health care in the u.s. and the world
DESCRIPTION
Health Care in the U.S. and the World. Martin Donohoe. Determinants of Health. Era Socioeconomic status Sex Race Location Environment Genetics Health Habits Access to Care. The State of U.S. Health Care. 52 million uninsured 45,000 deaths/year 30 million more underinsured - PowerPoint PPT PresentationTRANSCRIPT
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Martin DonohoeMartin Donohoe
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Determinants of HealthDeterminants of Health EraEra Socioeconomic statusSocioeconomic status SexSex RaceRace LocationLocation EnvironmentEnvironment GeneticsGenetics Health HabitsHealth Habits Access to CareAccess to Care
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The State of U.S. Health The State of U.S. Health CareCare
52 million uninsured52 million uninsured 45,000 deaths/year45,000 deaths/year
30 million more underinsured30 million more underinsuredRemain in dead-end jobsRemain in dead-end jobsGo without needed care Go without needed care and/or prescriptionsand/or prescriptions
MarryMarry
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Reasons for No Health Insurance Reasons for No Health Insurance Coverage (2009)Coverage (2009)
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The State of U.S. Health The State of U.S. Health CareCare
US ranks near the bottom US ranks near the bottom among westernized nations in among westernized nations in overall population health (#24), overall population health (#24), life expectancy (#42), infant life expectancy (#42), infant and maternal mortality, etc.and maternal mortality, etc.
15% of Americans live in 15% of Americans live in povertypoverty
22% of US children live in 22% of US children live in povertypoverty
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Health Care Expenditures Health Care Expenditures per Capitaper Capita
U.S. = $7,960U.S. = $7,960 Canada, Australia, Japan, Canada, Australia, Japan,
Europe: $3,000 to $6,000Europe: $3,000 to $6,000Average for low income Average for low income developing nations = $22-developing nations = $22-2525
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Who Pays for Health Who Pays for Health Care?Care?
Government (federal, state, and local)Government (federal, state, and local) Medicare, Medicaid, VA, IHS, jails and Medicare, Medicaid, VA, IHS, jails and
prisonsprisons Private insurancePrivate insurance
Primarily employer-basedPrimarily employer-based Out-of-pocketOut-of-pocket Health care costs = 17.6% of GDP (1/2 of Health care costs = 17.6% of GDP (1/2 of
worldwide health care costs)worldwide health care costs)
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Health Insurance Health Insurance IndustryIndustry
DelistingDelisting
Cherry pickingCherry picking
Pre-existing conditionsPre-existing conditions
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Health Insurance Health Insurance IndustryIndustry
High administrative costsHigh administrative costs 15-30% (vs. 2-3% for Medicare and 15-30% (vs. 2-3% for Medicare and
Medicaid)Medicaid) Average full-time physician spends Average full-time physician spends
over $85,000/yr on billing and over $85,000/yr on billing and insurance functionsinsurance functions
17,849 different billing codes (in 17,849 different billing codes (in 2012 increases to 141,058)2012 increases to 141,058)
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Health Insurance Health Insurance IndustryIndustry
Large profit marginsLarge profit margins
CorruptionCorruption
Loyalty: shareholders (not Loyalty: shareholders (not patients)patients)
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Drug Companies’ Cost Drug Companies’ Cost StructureStructure
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Innovation:Innovation:Published Research Leading to DrugsPublished Research Leading to Drugs
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Premature Deaths in the Premature Deaths in the U.S.U.S.
