.4 trillion paid vs 2.3 trillion spending in 2008). If the 15% saving in
indirect health care cost (31% of overall 2.3 trillion costs now) is not
approached, it should be acceptable for increasing your Tax as you don’t have
to pay any premiums, copayment, and deduction when you sick. You don’t have to
worry about any medical bill whatever how severe is your illness later. You
don’t have to file bankruptcy because you are sick.
Everybody in America can live in his or her equal right and
dignity. We need more health reform. Let American stand on the side of freedom,
human dignity and rights. Together, we can: health care for all with no tax on
you, no tax on me, and no taxing the baby on the knee (Applause?).
Frequently asked questions for whether we can
offer health care for all can be answered by the following:
1)
Why do I pay for someone who doesn’t want to
work (no insurance) and support himself?
The U.S. Census Bureau
estimates that 45.7 million Americans (about 15.3% of the total population) had
no health insurance coverage at some point during 2007. About 50% of uninsured
Americans are working-class persons whose employers do not provide health
insurance, and who earn too much money to qualify for one of the local or state
insurance programs for the poor, but do not earn enough to cover the cost of
enrollment in a private health insurance plan designed for individuals. Another
study by the Commonwealth Fund published in Health Affairs estimated that 16
million U.S. adults were underinsured in 2003.
You have always paid for
uninsured or underinsured people. Your taxes and donations paid to Medicaid,
Medicare, the State Children’s Health Insurance Program, and other similar
state-based insurance programs for poor and near-poor citizens and Veterans
Health Care. The changes of annual premium are partially based on the previous
year’s loss from individuals who can’t pay for hospitals and clinics. We don’t
know exact number of loss. However, we do know that 80–85% of uncompensated
care costs have been paid with more than 200 billion a year by the federal
government, and by state and local tax to hospitals. Another $100 billion in
uncompensated costs is paid from private funding such as charity and free
clinics.
Uninsured people are less
likely to have regular health care and use preventive services because they have
to pay more payment for each visit. They are more likely to delay seeking care,
resulting in more medical crises, which are more expensive than ongoing regular
treatment for such conditions as diabetes and high blood pressure. The uncontrolled
rate in 75 million patients with hypertension who seeks treatment was about
only 55% (41 million) based on data from National Institute of Health in 2010. 21
million hypertension patients in uninsured and underinsured populations could belong
to uncontrolled group because they don’t have enough money for continuously
long-term medications and no or limited health care access.
Uninsured patients are twice
as likely to visit hospital emergency rooms as those with insurance. In Texas, 9 patients made nearly 2,700 ER
visits in 5 years. In Utah, a woman made 90 ER visits a year. The ER costs are 5-10 times more expensive
than regular office visits. If healthcare is everyone, people could go to the
doctor’s office without pay copayment and deduction for any uncomfortable
symptoms instead going to the ER.
One thing most people forget
to mention is that we give ‘universal’ health care to people in jails (total
7.3 million in jail, prison, on probation or on parole in 2009). Near 40% of
people in jail have a chronic medical condition.
Georgia, one of the 10 largest prison systems in the country, spends about $3
billion ($8500/person) a year on inmate medical care. The health care that is
rendered behind bars is better than what is received in the general population
($7681/person). Many people released
from jail will lost their health care because of most likely uninsured as they're
difficult to find you a job. In addition, we provide billions to other
countries for humanity activities. Why we don’t want to take care of our own
people?
2)
I love my current health insurance. I am
secured now and I will enjoy Medicare when I am getting old (> 65 years
old).
Based on recent research,
more than 62 percent of bankruptcies are linked to medical bills, more than 77%
of these bankrupt families had health insurance and most medical debtors were
well-educated middle-class homeowners. 61% of the bankrupt have private
insurance coverage, and 16% of the bankrupt have Medicare or Medicaid. Medicaid
and Medicare are not entirely free programs. You still need to pay premiums and
copayments for part of the programs. In addition, you need to pay long-term
care insurance too if you can’t take care of yourself.
