Paul Y. Song, MD

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Healthcare Reform Beyond the ACA

• Paul Y. Song, MD

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Of all the forms of inequality, injustice in
health care is the most shocking and
inhumane. Martin Luther King Jr.
In a speech to the Medical Committee for Human
Rights, 1966
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Hippocratic Oath

• I will follow that system of regimen, which
  according to my ability and judgment, I consider
  for the benefit of my patients, and abstain from
  whatever is deleterious and mischievous.

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Now estimated to be 3.13 Trillion in 2014.
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Who are the Uninsured?
NON-WORKER 19.5
PART-TIME WORKER 14
FULL-TIME WORKER 66.5

• Of the 50.7 million, over 20 million are fully
  employed.
• 70 of all uninsured are from families with one
  or more full-time workers.

Urban Institute and Kaiser Commission on Medicaid
and the Uninsured estimates based on the Census
Bureau's March 2008 and 2009 Current Population
Survey (CPS Annual Social and Economic
Supplements).
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Medical Related Bankruptcies

• Number of medical related bankruptcies increased
  50 during the last 9 years.
• In 2013, there were over 1.7 million medical
  related bankruptcies.
• 75 were insured.
• 10 million insured are projected to accumulate
  medical bills they cannot pay off in 2015.

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The six largest insurers denied over 45.7 million
claims over the past nine years in CA alone.
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Between 2003 and 2010 median incomes increased by
only 10 - The Commonwealth Fund
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www.opensecrets.org
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• 475 Billion subsidy to the private insurance
  industry that mandates
• 15 Million Americans to buy coverage from an
  industry that only
• makes money by denying people care.

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United Health Group stock price is up 263 since
Obamacare became law! In 2013, UnitedHealth was
up 33, Wellpoint 50, Aetna 46, and Cigna 60.
This year stock prices have hit all time highs!
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But...
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Inconvenient Truth

• Family premiums already are at 16,800 per year
  and rising, with employees having to contribute
  more every year.
• Premiums, copays, and out-of-pocket costs will
  continue to increase as insurance companies
  continue to maximize their profits under the ACA.
• 36 million will remain uninsured in 2015.
• No provisions to regulate excessive insurance
  premium hikes.

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Anything But Universal Health Care!!
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Many patients enrolled in the exchange are
finding less and less providers who will see them.
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Medicaid Expansion

• Kaiser Family Foundation estimates that the
  refusal of 25 states to expand Medicaid will
  result in 5 million without affordable coverage.
• A NEJM study found that for every 500,000 adults
  newly covered by Medicaid, 2,840 fewer deaths
  would be prevented.

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• The foreigner residing among you must be treated
  as your native-born. Love them as yourself, for
  you were foreigners in Egypt. I am the Lord your
  God.
• - Leviticus 1934

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Too Much Dependence on Employer Based Healthcare
Coverage

• Healthcare benefits has become the biggest area
  of labor negotiation strife!!
• Too many Americans are stuck in jobs they hate
  simply because they receive coverage through
  their employers.

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Kaiser Family Foundation 2012
In the past 12 years, Premiums have increased
160 while wages have only Increased 35 and
inflation has increased 35.
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Hard for Employers Too!

• In 2011 159 Million Americans had employer
  sponsored healthcare coverage.
• For every 1.00 that US companies spend on health
  care, companies in Japan, Germany, France, and
  Canada spend 63 cents which leads to more
  off-shoring of jobs and less job creation.

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So why are we spending so much and getting so
little?!!!
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Prior to the ACA, private insurers wasted 31
cents of every dollar on administrative overhead,
sales and marketing, lobbying, billing,
underwriting, and exorbitant executive
compensation.This waste is now estimated to be
over 475 Billion a year!!
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1965
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Medicare A Single Payer System!!

• Established in 1965 when only 44 of adults over
  65 years of age were uninsured and 1/3 of all
  seniors were living in poverty.
• Commonwealth Fund - Medicare patients continue to
  have much greater satisfaction, better access to
  care, and fewer billing problems than those with
  employer sponsored plans.
• Kaiser Family foundation study showed greater
  overall satisfaction and much more cost
  efficiency than private insurance companies.

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Medicare A Single Payer System!!

• Medicare spends approximately 2 on
  administrative costs.
• Patients have greater choice and do not need
  pre-authorizations.
• The government does not tell doctors how to
  practice, what tests to order, which hospitals to
  go to, or what medications to prescribe.

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Source Kaiser Family Foundation Centers for
Medicare and Medicaid Services
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GOP pledged that by placing at least 20 of
Medicare beneficiaries in private HMOs would save
270 Billion over seven years.
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Medicare has overpaid private insurers by 282.6
billion, or 24.4 of all Medicare payments, since
1985. In 2012 alone, we find that MA plans are
being overpaid by 34.1 billion, or 6.2 of total
Medicare spending. -
Hellander, Woodhandler, Himmelstein Int. J. of
Health Services (2012)
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Pharmaceutical costs are rising
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In 2006, the first year of Medicare Part D, the
combined profits of the largest drug Companies
soared 34 to 76.3 Billion.
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Medicare Part D

• A much bigger government run healthcare program
  than Obamacare.
• It is illegal for Medicare, the nations biggest
  health plan, to use its market power to negotiate
  for lower prescription drugs prices.
• Medicare is also banned importation of cheaper
  drugs and gave drug companies stronger
  protections against their generic competitors.
• The per capita spending on drugs in the US is 40
  higher than in Canada and 75 greater than in
  Japan and 300 higher than the amount spent in
  Denmark.
• Administrative costs are almost 10.

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Private Medicare Drug Plans US Congressional
Committee on Oversight and Government Reform
Report 2007
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How to Best Strengthen and Preserve Medicare

• Identify and acknowledge wasteful spending within
  the program Medicare Advantage and Part D.
• Eliminate these indefensible subsidies for big
  corporations.
• Rid the program of all very expensive and
  inefficient private solutions.

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Single Payer Friedman U. Mass Study 2013

• An estimated 592 Billion would be saved
  annually.
• 476 Billion would be saved by slashing
  administrative waste associated with the private
  insurance industry.
• 116 Billion would be saved by reducing
  pharmaceutical prices to European levels.
• 1.8 Trillion (inflation adjusted) will be saved
  over the next 10 years.

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Challenges of Setting up a State Only Single
Payer System

• Too many existing federal restrictions.
• Medicaid and limited Medicare waivers are not
  clearly enough to assemble a single payer system.
• ERISA prevents the state from moving self-funded
  employer sponsored health plans into a state
  system.
• Control of Medicare or Military Tri-care could
  not be transferred to a state.
• Big multi-state employers cannot be forced into
  the program.

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Strengthen, Preserve, and Expand Medicare

• Allow everyone to buy into Medicare instead of
  private insurance with premiums based on their
  ability to pay.
• Bringing in a younger and healthier pool with
  spread out risk and provide a strong financial
  infusion to further strengthen Medicare.

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Why Single Payer is Inevitable

• Healthcare costs will continue to climb for the
  federal government, states, cities, companies,
  and individuals which are simply unsustainable.
• This will lead to fewer overall benefits and more
  skin in the game by everyone who is insured.
• Ideology will eventually be replaced by reality
  once a critical mass of people experience the
  looming dramatic change in their healthcare.

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