10% due to inadequate 10% due to inadequate medical caremedical care
60% due to behaviors, social 60% due to behaviors, social circumstances, and circumstances, and environmental exposuresenvironmental exposures
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Address Social Factors Address Social Factors Responsible for Illness and Responsible for Illness and
DeathDeath Deaths in 2000 attributable to:Deaths in 2000 attributable to:
Low education: 245,000Low education: 245,000Racial segregation: 176,000Racial segregation: 176,000Low social support: 162,000Low social support: 162,000 Individual-level poverty: Individual-level poverty:
133,000133,000 AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465
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Address Social Factors Address Social Factors Responsible for Illness and Responsible for Illness and
DeathDeath Deaths in 2000 attributable to:Deaths in 2000 attributable to:
Income inequality: 119,000 Income inequality: 119,000 (population-attributable (population-attributable mortality – 5.1%)mortality – 5.1%)
Area-level poverty: 39,000 Area-level poverty: 39,000 (population-attributable (population-attributable mortality – 1.7%)mortality – 1.7%)
AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465
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Address Social Factors Address Social Factors Responsible for Illness and Responsible for Illness and
DeathDeath Deaths in 2000 attributable to:Deaths in 2000 attributable to:
AMI – 193,000AMI – 193,000CVD – 168,000CVD – 168,000Lung CA – 156,000Lung CA – 156,000
AJPH 2011;101:1456-1465AJPH 2011;101:1456-1465
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Major Contributors to Major Contributors to Illness and DeathIllness and Death
40% of US mortality due to tobacco, 40% of US mortality due to tobacco, poor diet, physical inactivity, and poor diet, physical inactivity, and misuse of alcoholmisuse of alcohol
Every $1 invested in programs Every $1 invested in programs covering above items saves $5.60 in covering above items saves $5.60 in health care costshealth care costs
Prevention: 2-4% of national health Prevention: 2-4% of national health care expenditurescare expenditures
NoncomplianceNoncompliance
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Poverty and HungerPoverty and HungerUS: 15% of residents and 22% US: 15% of residents and 22% of children live in povertyof children live in poverty
Rates of poverty in Blacks and Rates of poverty in Blacks and Hispanics = 2X WhitesHispanics = 2X Whites
Poverty associated with worse Poverty associated with worse physical and mental healthphysical and mental health
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Economic DisparitiesEconomic DisparitiesWomen 75 centsWomen 75 cents/$1 Men/$1 MenMedian income of black Median income of black
U.S. families as a percent U.S. families as a percent of white U.S. families of white U.S. families 62%62%60% in 196860% in 1968
63% for Hispanic families63% for Hispanic families
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Educational ApartheidEducational Apartheid
High levels of de facto school High levels of de facto school segregation by race and SESsegregation by race and SES
Gross discrepancies in per-pupil Gross discrepancies in per-pupil spending and teacher salariesspending and teacher salaries
Achievement and graduation gaps Achievement and graduation gaps growinggrowing
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Racial Disparities in Racial Disparities in Health Care CoverageHealth Care Coverage
Percent uninsured:Percent uninsured: Whites = 12%Whites = 12% Asians = 17%Asians = 17% African-Americans = 21%African-Americans = 21% Hispanics = 32%Hispanics = 32% Undocumented immigrants = 100% Undocumented immigrants = 100%
(emergency care exception)(emergency care exception) CA Proposition 189CA Proposition 189
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Racial Disparities in Health Care:Racial Disparities in Health Care:African-AmericansAfrican-Americans
Higher maternal and infant Higher maternal and infant mortalitymortality
Higher death rates for most Higher death rates for most diseasesdiseases
Shorter life expectanciesShorter life expectanciesLess health insuranceLess health insuranceUndergo fewer diagnostic tests / Undergo fewer diagnostic tests / therapeutic procedurestherapeutic procedures
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Racial Disparities in Health Racial Disparities in Health Care:Care:
African-AmericansAfrican-AmericansEqualizing the mortality rates Equalizing the mortality rates of whites and African-of whites and African-Americans would have averted Americans would have averted 686,202 deaths between 1991 686,202 deaths between 1991 and 2000and 2000Whereas medical advances Whereas medical advances averted 176,633 deathsaverted 176,633 deaths AJPH 2004;94:2078-2081AJPH 2004;94:2078-2081
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Outside the USOutside the USOne billion people lack clean One billion people lack clean
drinking water and 3 billion lack drinking water and 3 billion lack sanitationsanitation13,000-15,000 deaths per day 13,000-15,000 deaths per day worldwide from water-related worldwide from water-related diseasesdiseases
Hunger kills as many individuals in Hunger kills as many individuals in eight days as died during the atomic eight days as died during the atomic bombing of Hiroshimabombing of Hiroshima
