What would Single Payer Mean for NPs?

What would Single Payer Mean for NPs? NPO 39 TH ANNUAL EDUCATION CONFERENCE NANCY SULLIVAN, RN, MS, FACNM CHRIS TANNER, RN, PHD, ANEF REPRESENTING NURSES FOR SINGLE PAYER (NFSP) A MOVEMENT TO GAIN UNIVERSAL, COMPREHENSIVE, PUBLICLY FUNDED HEALTH CARE Overview Current payment methods and impact on: Quality, access and outcomes of care Daily practice of providers Four models of health care coverage already tested in the developed world Self pay Socialized medicine Single payer, government funded Government regulated, private insurers Proposed state & federal approaches to universal, publicly funded care: Oregon s proposed legislation Colorado s ballot initiative ACA public option Physicians for National Health Program Impact on care 1

American Health Care Financing Issues with current payment system THE MOST EXPENSIVE IN THE DEVELOPED WORLD The most expensive 20 15 Health Care Spending 10 as % of GDP 5 0 Estonia Turkey Mexico Luxembourg Poland Korea Czech Republic Chile Israel Hungary Slovak Republic Slovenia Ireland Australia Finland Iceland Greece Italy Norway Spain United Kingdom Sweden Japan Portugal New Zealand ¹ Belgium ¹ Austria Denmark Switzerland Canada Germany France Netherlands United States 2

Health care costs predicted to continue rising 19% Health Care Costs As Share Of Gross State Product 18% 17% 16% 15% 14% 13% 12% 11% 10% 1991 1994 1997 2000 2003 2006 2009 2012 2015 2018 2021 2024 Health Insurers Making Record Profits as Many Postpone Care NYTimes May 13, 2011 Cigna, Humana CEOs earn millions in pay jumps http://www.fiercehealthpayer.com/story/cigna-humana-ceos-earn-millions-pay-jumps/2012-03-07 Cigna profit exceeds expectations; lower costs help Reuters, August 1, 2013 3000% Rising administrative costs Growth Since 1970 2500% 2000% 1500% 1000% 500% 0 1970 1980 1990 2000 2010 Physicians Administrators Data updated through 2013 Source: Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of CPS 3

Rising Drug Prices TO KEEP IN MIND WHEN YOU READ ALL THE HYPE ABOUT RISING DRUG PRICES: PATIENTS WHO ARE THE SICKEST AND REQUIRE THE MOST EXPENSIVE DRUGS ARE THE MOST VULNERABLE TO SOARING DRUG PRICES. IT S SORT OF EMBEDDED IN THE HEALTH CARE SYSTEM THAT THE PRICE IS NEVER THE PRICE, UNLESS YOU RE A CASH- PAYING CUSTOMER, STATES THE PRESIDENT OF A BUSINESS RESEARCH COMPANY, AND IN THAT CASE, WE SOAK THE POOR. (K. THOMAS, NYT, AUG 24, 2016) Individuals and Families are bearing more of the cost of health insurance & treatment Between 2011-1016, incomes have increased by 11% while... Deductibles increased 63% on average for people who get health insurance through employers Workers contributions to premiums have increased by 23% Source: KFF.org 2016 Employer Health Benefits Survey 4

Individuals and Families are bearing more of the cost of health insurance & treatment Average price of brand-name medicines jumped 164% from 2008-2015* 24% of Amercians find it very or somewhat difficult to afford prescription drugs** Sources:* Express Scripts 2015 Drug Trend Report, Executive Summary, March 2016 **2015 Kaiser Family Foundation survey Even with the Affordable Care Act.... The large increase in health care costs has created hardships, and sometimes disasters, for individuals and families Due to lack of affordable health care, each year 600 Oregonians die 8,000 go bankrupt 5

Case Study: Lane County, Oregon Population 356,000 800 personal bankruptcies in 2014, with 72% related to medical debt AND 10 biggest creditors all medical businesses. Non-profit PeaceHealth increased profits from $39.6 million in 2013 to $97.4 Million in 2014. PeaceHealth used aggressive collection tactics against Hollie Murphie, who was so underinsured with her employee plan that she was left with thousands of dollars of medical Bills. Peace Health garnished her wages to cover cost of her surgery. The best health care system? SHORTER LIVES, POORER HEALTH, LOWER SATISFACTION, LESS ACCESS TO CARE 85 Life Expectancy at Birth, Affluent Countries 80 75 70 65 US life expectancy lower even for those with insurance! 60 6

Years of Lost Life Before Age 50 in Men, 2006-2008 National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health Years of Lost Life Before Age 50 in Women, 2006-2008 National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health Infant Mortality Rates in 17 countries,2005-2009 National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health 7

