Economics and Health Disparity in the US

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Economics and Health Disparity in the US

• sam.baker_at_sc.edu
• Department of Health Services Policy and
  Management
• Arnold School of Public Health
• University of South Carolina

2
Economics and health disparity

• Economic circumstances affect environment and
  behavior, which affect well-being
• Economic circumstances affect health care access,
  which affects well-being
• The health care financing system affects economic
  circumstances, which

3
Some slides are courtesy of
PHYSICIANS FOR A NATIONAL HEALTH PROGRAM
332 SOUTH MICHIGAN AVENUESUITE 500CHICAGO, IL
60604TEL [phone]WWW.PNHP.ORG
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Economics and health disparity

• Economic circumstances affect environment and
  behavior, which affect well-being
• Economic circumstances affect health care access,
  which affects well-being
• The health care financing system affects economic
  circumstances, which

5
Causes Of Excess Deaths AmongAfrican Americans
Cardiovascular 39
Cardiovascular 25
Source Himmelstein Woolhandler - Analysis of
data from NCHS
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Distribution of Wealth, 1976 1998
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Despite Higher GDP, Most Americans Have Less
Disposable Income than Canadians
Source Monthly Labor Review April, 1998Note
Mean earnings in the U.S. were 15.5 higher than
in Canada in 1995
12
Poverty Rates, 1997U.S. and Other Industrialized
Nations
Source Luxembourg Income Study Working
PapersNote U.S. figure for 1997, other nations
most recent available year
13
Americans Lead the World in Hours Worked
Source International Labor Organization, 1999
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• Science. 2004 Sep 17305(5691)1736-9.
•   Inflammatory exposure and historical changes
  in human life-spans.Finch CE, Crimmins
  EM.Andrus Gerontology Center and Departments of
  Biological Sciences and of Sociology, University
  of Southern California, Los Angeles, CA 90089,
  USA. cefinch_at_usc.eduMost explanations of the
  increase in life expectancy at older ages over
  history emphasize the importance of medical and
  public health factors of a particular historical
  period. We propose that the reduction in lifetime
  exposure to infectious diseases and other sources
  of inflammation--a cohort mechanism--has also
  made an important contribution to the historical
  decline in old-age mortality. Analysis of birth
  cohorts across the life-span since 1751 in Sweden
  reveals strong associations between early-age
  mortality and subsequent mortality in the same
  cohorts. We propose that a "cohort morbidity
  phenotype" represents inflammatory processes that
  persist from early age into adult life.
• U.S. Civil War veterans who had infectious
  disease as young men were more likely to have
  heart disease after age 50. Frequent diarrhea
  during infancy, a sign of infection, is linked to
  cardiovascular disease in adulthood. Americans
  now in their 50s are 15 more likely to have
  cardiovascular disease, and twice as likely to
  have cancer, if they had a serious infectious
  disease in childhood.
• Men who weighed less than 5.5 pounds at birth
  have, on average, a 50 greater chance of dying
  of heart disease. Women 23. (Race effect?
  Which way?)

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An aside on genetics as a residual explanation

• Differences not attributable to the immediate
  environment are attributed to genetic differences
• E.g. cardiovascular disease race differences
• Environment effects during development and early
  childhood can affect adult health and the next
  generation (e.g. hypertension and pre-eclampsia).

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Economics and health disparity

• Economic circumstances affect environment and
  behavior, which affect well-being
• Economic circumstances affect health care access,
  which affects well-being
• The health care financing system affects economic
  circumstances, which

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45 million uninsured, 15.6 of public, in 2003
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Number Uninsured/In Poverty 1967-1998
Source Social Security Bul, HIAA, CPS
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Who Are The Uninsured?
Studentsgt18, Homemakers, Disabled, Early
retirees
Source Himmelstein Woolhandler - Tabulation
from 1999 CPS
23
Blacks and Hispanics Full Time Jobs Provide
Less Insurance
Source Commonwealth Fund, 3/2000
24
Are Emily and Brendan More Employable than
Lakisha and Jamal?
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Former Welfare RecipientsJobs May Not Bring
Coverage
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Uninsured Forego Care for Serious Symptoms
Source Arch Int Med 2000 1269 - analysis of RWJ
Foundation SurveySerious Sx loss of
consciousness, breast lump, chest pain gt 1
minute, etc.Potentially Serious Sx Difficulty
urinating, productive cough with fever etc.
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Health care foregone
28
Un- and underinsurance costs money and lives
29
Later diagnosis of cancers
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Uninsured get less heart care
31
Uninsured get less trauma care
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Uninsurance 6th Leading Cause ofDeath among
persons under 65

• http//www.iom.edu/IOM/IOMHome.nsf/Pages/Consequen
  cesofUninsurance
• Primary prevention and screening
• Cancer care
• Chronic disease care diabetes, cardiovascular
  disease, end-stage renal disease, HIV, mental
  illness

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Uninsurance as Cause of Death continued

• Acute care for cardiovascular disease, trauma
• Surprisingly, provider response to traumatic
  injury can be influenced by insurance status.
  Uninsured trauma victims are less likely to be
  admitted to a hospital, receive fewer services
  when admitted, and are more likely to die than
  are insured trauma victims.