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WaterWaterAmount of money needed each Amount of money needed each year (in addition to current year (in addition to current expenditures) to provide water expenditures) to provide water and sanitation for all people in and sanitation for all people in developing nations = $9 billiondeveloping nations = $9 billion
Amount of money spent annually Amount of money spent annually on cosmetics in the U.S. = $8 on cosmetics in the U.S. = $8 billionbillion
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OverpopulationOverpopulationWorld population - exponential World population - exponential
growthgrowth1 billion in 18001 billion in 18002.5 billion in 19502.5 billion in 19506 billion in 20006 billion in 20007 billion in 20117 billion in 2011est. 8-10 billion by 2050est. 8-10 billion by 2050
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Status of WomenStatus of Women
Women do 67% of the Women do 67% of the world’s workworld’s work
Receive 10% of global Receive 10% of global incomeincome
Own 1% of all propertyOwn 1% of all property
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Worldwide, every minuteWorldwide, every minute 380 women become pregnant (190 380 women become pregnant (190
unplanned or unwanted)unplanned or unwanted) 110 women experience pregnancy-related 110 women experience pregnancy-related
complicationscomplications 40 women have unsafe abortions40 women have unsafe abortions 1 woman dies from childbirth or unsafe 1 woman dies from childbirth or unsafe
abortionabortion
Reason: Lack of access to reproductive Reason: Lack of access to reproductive health serviceshealth services
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Deaths in WarDeaths in War1818thth Century = 19/million population Century = 19/million population1919thth Century = 11/million population Century = 11/million population2020thth Century = 183/million Century = 183/million populationpopulation
Civilian Casualties:Civilian Casualties:10% late 1910% late 19thth Century Century85-90% in 2085-90% in 20thth Century Century
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Inverse Care LawInverse Care Law
Those countries that Those countries that need the most health need the most health care resources are care resources are getting the leastgetting the least
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Brain DrainBrain Drain
U.S. is largest consumer U.S. is largest consumer of health care personnelof health care personnel
Five times as many Five times as many migrating doctors flow migrating doctors flow from developing to from developing to developed nations than in developed nations than in the opposite directionthe opposite direction
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Tobacco – Weapon of Mass Tobacco – Weapon of Mass DestructionDestruction
Direct medical costs = $100 Direct medical costs = $100 billion/yr billion/yr
Lost productivity = $97 billion/yrLost productivity = $97 billion/yr Medical care and lost Medical care and lost
productivity due to tobacco use productivity due to tobacco use costs each U.S. citizen costs each U.S. citizen approximately $600/yrapproximately $600/yr
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Consequences of Environmental Consequences of Environmental DestructionDestruction
Global warming: 160,000 Global warming: 160,000 deaths and 5.5 million deaths and 5.5 million disability-adjusted life years disability-adjusted life years lost per year (will double by lost per year (will double by 2020)2020)
Air pollution: 60,000 - 75,000 Air pollution: 60,000 - 75,000 premature deaths/yr. (U.S.); premature deaths/yr. (U.S.); 1.8 million worldwide1.8 million worldwide
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Consequences of Consequences of Environmental Environmental
DestructionDestruction Pesticides in food Pesticides in food → → 1,000,000 1,000,000
deaths over the last 6 years; 1 deaths over the last 6 years; 1 million cancers in current generation million cancers in current generation of Americansof Americans
Lead and mercury exposure multi-Lead and mercury exposure multi-billion dollar problemsbillion dollar problems
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Toxic PollutantsToxic Pollutants
¼ US citizens live within 4 miles ¼ US citizens live within 4 miles of a Superfund siteof a Superfund site
Environmental RacismEnvironmental RacismWaste dumps/incinerators Waste dumps/incinerators more common in lower SES more common in lower SES neighborhoodsneighborhoods
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Extinction/Species LossExtinction/Species Loss
Mass ExtinctionMass ExtinctionMore than 1/2 of the top 150 More than 1/2 of the top 150
prescription drugs from plants, prescription drugs from plants, other living organismsother living organisms
More than 250,000 known More than 250,000 known flowering speciesflowering species <0.5% surveyed for medicinal <0.5% surveyed for medicinal valuevalue
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Overconsumption Overconsumption (“Affluenza”)(“Affluenza”)
U.S. = 6.3% of world’s populationU.S. = 6.3% of world’s populationOwns 50% of the world’s wealthOwns 50% of the world’s wealth
U.S. responsible for:U.S. responsible for:25% of world’s energy consumption25% of world’s energy consumption33% of paper use33% of paper use72% of hazardous waste production72% of hazardous waste production
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But Are We Happier?But Are We Happier?
