Single Payer Systems: Equity in Access to Care

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1 Single Payer Systems: Equity in Access to Care Lynn A. Blewett University of Minnesota, School of Public Health The True Workings of Single Payer Systems: Lessons or Warnings for U.S. Reform Journal of Health Politics Policy and Law The Hubert H. Humphrey Institute of Public Affairs University of Minnesota, Minneapolis MN May 10, 2008 Funded by a grant from the Robert Wood Johnson Foundation Overview of Presentation Trends in coverage and access International comparisons Thoughts on equity Concluding comments 2 1

2 Recent Trends 3 Drivers of Health Reform Increasing number of uninsured Drop in employer-sponsored coverage Kids impact moderated by SCHIP No safety net for adults Increasing number of underinsured Higher out-of-pocket costs Lack of national efforts for reform Iraq, immigration, etc., dominating Congress 4 2

3 Continued Increase in Uninsured Millions of Uninsured, all ages New verification question % of Population Source: U.S. Census Bureau, Current Population Surveys (March), Drop in Employer-Sponsored Coverage (U.S.) 70% 65% 64.2% 60% 59.7% 55% 50% Source: US. Census Bureau, Income, Poverty, and Health Insurance Coverage in the United States:

4 Increase in Uninsured Children # of children % of children 150, %+ FPL 21.2% 340, % FPL 47.5% 220,000 <200% FPL 31.3% 710,000 New Uninsured Children Note: 200% to 399% of the federal poverty level (FPL) is apx $40,000-$80,000 in annual income for a family of four in Source: Kaiser Family Foundation Country Classifications of Health Systems 8 4

5 Comparing Five Country Systems Social Health Insurance Models Germany Netherlands Single Payer Systems United Kingdom Canada Private Multi-Payer US

6 Germany: Social Health Insurance Public insurance mandatory for citizens < 48,000 Covers preventive services, inpatient and outpatient hospital care, and physician services Administered by over 200 non-profit Sickness Funds (SFs) Financed by compulsory contributions to the SFs from employees and employers based on wages Private health insurance: civil servants, self-employed, those earning > 48,000; Financed by risk-related premiums and copayments Private expenditures on health = 23.1% of total HC $ 11 Netherlands: Social Health Insurance Each person is required to purchase individual private health (community rated premiums with risk adjustment) from competing plans Mandated national benefit set including dental and drugs Financed by income-related contribution that are compensated by employer compensation employer-based financing About 2/3 of all citizens receive a government subsidy to help pay for coverage in the private market Private expenditure = 37.6% of HC $ 12 6

7 Canada: Single Payer Model Universal mandatory coverage Standard benefits for medically necessary hospital, physician, and surgical-dental services (no dental or prescription drugs) Federal funding to each province and territory to administer their own public programs Most providers private (i.e. not government employees) Financed from general income tax and social security contributions Private expenditures = 30% of total HC $ 13 United Kingdom: Single Payer National Health Service (NHS) is universal mandatory coverage Comprehensive benefits includes preventive services, physician services, inpatient and outpatient hospital services Cost-sharing limited to prescription drugs and dental services Most providers are public and salaried Financed through general income tax Private expenditure on health = 13.7% of HC $ 14 7

8 Private Voluntary - US Private voluntary health insurance with supplemental public coverage for select populations (elderly/disabled, low-income children and families No standard benefit package Most private insurance is employer-based with employers paying on average 74% of premium cost/employee 26% Financed by tax subsidy to employers who offer; Public insurance is financed by the federal and state governments and through tax revenue schemes Private expenditure on health = 55.3% of HC $ 15 US Health Care Financing and Coverage Total Health Care Spending, 2006: $2.1 Trillion Non-elderly Health Insurance Coverage, 2006 Uninsured 17.8% Public 46% Private 54% Public 15.0% Private 67.2% SOURCE: Centers for Medicare & Medicaid Services, Office of the Actuary, National Health Statistics Group. SOURCE: SHADAC Analysis of the 2007 Annual Social and Economic Supplement to the Current Population Survey 16 8

9 Total expenditure on health: % of GDP (2005) 20% U.S. Health Care Spending Outpaces Other Countries 15% Total expenditure on health as percentage of gross domestic productin % 10% 10.6% 20.0% 9.2% 15.0% 10.6% 10.0% 9.8% 9.2% 9.8% 8.1% 15.4% 8.1% 5.0% 5% 0.0% Germany Netherlands Canada UK USA 0% Germany Netherlands Canada UK USA SOURCE: World Health Organization, available at 17 Total Per Capita Spending (2005) $10,000 US Per Capita Government Spending is Similar to other Countries $8,000 $2,725 $6,000 $4,000 $2,709 $2,146 $2,121 $2,502 $6,096 $2,000 $3,521 $3,442 $3,038 $2,900 $0 Germany Netherlands Canada UK USA Per capita government expenditure on health at average exchange rate (US$) Per capita total expenditure on health at average exchange rate (US$) SOURCE: World Health Organization, available at 18 9

10 Distribution of Private and Public Spending US has greatest share of private spending But Canada private spending greater than UK and Germany 100% 80% 44.7% 60% 76.9% 62.4% 69.8% 86.3% 40% 55.3% 20% 0% 37.6% 30.2% 23.1% 13.7% Germany Netherlands Canada UK USA Private Public SOURCE: World Health Organization, available at 19 Barriers to Access 40% US Outlier in Terms of Barriers to Access Netherlands SHI Fairs Best 37% 30% 20% 21% 25% 23% 23% 10% 0% 12% 11% 12% 8% 8% 8% 5% 5% 5% 4% 1% 2% 2% 2% 3% Germany Netherlands Canada UK USA Did not visit doctor when sick Skipped medical test, treatment, or follow-up recommended by doctor Did not fill Rx or skipped doses Yes to at least one of the above SOURCE: Commonwealth Fund International Health Policy Survey,