Poorer health, using many indicators The USA has the highest prevalence of diabetes in young adults age 15-44 of any developed country. Americans under 50 have the highest incidence of heart attack, stroke, cancer, diabetes, and activity limitations in comparison with 10 other developed countries. National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health 70% Access To Health Care 60% 50% Cost- Related 40% Access 30% Problem 20% 10% 0% 16% Americans have the most problems even those with insurance 13% 18% 15% 22% 21% 10% 6% USA Uninsured USA Insured AUS CAN FRA GER NET NZL NOR SWE SWI UK USA All 13% 4% 37% 27% USA Ins 63% USA Unins Did not see a doctor when sick or did not get recommended care because of cost, did not fill Rx or skipped doses because of cost Commonwealth Fund data reported in Schoen, C et al.health Affairs 32,No.12 (2013):2205-2215 Satisfaction with health system Proportion saying health care system works well 60% 40% 20% 0% Australia Canada France Germany Netherlands New Zealand Norway Sweden Switzerland UK USA 8

What do these countries have in common? Some form of universal, publicly funded health care Some Examples of Other Health Financing Models: Germany, Japan, Belgium & Switzerland The Bismarck Model Both health care providers and payers are private entities Private health insurance plans, financed by employers and employees through payroll deduction Unlike US health plans non-profit charities that cover everyone Physicians and many hospitals are privately owned Tight regulation of medical services and fees Source: Reid, T.R. (2010) The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books 9

Some Examples of Other Health Financing Models: GreatBritain, Italy, Spain & most of Scandinavia The Beveridge Model Health care is provided and financed by the government, through taxes No medical bills it s a service, like fire department & police protection Many hospitals & clinics owned by government Providers are government employees, although there are also private doctors who collect fees from gov. Most like the VA System Source: Reid, T.R. (2010) The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books Some Examples of Other Health Financing Models: Canada National Health Insurance Model Elements of both Bismarck & Beveridge Models Providers of health care are private Payer is government-run insurance program that every citizen pays into Plan collects monthly premiums and pays medical bills No need for marketing, no expensive underwiting offices to deny claims, no profit Considerable market power to negotiate lower prices Source: Reid, T.R. (2010) The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books Some Examples of Other Health Financing Models: Rural regions of Africa, India, China & South America The Out of Pocket Model Most medical care paid for by patient with no insurance or government plan to help Out of pocket expenses account for 95% of health spending in Cambodia, 21% in US (in 2008)** Source: Reid, T.R. (2010) The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books World Bank Data (2016) Out of pocket health expenditure on health. Accessd from http://data.worldbank.org/indicator/sh.xpd.oopc.zs 10

All four models present in US: For most working people under 65, and for those with no employer coverage but eligible for enrollment in Federal exchange, we re Germany or Japan For Native American, military personnel and veterans, we re Britain For those over 65, we re Canada For the 30 million uninsured, we re Cambodia Source: Reid, T.R. (2010) The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books What could a universal, publicly funded health system look like? FEDERAL LEGISLATION AND STATE BY STATE INITIATIVES Proposed Federal Legislation: Universal Coverage Single Payer Bill YES. Everyone is covered automatically at birth. Affordable Care Act NO. 30 million will still be uninsured in 2022 and tens of millions will remain underinsured. 11

Proposed Federal Legislation: Full Range of Benefits Single Payer Bill YES. Coverage for all medically necessary services. Affordable Care Act NO. Insurers continue to strip down policies and increase patients co-payments and deductibles. Proposed Federal Legislation: Savings Single Payer Bill YES. Redirects $400 billion in administrative waste to care; no net increase in health spending. Affordable Care Act NO. Increases health spending by about $1.1 trillion over 10 years. Adds further layers of administrative bloat to our health system through the introduction of statebased exchanges. Proposed Federal Legislation: Cost Control/Sustainability Single Payer Bill Yes. Large-scale cost controls (negotiated fee schedule with physicians, bulk purchasing of drugs, hospital budgeting, capital planning, etc) ensure that benefits are sustainable over long term. Affordable Care Act No. Preserves a fragmented system incapable of controlling costs. Gains in coverage are erased by rising outof-pocket expenses, bureaucratic waste and profiteering by private insurers and Big Pharma. 12

Proposed Federal Legislation: Choice of Doctor and Hospital Single Payer Bill Yes. Patients will be allowed free choice of their doctor and hospital. Affordable Care Act No. Insurance companies continue to deny and limit care and to maintain restrictive networks. Proposed Federal Legislation: Progressive Financing Single Payer Bill Yes. Premiums and outof-pocket costs are replaced with progressive income and wealth taxes. 95% of Americans would pay less for care than they do now. Affordable Care Act No. Continues the unfair financing of health care whereby costs are disproportionately paid by middle and lowincome Americans and those families facing acute or chronic illness. Basic Premise 13