The out-of-pocket expenses
are large if you have a chronic disease. Out-of-pocket medical costs are
$17,943 for all medically bankrupt families, $26,971 for uninsured patients,
$17,749 for those with private insurance, $14,633 for those with Medicaid,
$12,021 for those with Medicare, and $6545 for those with Veterans
Affairs/military coverage. For patients who initially had private coverage but
lost it, the family’s out-of-pocket expenses averaged $22,568. In addition, 40%
of the medical bankrupted family lost insurance after 2 years of illness. When
you need health insurance the most, you lose it. You are one illness away from
financial ruin or bankruptcy in our country.
3)
In the new health care system, doctor
shortage will be getting worse and doctors’ incomes will be lowered. The
quality of health care will be down with long waits for treatment.
One of the Principles of
medical ethics in the American Medical Association Code of Medical Ethics is ‘A
physician shall support access to medical care for all people’.
People worry about physician
shortage if health care is available for all. This problem is a long-term
problem and is not because of health care for all. The U.S. is short by between
40,000 and 50,000 primary care doctors especially in underserved areas in 2008,
a figure that’s expected to top 125,000 or even worse by 2020, according to the
American Academy of Family Physicians. The
current estimated shortage of primary care doctors is only 7,400 in the June
2010 report issued by the American Association of Medical Colleges. However, based
on the Association of American Medical College website, 3000 to 6000 medical
graduates can’t be matched to medical training programs each year. They are not
eligible for licensure by a US medical licensing authority if you don’t have
trained in residency program even though you passed all United States Medical
Licensing Examination (USMLE Step 1, Step 2 Clinical Knowledge, Step 2 Clinical
Skill and Step 3). ‘Step 3 assesses whether you can apply medical knowledge and
understanding of biomedical and clinical science essential for the unsupervised practice of medicine, with
emphasis on patient management in ambulatory settings’-based on USMLE.org
website statement. Majorities of unmatched medical graduates are foreign
medical graduates (FMG), certified by the Educational Commission for Foreign
Medical Graduates after passing the USMLE.
Most of those unmatched FMGs will have to find jobs not in health care
several years later because their USMLE test results are probably expired, and
they have to find a way to support themselves and even their family. Lawmakers have
failed to increase the number of federally funded residency positions. Congress
must lift the cap on residency funding. If state or
federal grants are limited, we can allow unmatched medical graduates to sign
contracts with local health agencies to serve underserved areas after training
and receive funds for their training. Or we can offer unpaid training in
approved training facilities or apprenticeships under individual physicians. The
unmatched medical graduates spent their effort, money, and time to acquire
medical experience in their own countries and possibly in the US, and passed
the USMLE. Most graduates were well trained and have a language advantage for
minorities. In the near future, 28 states may expand physician assistant and nurses'
role to be your doctor. It is not acceptable for not giving an opportunity to those
high talented medical graduates who have medical education, strict clinical
training and passed USMLE, especially for those passed all USMLE steps, to
pursue medical practice while we have a large shortage of physicians and expanded
the roles of physician assistant and nurses in the health care.
The physician’s incomes might
not be decreased but income in Doctors’ office might be lowered because of the
cut in administration cost. A physician’s income is normally based on patients’
visits in private sectors. If health care is provided
for all under a single insurance plan, while maintaining current health care
spending ($2.3 trillion), doctors’ incomes will not be affected much. A
physician, especially a family physician, will get more patient visits, and
does not have to worry about whether the patients can pay or not. This also
reduces the administration costs to deal with patients’ payments and deal with
different insurance companies. The physician currently is one of the most
stressful careers. As an ordinary person, a physician does not have to worry
about health spending when he and his family members are getting sick. This
saves money for them too under health care for all.