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Patients Refused Authorization for ER Care

• 8 to 12 of HMO patients presenting to 2 ERs
  were denied authorization
• Authorization delayed care by 20 to 150 minutes
• One HMO members story
• Refused at private hospital ER because didnt
  have insurance card
• Admitted to public hospital
• Then, the HMO insisted on transfer to the private
  hospital

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Patients Refused Authorization for ER Care

• Of those denied
• 47 had unstable vital signs or other high risk
  indicators
• 40 of children were not seen in f/u by primary
  MD
• Eventual diagnoses included meningococcemia (2),
  ruptured ectopic (2),shock due to hemorrhage (2),
  septic hip, PE, MI (2), ruptured AAA,
  pancreatitis, peritonsillar abscess, small bowel
  obstruction, unstable angina, pneumothorax,
  appendicitis, meningitis(3)

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Sick HMO Patients Barriers to Care
Source Consumer Reports 7/200041 - based on
survey of 52,000 readers
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Tradeoff Savings for OutcomeHMOs Push Heart
Surgery Patientsto High-Mortality Hospitals
Source JAMA 2000 2831976CABG coronary
artery bypass graft surgery
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Milliman RobertsonPediatric Length of Stay
Guidelines

• 1 Day for Diabetic Coma
• 2 Days for Osteomyelitis
• 3 Days for Bacterial Meningitis
• They're outrageous. Theyre dangerous. Kids
  could die because of these guidelines.
• Thomas Cleary, M.D. Prof. of Pediatrics, U.
  Texas, Houston
• Listed as "Contributing Author" in MR manual

Source Modern Healthcare May 8, 200034
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Milliman Robertson

• We do not base our guidelines on any randomized
  clinical trials or other controlled studies, nor
  do we study outcomes before sharing the evidence
  of most efficient practices with colleagues.

Wall Street Journal 7/1/98
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Racial Disparity in Access to Kidney Transplants
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Pharmacies in Minority NeighborhoodsFail to
Stock Opioids
Source N Engl J Med 2000 2421023
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Minority Physicians ProvideMore Care for the
Disadvantaged
Ethnicity of Physician
Source AJPH 199787817
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Economics and health disparity

• Economic circumstances affect environment and
  behavior, which affect well-being
• Economic circumstances affect health care access,
  which affects well-being
• The health care financing system affects economic
  circumstances, which

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5440 per person
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Health Spending, 1990 1998U.S. Costs Rose
More Than Other Nations
Source Health Affairs 2000 19(3)150
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Elderly as Percent of Total Population, 2000
Source Health Affairs 2000 19(3)192
48
Risky People Charged More
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Firms Shift Health InsuranceCosts to Workers
Source Int J Health Serv 199929498
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Rising Out-of-Pocket Costs for SeniorsVoucher/Pre
mium Support Proposals Would Worsen
Percent of Income
Source Senate Select Committee on Aging AARP
4/95 3/98 and Commonwealth Fund May, 1999
projections (adjusted to include nursing home
costs)
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Federal Tax Subsidies forPrivate Health
Spending, 1998
Note Total federal tax subsidy 111.2
billionSource Health Affairs 1999 18(2)176
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Who Pays for Healthcare?
Amount in 1998(billions)
Percent
Government
736.8
64.1
Medicare
216.2
Medicaid
170.6
Premiums for public employees
67.3
Tax subsidy for private insurance
124.8
Other
157.9
Private employers
216.5
18.8
Individuals (excludes tax subsidy)
195.8
17.0
Total
1149.1
100
Source Himmelstein Woolhandler - Unpublished
analysis of NCHS data, Health Affairs
199918(2)176 Includes VA, NIH, subsidy for
public hospitals, worker's comp, health
departments etc.
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Who Pays for Health Care, US DHHS version (2002)
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Behind Who Pays, 1998
Source Himmelstein Woolhandler - Unpublished
analysis of NCHS data, Health Affairs
199918(2)176 Includes VA, NIH, subsidy for
public hospitals, worker's comp, health
departments etc.
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U.S. Public Spending Per Capita for Healthis
Greater than Total Spending in Other Nations
Note Public includes benefit costs for govt.
employees tax subsidy for private
insuranceSource NEJM 1999 340109 Health Aff
2000 19(3)150
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Who Pays For Health Care? Regressivity Of U.S.
Health Financing
Source Oxford Rev Econ Pol 19895(1)89
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Many Americans Can't Afford the BasicsPercent of
Insured and Uninsured with Unmet Needs
Source Census Bureau - "Extended Measures of
Well-Being Meeting Basic Needs"
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Financial consequences
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U.S. Seniors Paying More for Ten Top Selling
Drugs