Average American works 200 Average American works 200 more hrs/yr than in 1960 (#1 more hrs/yr than in 1960 (#1 in world)in world)
Vacations shorterVacations shorterNo guaranteed paid sick leaveNo guaranteed paid sick leave8/10 Americans want a new job8/10 Americans want a new job
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But Are We Happier?But Are We Happier?
Fewer close friendsFewer close friendsMore loneliness/depressionMore loneliness/depressionPharmaceutical fixesPharmaceutical fixes
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US Charity Care SufferingUS Charity Care Suffering Public hospitals and ERs closingPublic hospitals and ERs closing
Long waits mean many leave before being seenLong waits mean many leave before being seen Free clinic demand increasing, more Free clinic demand increasing, more
patients being turned awaypatients being turned away Hospitals turning to lucrative initiatives to Hospitals turning to lucrative initiatives to
improve financial situationimprove financial situation Cosmetic surgery, luxury clinics, aggressive Cosmetic surgery, luxury clinics, aggressive
billing practices (including charging uninsured billing practices (including charging uninsured more than insured), recruiting wealthy foreign more than insured), recruiting wealthy foreign patientspatients
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Maldistribution of WealthMaldistribution of WealthU.S: Richest 1% of the U.S: Richest 1% of the
population owns 50% of the population owns 50% of the country’s wealth country’s wealth -poorest 90% own 30%-poorest 90% own 30%-widest gap of any industrialized -widest gap of any industrialized nationnation
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Maldistribution of Maldistribution of Wealth is DeadlyWealth is Deadly
880,000 deaths/yr in U.S. 880,000 deaths/yr in U.S. would be averted if the would be averted if the country had an income gap country had an income gap like Western European like Western European nations, with their stronger nations, with their stronger social safety netssocial safety nets
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Maldistribution of wealthMaldistribution of wealth
Less than 4% of the combined Less than 4% of the combined
wealth of the 225 richest individuals wealth of the 225 richest individuals
in the world would pay for ongoing in the world would pay for ongoing
access to basic education, health access to basic education, health
care (including reproductive health care (including reproductive health
care), adequate food, safe water, care), adequate food, safe water,
and adequate sanitation for all and adequate sanitation for all
humanshumans
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Health Requires EqualityHealth Requires Equality““All men are created equal”All men are created equal”
Declaration of IndependenceDeclaration of Independence
““Some people are more equal Some people are more equal than others”than others”George OrwellGeorge Orwell
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Hudson River, 2009Hudson River, 2009
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U.N. Declaration of Human U.N. Declaration of Human RightsRights
““Everyone has the right to Everyone has the right to a standard of living a standard of living adequate for the health and adequate for the health and well-being of himself and of well-being of himself and of his family, including food, his family, including food, clothing, housing and clothing, housing and medical care”medical care”
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SolutionsSolutionsPay as you goPay as you goInsuranceInsuranceGovernment-run programGovernment-run program
VA, IHSVA, IHSPPACAPPACASingle PayerSingle Payer
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What You Can DoWhat You Can Do Educate yourselves and othersEducate yourselves and others
““Information is the currency of Information is the currency of democracy” (Thomas Jefferson)democracy” (Thomas Jefferson)
Join groups working to improve Join groups working to improve health carehealth care
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Act Now!Act Now!