Health care quality should
not be lowered after health care for everyone. The WHO ranks the US health care
system as 37th in overall performance, and 72nd by overall level of health and
worst in rich countries. Medical errors happen more frequently here than in
other rich countries. Under health care for all, all physicians have the same
training as before. Malpractice lawsuits, 3% of overall health spending, about
60 billion/year in 2008, are still an option for medical errors. A recent study by the Institute of Medicine of the
National Academy of Sciences estimated that as many as 98,000 patients may be
killed each year in hospitals alone as a result of medical errors by about
815,000 physicians. If physicians’ income is not just related to how many patients’
visits in their office each day, they will spend more time to take care each
patient, carefully check their medical history and interactions among all
medications. This practice should reduce medical errors.
Overall
quality of health care in Britain and Canada is better than ours, even though
the waiting time for non-emergency care in Britain and Canada might be longer
than us. Good health care includes prevention, prediction, preemption, protection
and personal treatments. The patients in health care for all system are likely
to receive more preventative care and less medical errors.
Long waiting for family physicians and specialist visits
for non-emergency care are common in our country and other rich countries with
health care for all. Most of us have experienced waiting for days for our own
family physicians and weeks waiting for a specialist’s visit in non-emergency
situations. What is the difference between one month and two months of waiting? Both situations are not good. Patients might have
died waiting for treatment. This problem is difficult to resolve if
any physician shortage exists.
4)
The Medicare and the post office the
government runs are all in trouble. So if government runs the health care, it
is socialism, and it will not run well. We don’t want the government involved
our health care.
Most developed rich
countries, for example Great British and Canada, give health care for all
citizens. They are not Socialism but still Capitalism. We all love freedom, but
at the same time we all want to have good welfare, human dignity, and rights.
It might be misleading to
believe that everything government-run is in trouble. Do private companies
handle everything better? When so many large companies such as Lehman
Brothers Holdings Inc, General Motor, American Home mortgage Inc, MCI Worldcom, and Enron companies bankrupted, millions of the
people lost their retirements, investments and jobs. When bailout money goes to
AIG, Fannie Mae, Freddie Mac, and big banks, how can we say private companies
are better than others? Government is not our enemy; it is voted by our
taxpayers and sometimes is probably a lifesaver. When your banks claimed bankruptcy
after moving excess profits in their own pockets for many years, the FDIC
protected you. When your company claimed bankruptcy, you claimed unemployment
benefits from the government. When your companies are one step away from
bankruptcy, they ask the government for a bailout. When your health insurance company
no longer wants to insure you because you are either too sick, getting older,
or no longer able to work, (local, state and federal) governments cover you
through Medicaid and Medicare, and reimburse hundreds of billion per year to
your unpaid care costs to local hospitals and clinics. Another well-known ‘bad’
example of government affairs is USPS. However, if there is no USPS, we might
have to send our regular letters for more than $1 a piece instead of $0.44 (if
regulations prohibit private companies to do business with first class mails,
then it will be another story). We are very sorry for the victims who lost
everything after recent Ponzi schemes (e.g. Madoff's 60 billion and Texas Stanford $7 billion).
However, the victims asked help from the government after the Ponzi scheme.
In addition, how many health
insurance companies are private? Many insurance companies are public. If you
can pay insurance for FDIC and unemployment, why don’t you want to pay health
insurance and get protected when you need it most? We're currently one illness
away from financial ruin or bankruptcy.
We might need non-profit
insurance companies if not government-run agencies. Based on the Securities and
Exchange Commission record, the five biggest for-profit health insurers,
UnitedHealth Group Inc., WellPoint Inc., Aetna Inc., Humana Inc., and Cigna
Corp., made a combined profit of $12.2 billion in 2009. There are hundreds or
even thousands of health insurance companies in America. Why you can provide
money to pay millions to insurance company executives but do not take care of
your own future? The money from switching for-profit to non-profit insurance
companies to reduce administration costs and excess profits is enough to cover
health care for everyone (Figure and Table).
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