Health Care for All Oregon Act (SB 631) Who is covered? All persons residing or working in Oregon All people are currently covered for acute emergency room care (expensive) legal, ethical, & moral requirement. Bill would broaden coverage could prevent many emergency room visits & better maintain health. Theme of SB 631 Simplify administration cover all residents (universal) for all medically necessary services (comprehensive) single-payer same payments for same services no copays and deductibles Theme of SB 631 Flexible payment systems, tailored by provider, to best meet needs of providers and system global budgets fee for service other transparent & fair systems as needed 14

Administrative simplicity generally leads to equity All residents covered equally All medically necessary services covered Same payments for same services Equity for providers Equity for patients Now private insurers, Medicare, Oregon Health Plan, individuals pay differently How do we get there? HCAO A Movement committed to the belief that health care is a human right. Working to ensure every person in Oregon has access to an equitable, affordable, comprehensive, high-quality, publicly funded universal health care system a system that will save lives and save money at the same time. 15

The growth of a movement 2012-2015 Local action groups in 14 counties 120 organizational members (including Nurses for Single Payer and ONA)with more joining every month 18,000 supporters Contributions of over $500,000 from more than 800 donors 1200 Universal Care advocates participated in lobby day February 2015, meeting with 70 legislators HCAO Actions 2012-2015 Testified to Oregon Senate Health Care Committee 2015 Completed 2 professional voter polls one to determine support for a ballot measure on publicly financed health care and a 2nd on amending the Oregon Constitution to declare that Health Care is a Human Right. Led efforts to obtain state funding for HB2828, a bill that provides $300,000 to study models for financing a universal health care system in Oregon. Study now being conducted by the Oregon Health Authority Health Care for All Oregon 2016-2020 Increase the reach of our statewide educational program Increase our base of support on all fronts With our allies, implement legislation to educate the public while coordination with other local, state, and national campaigns to make universal, publicly funded healthcare a reality in Oregon and the U.S. Collect signatures to qualify an initiative petition supporting this legislation if the legislature fails to refer an appropriate bill to the voters. 16

Health Care for All Oregon, 2016-2020, continued Continue work to get a publicly funded health care bill on the 2020 ballot. Increase the reach of our statewide educational program Increase our base of support on all fronts Implement legislative strategy: Lobby the 2017 legislature to create a funded work group charged with designing a health care system based on the HB 2828 study recommendation. Health Care for All Oregon, 2016-2020, continued Write a bill with a defined tax structure by 2018. Lobby the legislature to place advisory questions on the 2018 ballot a way to engage voters on our issues and inform the legislative process prior to voting on a measure in 2020. Lobby the legislature to refer our plan to the voters for the 2020 ballot in the 2018 or 2020 session. Nurses for Single Payer 55,000 registered nurses in Oregon Nurses are the largest and most highly respected health profession live and work in every community in Oregon are well known and respected in their communities understand why the current system isn t working and what we need to do to fix it 17

Nurses for Single Payer Goals We want 55,000 nurses to favor publicly funded, universal care We want 10,000 nurses to agree to: speak with colleagues, neighbors, friends knowledgably about the need for universal, publicly funded health care publicly support legislation and ballot initiative argue against the health insurance lobby and others who will strongly oppose this change What are Nurses Doing in Other States? In New York State, the New York State Nurses Association states that their mission is to care for all New Yorkers. That is why they endorse a single-payer Medicare for All system that ensures access to highquality care for everyone The NY House of Delegates has now passed single-payer legislation twice. http://www.nysna.org/healthcare-forall-0#.v-m6xtymq-8 What are Nurses Doing in Other States? National Nurses United, with close to 185,000 members in every state, is the largest union and professional association of registered nurses in U.S. history. NNU is a strong and vocal supporter of the American Health Security Act of 2015, H.R. 1200 and the Expanded & Improved Medicare For All Act, H.R. 676, that requires each participating state to set up and administer comprehensive healthcare services as an entitlement for all, through a progressively financed, single-payer system, administered by the states. http://www.nationalnursesunited.org/site/entry/ medicare-for-all 18

What could single payer do for advanced practice? Improved care coordination Increase in team-based care Driver of legislative changes needed for expanded scope of practice in states with restrictions Proportion of time spent in patient care (vs administrative tasks) What else? What Can You Do? GET INVOLVED NFSP & HCAO GET INFORMED LISTEN FOR COMPELLING STORIES ENGAGE IN ADVOCACY AND EDUCATION MEET YOUR LEGISLATOR PARTICIPATE IN THE BALLOT INITIATIVE PROCESS 19