11 Yearly Out-of-pocket Expenses for Medical Bills Over 50% of UK Citizens had NO medical bills: 1/3 of U.S. citizens paid more than $1,000 60% 52% 40% 38% 30% 20% 9% 17% 10% 15% 5% 21% 17% 12% 12% 4% 10% 9% 0% Germany Netherlands Canada UK USA None $1-$100 More than $1,000 SOURCE: Commonwealth Fund International Health Policy Survey, Yearly Out-of-pocket Expenses for Medical Bills Over 50% of UK Citizens had NO medical bills: 1/3 of U.S. citizens paid more than $1,000 60% 50% 52% 40% 38% 30% 30% 20% 10% 9% 10% 5% 21% 12% 4% 10% 0% Germany Netherlands Canada UK USA None More than $1,000 SOURCE: Commonwealth Fund International Health Policy Survey,

12 Age-standardized Mortality Rates per 100,000 Population (2002) Similar rates across countries: US better in Cancer Mortality Germany Netherlands Canada UK USA Non-communicable diseases Cardiovascular diseases Cancer Injuries SOURCE: World Health Organization, available at 23 Satisfaction with Health System 80% More than half of each country s Citizens believe fundamental change or complete overall is needed 60% 40% 51% 42% 49% 60% 57% 48% 34% 20% 20% 27% 9% 26% 26% 12% 15% 16% 0% Germany Netherlands Canada UK US Minor changes needed Fundamental changes needed Rebuild completely SOURCE: Commonwealth Fund International Health Policy Survey,

13 Summary of Country Comparisons US is outlier on health care spending and on barriers to access to care Health outcomes are similar across countries with US fairing best on cancer outcomes, worst on injury outcomes Other country system rank high on some indicators, low on others no clear best system 25 Health Care Goals and Equity 26 13

14 WHO Health Care Goals Equity in access to health care service, including financial access to essential public and private services Financial protection: prevention of individuals from falling into poverty as a result of contributions to health care or a catastrophic expenses, and Health Status: protect and improve the health status of individuals and populations by ensuring financial access to essential health services. 27 Equity in Financing Move toward equalization in the ratio of health to non-food spending is identical regardless of their income or health status 5-10 % of income? Tax incidence: those with greater incomes should contribute more to finance the system Single payer systems with income tax system more able to achieve equitable financing Protection against catastrophic loss Pooling risks and maximizing prepayment 28 14

15 Equity in Access All citizens should have the same access to care regardless of income, health status, race/ethnicity, age, geographic location, employment status Equal access to core benefits Uniform benefit set Equal access to best treatment protocols and unbiased care How care is provided at the site of care 29 Risk Pooling and Equity 30 15

16 Concerns with Single Payer in US 1. US Aversion to taxes 2. Persistent Health Disparities 3. Political Process in US System U.S. Aversion to taxes Concern that we would not accept the tax levels required to fully fund a comprehensive benefits and access for all We seem to better accept hidden taxes (employer subsidy) and cross subsidies (cost shifting) we still pay but it s not a TAX Possible outcome is two-tier system of care Inequity in benefit Inequity in access to certain providers Income inequity 32 16

17 2. Insurance Does Not Equal Access Potential to Receive High- Quality Health Care Eisenberg s Voltage Drops 1. Insurance Available 2. Enrolled in Insurance 3. Providers/Services Covered 4. Informed Choice Available 5. Consistent Source of Primary Care Available 6. Referral Services Accessible JAMA 284 (16). October 25, : High-Quality Care Delivered Receive High-Quality Health Care 33 Persistent Inequities in US System.that won t be solved by Universal Coverage Disparities in physician access Urban vs. Rural Inner City vs Suburbs State vs State Disparities in physician practice patterns Wenberg Race and ethnic disparities in access and treatment 34 17

18 Medicare as Single Payer Example Non-whites less likely to be screened for colorectal cancer (Ananthakrishnan 2007) Hispanics diagnoses with depression were less likely to receive treatment and those who were treated were less likely to receive psychotherapy (Crystal 2003) Blacks and Hispanics less likely to receive pneumococcal and flu vaccinations than whites (Winston 2006) Universal coverage is one component needed to achieve EQUITY Politicization of Decision Making No consensus in US on role of government in health care Concern with current state of politics, stakeholders, lobbyists, and money Medicare prescription drug bill Donut hole Law prohibiting federal government from negotiating drug prices SCHIP Reauthorization delayed and funding put in jeopardy 36 18

19 Concluding Thoughts (1) The US must join other countries to achieve universal coverage NOW Universal coverage can be achieved independent of financing mechanism US must find its own unique model of reform to achieve universal coverage 37 Concluding Thoughts (2) Citizens of almost every HC system think fundamental reform is needed No system is superior in all aspects of comparisons Single payer may not be the right vehicle for Universal Coverage in the US Concern about the taxes required to support it Concern that other social inequities will persist with limited resources to address them Politics of health care could dominate the future design and process 38 19

20 Concluding Thoughts (3) A hybrid social insurance with private sickness funds or private regulated insurance may be a more appropriate model Maintains some elements of a market and competition Maintains the role of employers in financing health care Moves toward universal coverage Could retains role of state in buying coverage for lowincome populations Reform toward Universal Coverage is complicated but needed and achievable! 39 Contact Information State Health Access Data Assistance Center (SHADAC) University of Minnesota School of Public Health Division of Health Policy and Management 2221 University Avenue, Suite 345 Minneapolis Minnesota Principal Investigator: Lynn A. Blewett, Ph.D

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