"If you think you are too "If you think you are too small to have an impact, small to have an impact, try going to bed with a try going to bed with a mosquito in your tent“mosquito in your tent“
- African Proverb- African Proverb
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Further Info/References/Contact Further Info/References/Contact InfoInfo
Public Health and Social Justice WebsitePublic Health and Social Justice Websitehttp://www.phsj.org
Physicians for a National Health PlanPhysicians for a National Health Planhttp://www.pnhp.org/
Kaiser Family FoundationKaiser Family Foundationhttp://www.kff.org/
Martin DonohoeMartin [email protected]
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
2014: 26 million uninsured adults 2014: 26 million uninsured adults with incomes under $29,327 will gain with incomes under $29,327 will gain coverage through Medicaid with little coverage through Medicaid with little or no premium or cost sharingor no premium or cost sharing
2014: Up to 17 million adults with 2014: Up to 17 million adults with incomes between $29,327 and incomes between $29,327 and $88,200 for a family of 4 will get tax $88,200 for a family of 4 will get tax credits to help purchase private credits to help purchase private health plans through new state health plans through new state insurance exchanges (sliding scale)insurance exchanges (sliding scale)
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
2014: No denial of coverage or higher 2014: No denial of coverage or higher premiums for preexisting conditionspremiums for preexisting conditions Up to ½ of AmericansUp to ½ of Americans
2010: Uninsured with preexisting 2010: Uninsured with preexisting conditions eligible for special insurance conditions eligible for special insurance plans after 6 months without insuranceplans after 6 months without insurance
2010: Young adults up to age 26 may 2010: Young adults up to age 26 may stay on parents’ health planstay on parents’ health plan
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
2010: Small business tax credits to 2010: Small business tax credits to offset costs of insuring employeesoffset costs of insuring employees
2010: Insurers cannot deny 2010: Insurers cannot deny coverage to children with coverage to children with preexisting conditionspreexisting conditions
2010: No lifetime benefit limits and 2010: No lifetime benefit limits and no rescisionsno rescisions
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
2010: Health plans must provide 2010: Health plans must provide preventive services without cost-preventive services without cost-sharingsharing
50% cost-sharing discount for 50% cost-sharing discount for seniors in Medicare “donut hole”seniors in Medicare “donut hole”
Creates public website listing Creates public website listing payments from drug, device, payments from drug, device, biological, and medical products biological, and medical products companies to physicianscompanies to physicians
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
Problems:Problems:Complex, increases bureaucracyComplex, increases bureaucracyLeaves 23 – 40 million without Leaves 23 – 40 million without
insuranceinsurance40% of these eligible for, but not 40% of these eligible for, but not enrolled in, Medicaid or CHIPenrolled in, Medicaid or CHIP
22% undocumented immigrants22% undocumented immigrants
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
Problems:Problems:No effective cost control measuresNo effective cost control measuresWill not reduce medical Will not reduce medical
bankruptciesbankruptciesWill drain $billions from Medicare Will drain $billions from Medicare
payments to safety net clinics, payments to safety net clinics, threatening the remaining threatening the remaining uninsureduninsured
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
Unfair to women - segregation of Unfair to women - segregation of abortion funding, may affect abortion funding, may affect contraceptive coveragecontraceptive coverage
Poor likely to purchase less Poor likely to purchase less expensive plans with worse expensive plans with worse coverage and higher deductibles coverage and higher deductibles and copaymentsand copayments
?Penalties if poor do not buy ?Penalties if poor do not buy insurance?insurance?
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
Problems:Problems:Loopholes allow charges up to 3x Loopholes allow charges up to 3x
higher for elderly, higher charges higher for elderly, higher charges for large companies with for large companies with predominantly female workforcespredominantly female workforces
Benefits insurance companies, Benefits insurance companies, continues present inefficienciescontinues present inefficiencies
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PPACAPPACAPatient Protection and Patient Protection and Affordability Care ActAffordability Care Act
Problems: Inadequate numbers of primary Inadequate numbers of primary
care providerscare providersCommunities with a high Communities with a high number of PCPs per capita have number of PCPs per capita have lower medical costs and better lower medical costs and better outcomesoutcomes
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"If anyone...has a better approach "If anyone...has a better approach that will bring down premiums, bringthat will bring down premiums, bringdown the deficit, cover the uninsured, down the deficit, cover the uninsured, strengthen Medicare for seniors,strengthen Medicare for seniors,and stop insurance company abuses, and stop insurance company abuses, let me know."let me know."-- President Obama, State of the -- President Obama, State of the Union, 1/27/10Union, 1/27/10
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Single PayerSingle Payer Cradle to grave, portable insurance for Cradle to grave, portable insurance for
everyoneeveryone All medically-necessary services coveredAll medically-necessary services covered Free choice of doctor and hospitalFree choice of doctor and hospital Global and local budgeting determined Global and local budgeting determined
by physicians, patients, other health by physicians, patients, other health professionalsprofessionals
Cost savingCost saving Broad supportBroad support
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Single PayerSingle PayerNot socialism any more than Not socialism any more than
having a police force and fire having a police force and fire department which serve department which serve everyone or offering free public everyone or offering free public education to children through education to children through grade twelve is socialismgrade twelve is socialismImagine if insurance companies Imagine if insurance companies ran the fire departmentran the fire department