The Role of Physicians in Serving the Uninsured

Natl Congress on the Un & Under InsuredDecember 10, 2007 / Washington, DC

Ronald M. Davis, MD

President

American Medical Association

1847 – Founding of the AMA

AMA mission

• To promote the science and art of medicine and the betterment of public health

• Unchanged since 1920

AMA’s health care advocacy agenda for 2007

• Expand medical coverage for the uninsured

• Reform the Medicare physician payment system

• Reform the medical liability system• Improve the quality and safety of

health care• Improve public health through …

• Healthy lifestyles • Reducing health disparities• Disaster preparedness

The uninsured: An all-too-familiar crisis

• 47M Americans w/o health insurance• 14.9% for non-Hispanic whites

• 20.3% for African Americans

• 34.1% for Hispanics (2006 CPS)

• Most uninsured (8 out of 10) work

• Of those with health insurance, many (1 in 3) worry about losing it

AMA Principles of Medical Ethics

• Adopted – 1957

Revised – 1980 & 2001

• IX. A physician shall support access to medical care for all people

• 90% of AMA members surveyed said they think the number of uninsured is a major problem or an outright crisis

Charity care by physicians

• AMA data• 65% provided charity care in 1999

• 8.8 hours / week (4.4 hours – free care; 4.7 hours – care for reduced fee); 14.4% of total patient care hours

• $18 billion in uncollected accounts receivables; $18-20 billion in donated (charity) care

• > $2,000 worth of uncompensated care each week

Charity care by physicians (cont.)

• Center for Studying Health System Change• Surveys of 12,000 physicians in 1996-97 and

6,600 physicians in 2004-05

• Proportion providing free or reduced-cost care fell from 76% to 68%

• Charity care hours per 100 uninsured patients declined from 7.7 to 6.3 hours (18% decrease)

• AMA President J. Edward Hill, MD:“Charity care is not the solution to the problem of the uninsured in this country.”

American Medical News, April 17, 2006

Expanding coverage of the uninsured and increasing access

• Short-term: advocate for incremental measures to expand coverage for children and lower income families and individuals

• Long-term: press for adoption of a consumer-driven, market-based plan to expand coverage through tax credits and insurance market reforms

The AMA’s simple plan

Give people money to buy health insurance

Three pillars

• Tax credits to individuals and families

• Individual ownership and choice

• Insurance market reforms

Current system inequities

• A worker gets $6,000 in health benefits and pays no taxes on them

• The federal government subsidizes health insurance coverage to the tune of $120 billion per year

• Workers in the highest tax bracket get the biggest tax break / a greater tax subsidy

1. Tax credits must be …

• Large enough to cover the cost of coverage

• Inversely related to income

• Refundable (“voucher” for low-income persons)

• Available in advance

• Only available to those who get coverage for every family member

• Only for the purchase of insurance

2. Choice

• Americans would benefit from choosing from an array of plans

• Currently, there is little choice

Under job-based coverage

• Almost 40% of companies offer no health benefits

• Of those that do, almost 9 out of 10 offer only one plan

Under the AMA proposal . . .

• People can• Buy the coverage they want and need

• Buy it through their employer – or not

• Keep or change their coverage at will

• Insurers are compelled to create what people want and need

Benefits of choice

• Patient choice generates:

• Competition among health plans

• More vibrant health insurance markets

3. Market reforms

• Risk pools for high-risk persons

• Guaranteed renewability

• Association health plans

Costs and impact

• Current situation:

Govt gives $120 billion in tax subsidies for employer-based health benefits because employees don’t pay taxes on health benefits (wealthiest Americans benefit most)

• AMA proposal:

Redirect $120 billion in tax subsidies and add $30 - $60 billion

• Coverage for 94% of Americans

• www.ama-assn.org/go/insurance-reform

Individual responsibility to obtain health insurance (policy adopted in June 2006)

• Require individuals and families earning > 500% of the FPL to obtain health insurance coverage now

• Upon implementation of a system of refundable tax credits or other subsidies to obtain health care coverage, require individuals and families earning < 500% of the FPL to obtain coverage

Health Coverage Coalition for the Uninsured (HCCU)

• Diverse group of 16 influential national organizations, including AARP, Families USA, APHA, Chamber of Commerce, AMA, AAFP, AHA, AHIP, BCBS, Catholic Health Association, J & J

• Issued recommendations in Jan 2007

• Mix of private- and public-sector strategies

• www.coalitionfortheuninsured.org

SCHIP Rollercoaster• CHAMP Act passed House on Aug 1

• Reauthorize SCHIP (funding increased to $75B over next 5 years ($50B increase)

• Replace Medicare physician payment cuts with 0.5% increases in 2008-2009

• Eliminate overpayments to M-A plans

• Increase cigarette tax from 39¢ to 84¢ / pack

• SCHIP Reauthorization Act passed Senate on Aug 2

• Reauthorize SCHIP; funding increased to $60B over next 5 years ($35B increase)

• Increase cigarette tax from 39¢ to $1 / pack

SCHIP Rollercoaster (continued)

• Senate-House “compromise” sent to President Bush, who vetoed it on Oct 3

• House fell 13 votes short of overriding the veto on Oct 18 (273-156)

• House passed modified bill on Oct 25 (265-142)

• End coverage of childless adults

• Ban coverage for illegal immigrants

• Limit coverage to children in families with income < 300% of FPL ($61,950 family of 4)

• On to the Senate (Finance Committee)

2007 regional advertising

• Early primary states• Iowa• South Carolina• New Hampshire/

Boston area

• September - December• Television, radio,

newspapers and online• Pharmacy bags, billboards

and transit stations

Dedicated website

VoiceForTheUninsured.orgVoiceForTheUninsured.org

• See TV ads, hear radio ads

• View pictures of events

• Share a story

• Learn about the AMA solution

• Sign a petition supporting the AMA’s plan

• Obtain information• Links to candidates’ position on issue

• Issue-related facts and statistics

Voice for the Uninsured

Voice for the Uninsured

Leading Causes of Death in the U.S.

0 5 10 15 20 25 30 35

Heart diseaseCancerStrokeCOPD

Unintended injuriesDiabetes

Influenza/pneumoniaAlzheimer's diseaseNephritis/nephrotic

Septicemia

Percentage (of all deaths)0 5 10 15 20

TobaccoPoor diet/lack of exercise

AlcoholMicrobial agentsPollutants/toxics

Motor VehiclesFirearms

Sexual BehaviorsIllicit drug use

Percentage (of all deaths)

Leading Causes of Death, United States, 2000 Actual Causes of Death, United States, 2000

Partnership for Prevention report “Preventive Care” (August 2007)

Increasing the use of just 5 preventive services would save > 100,000 lives each year in the U.S.

• 45,000 if 90% of adults used aspirin daily

• 42,000 if 90% of smokers were advised by a health professional to quit and offered medication or other assistance

• 14,000 if 90% of adults aged > 50 were up to date with recommended screening for colorectal cancer

• 12,000 if 90% of adults aged > 50 were immunized against influenza annually

• 3,700 if 90% of women aged > 40 had been screened for breast cancer in the past 2 years

Medicare covers …

services and tools that are

“reasonable and necessary

for the

diagnosis or treatment

of illness or injury.”

Medicare covers …

services and tools that are

“reasonable and necessary

for the

PREVENTION, diagnosis or treatment

of illness or injury.”

“Coming together is a beginning;keeping together is progress; working together is success.”

Henry Ford – on partnership