What would Single Payer Mean for NPs? N P O 3 9 TH AN N U AL E D U - - PDF document

9/27/2016 1

N P O 3 9 TH AN N U AL E D U CATI ON CON F E R E N CE N AN CY S U LLI VAN , R N , M S , F ACN M CH R I S TAN N E R , R N , P H D , AN E F R E P R E S E N TI N G N U R S E S F OR S I N GLE P AYE R ( N F S P )

What would Single Payer Mean for NPs?

A M OVEM EN T TO GAIN U N IVER S AL, COM P R EH EN S IVE, P U B LICLY F U N D ED H EALTH CAR E

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

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Am erican Health Care Financing

TH E MOS T EX P EN S IVE IN TH E D EVELOP ED W ORLD

Issues with current paym ent system

5 10 15 20

Es Eston tonia Tu Turkey ey Mexic Mexico Lu Luxembou xembourg rg Po Poland Kor Korea Cz Czech Re Repu public Ch Chile Is Isra rael el Hu Hungary Slov Slovak Republ Republic ic Slov Sloven enia ia Ir Irela eland Au Austra ralia lia Fin Finland Ic Icela eland Gr Greece eece It Italy No Norway Spa Spain Un United K ed Kingdo ngdom Sweden Sweden Ja Japa pan Po Portuga ugal Ne New Z Zeal alan and ¹ Bel Belgium ium ¹ ¹ Au Austria ria Den Denmark Switzer Switzerland Ca Cana nada Ger Germany Fr Fran ance Ne Netherlands Un United Sta ited States es

He Healt alth Ca Care Spe Spending as as % %

• f GD
• f GDP

The m ost expensive

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10% 11% 12% 13% 14% 15% 16% 17% 18% 19% 1991 1994 1997 2000 2003 2006 2009 2012 2015 2018 2021 2024

Health Care Costs As Share Of Gross State Product

Health care costs predicted to continue rising Health Insurers Making Record Profits as Many Postpone Care

NYTim es May 13, 2011

Cigna, Hum ana CEOs earn m illions in pay jum ps

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

Rising adm inistrative costs

Growth Since 1970 Physicians Administrators 3000% 2500% 2000% 1500% 1000% 500% 1970 1980 1990 2000 2010

Data updated through 2013 Source: Bureau of Labor Statistics; NCHS; Himmelstein/Woolhandler analysis of CPS

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TO K E E P I N M I N D W H E N YO U R E A D A LL TH E H YP E A B O U T R I S I N G D R U G P R I CE S : “P A TI E N TS W H O A R E TH E S I CK E S T A N D R E Q U I R E TH E M O S T E X P E N S I V E D R U G S A R E TH E M O S T V U LN E R A B LE TO S O A R I N G D R U G P R I CE S . “I T’S S O R T O F E M B E D D E D I N TH E H E A LTH CA R E S YS TE M TH A T TH E P R I CE I S N E V E R TH E P R I CE , U N LE S S YO U ’R E A CA S H - P A YI N G CU S TO M E R , ” S TA TE S TH E P R E S I D E N T O F A B U S I N E S S R E S E A R CH CO M P A N Y, “A N D I N TH A T CA S E , W E S O A K TH E P O O R . ” ( K . TH O M A S , N YT, A U G 2 4 , 2 0 16 )

Rising Drug Prices

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 Em ployer Health Benefits Survey

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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 Sum m ary, March 2016 **2015 Kaiser Fam ily Foundation survey

The large increase in health care costs has created hardships, and sometimes disasters, for individuals and families 600 Oregonians die Due to lack of affordable health care, each year 8,000 go bankrupt

Even with the Affordable Care Act . . . .

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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.

S H ORTER LIVES , P OORER H EALTH , LOW ER S ATIS FACTION , LES S ACCES S TO CARE

The best health care system ? Life Expectancy at Birth, Affluent Countries

60 65 70 75 80 85

US life expectancy lower even for those with insurance!

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Years of Lost Life Before Age 50 in Men, 20 0 6-20 0 8

National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health

Years of Lost Life Before Age 50 in Wom en, 20 0 6-20 0 8

National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health

Infant Mortality Rates in 17 countries,20 0 5-20 0 9

National Academies Press (2013) Health in International Perspective: Shorter Lives, Poorer Health

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Poorer health, using m any 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

• f 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

Access To Health Care

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

Cost- Related Access Problem

16% 13% 18% 15% 22% 21% 10% 6% 13% 4% 37% 27% 63%

0% 10% 20% 30% 40% 50% 60% 70%

AUS CAN FRA GER NET NZL NOR SWE SWI UK USA All USA Ins USA Unins

USA Uninsured USA Insured Americans have the most problems – even those with insurance

Satisfaction with health system

0% 20% 40% 60%

Australia Canada France Germany Netherlands New Zealand Norway Sweden Switzerland UK USA

Propor

• rtion
• n

sa saying hea health care care sys system wo works we well

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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 Am erica: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books

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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 Am erica: 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 Am erica: 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 Am erica: 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

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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 Am erica: A Global Quest for Better, Cheaper and Fairer Health Care. New York: Penguin Books

FED ERAL LEGIS LATION AN D S TATE B Y S TATE IN ITIATIVES

What could a universal, publicly funded health system look like?

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.

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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

• ur health system

through the introduction of state- based 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 out-

• f-pocket expenses,

bureaucratic waste and profiteering by private insurers and Big Pharma.

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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 out-
• f-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 low- income Americans and those families facing acute or chronic illness.

Basic Premise

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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.

Them e of SB 631

Sim plify adm inistration

• cover all residents (universal)
• for all m edically necessary services

(com prehensive)

• single-payer
• sam e paym ents for sam e services
• no copays and deductibles

Them e of SB 631 Flexible paym ent system s, tailored by provider, to best m eet needs of providers and system

• global budgets
• fee for service
• other transparent & fair system s as

needed

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Adm inistrative sim plicity generally leads to equity

All residents covered equally All m edically necessary services covered Sam e paym ents for sam e services

• Equity for providers
• Equity for patients
• Now – private insurers, Medicare,

Oregon Health Plan, individuals pay differently

How do we get there?

HCAO

 A Movem ent com m itted to the belief

that health care is a hum an right.

 Working to ensure every person in

Oregon has access to an equitable, affordable, com prehensive, high-quality, publicly funded universal health care system —a system that will save lives and save m oney at the sam e tim e.

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The growth of a m ovem ent 20 12-20 15

 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 20 12-20 15

 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 20 16-20 20

 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.

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Health Care for All Oregon, 20 16-20 20 , 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, 20 16 -20 20 , continued

Write a bill with a defined tax structure by 2018. Lobby the legislature to place advisory questions

• n the 2018 ballot – a way to engage voters on
• ur 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

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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

• thers 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 high- quality care for everyone” The NY House of Delegates has now passed single-payer legislation twice. http:/ / www.nysna.org/ healthcare-for-

all-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

• f the Am erican Health Security Act of 20 15,

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

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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?

G E T I N V O LV E D – N F S P & H CA O G E T I N F O R M E D LI S TE N F O R CO M P E LLI N G S TO R I E S E N G A G E I N A D V O CA CY A N D E D U CA TI O N M E E T YO U R LE G I S LA TO R P A R TI CI P A TE I N TH E B A LLO T I N I TI A TI V E P R O CE S S

What Can You Do?