Source U.S. GAO www.house.gov/bernie/legislatio
n/pharmbill/international.html Zocor, Ticlid,
Prilosec, Relafen, Procardia XL, Zoloft, Vasotec,
Norvasc, Fosamax, Cardizem CD
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Financial Suffering at the End of Life
Source Ann Int Med 2000 132451 - SUPPORT Study
of 988 terminally ill patients Out-of-pocket
medical costs gt 10 of household income
Patient or family sold assets, took out mortgage,
used savings or took extra job
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Illness and Medical Costs,A Major Cause of
Bankruptcy

• 45.6 of all bankruptcies involve a medical
  reason or large medical debt
• 326,441 families identified illness/injury as the
  main reason for bankruptcy in 1999
• An additional 269,757 had large medical debts at
  time of bankruptcy
• 7 per 1000 single women, and 5 per 1000 men
  suffered medical-related bankruptcy in 1999

Source Norton's Bankruptcy Advisor, May, 2000
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Rate of abortions per 1,000 women aged 1544 in
the United States and in South Carolina, 19732000
Guttmacher Institute
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Guttmacher Institute data.
Two-thirds of women who have abortions cite
"inability to afford a child" as their primary
reason.
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Physician Visits Per Capita
Source OECD, 1999 - Data are for 1997 or most
recent available year
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U.S. Public Spending Per Capita for Healthis
Greater than Total Spending in Other Nations
Note Public includes benefit costs for govt.
employees tax subsidy for private
insuranceSource NEJM 1999 340109 Health Aff
2000 19(3)150
66
Hospital Inpatient Days Per Capita, 1997
Source OECD, 1999
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Difficulties Getting Needed Care
Source Commonwealth Fund Survey, 1998
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Continuity of Care
Source Commonwealth Fund Survey, 1998
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Reasons for Changing Health Plans
Changed job, or employer changed plan offerings
Source Health Affairs 2000 19(3)158
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Infant Mortality, 1997Deaths In First Year Of
Life/1000 Live Births
Source OECD, 1999 NCHS
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Life Expectancy For Women, 1997
Source OECD, 1999 NCHS
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Life Expectancy For Men, 1997
Source OECD, 1999 NCHS
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Minimum Standards For Canada's Provincial Programs

• Universal coverage that does not impede, either
  directly or indirectly, whether by charges or
  otherwise, reasonable access.
• Portability of benefits from province to province
• Coverage for all medically necessary services
• Publicly administered, non-profit program

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Who Pays For Health Care? Regressivity Of U.S.
Health Financing
Source Oxford Rev Econ Pol 19895(1)89
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Who Pays For Canada's NHP?Province Of Alberta
Source Premier's Common Future Of Health,
Excludes Out-of-Pocket Costs
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Health Care Spending Of GNPU.S. Canada,
1960-2001
Source Statistics Canada, Canadian Inst. for
Health Info., NCHS/Commerce Dept
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Number of Insurance Products
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Hospital Billing AdministrationUnited States
Canada, 2000
Source Woolhandler/Himmelstein NEJM 1991
3241253 1993 329400 (updated)
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Physicians' Billing Office ExpensesUnited
States Canada, 2000
SourceWoolhandler/Himmelstein NEJM 19913241253
(updated)
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Difference in Health SpendingPer Capita, U.S.
vs. Canada, 2000
Source Woolhandler/Himmelstein NEJM 1991
3241253 1993 329400 (updated)
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Infant MortalityU.S. Canada, 1955-1996
FIRST PROVINCE IMPLEMENTS NHP
U.S.
CANADA
Source OECD 1999, Statistics Canada CDF
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Infant Deaths by Income, Canada 1996Even the
Poor Do Better than U.S. Average
84
Homeless in TorontoDeath Rate Elevated, But
Lower than In U.S.
Source JAMA 2000 2832152
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Physician Services For The Elderly Canadians
Get More of Most Kinds of Care
Source JAMA 1996 2751410
86
Growth in Spending 1970-1998Medicare vs.
Private InsurersPer Enrollee
Source K. Levit, HCFA - Personal Communication -
3/1/00
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NIH Clinical Research Grants (RO1)Falling in
High Managed Care Markets
Source Moy et al. JAMA 1997 278217
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Economics and health disparity

• Economic circumstances affect environment and
  behavior, which affect well-being
• Economic circumstances affect health care access,
  which affects well-being
• The health care financing system affects economic
  circumstances, which feeds back to 1. and 2.

sam.baker_at_sc.edu
It doesnt have to be that way. We can do
better!