THE U'S' HEALTH CARE SYSTEM ENTERING THE 21ST CENTURY: A CROSSROADS

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THE U.S. HEALTH CARE SYSTEM ENTERING THE 21ST
CENTURY A CROSSROADS?

• David M. Carlisle, M.D., Ph.D.
• Director, Office of Statewide Health Planning and
  Development
• Associate Professor, David Geffen School of
  Medicine at UCLA

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The U.S. Health Care SystemAmericans . have
the finest health care in the world.
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LIFE EXPECTANCY AT BIRTH U.S. 1900-2050 (past
and projected)
( Years )
Source US Department of Commerce, Bureau of the
Census
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INFANT MORTALITY RATEU.S. 1950-2000
Deaths per 1,000 less than one year of age
CDC, National Center for Health Statistics.
Final Data for 2000
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ISCHEMIC HEART DISEASE DEATH RATE
Deaths per 100,000 (White Males thru 1976, all
thereafter)
ICD-7
ICD-6
ICD-8
ICD-9
National Center for Health Statistics
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LEADING CAUSES OF DEATH
1997
Heart Disease
Cancer
Stroke
COPD
Injury
Pneumonia/Flu
Diabetes
Suicide
Kidney Disease
Cirrhosis/CLD
National Center for Health Statistics
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LEADING CAUSES OF DEATH
1997
Heart Disease
Cancer
Stroke
COPD
Injury
Pneumonia
Pneumonia/Flu
Tuberculosis
Diabetes
Gastroenteritis
Suicide
Heart Disease
Kidney Disease
Liver Disease
Cirrhosis/CLD
Injury
Cancer
1900
Senility
Diphtheria
National Center for Health Statistics
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CONTRIBUTORS TO INCREASED LIFE EXPECTANCYUS,
20TH CENTURY
TOTAL INCREASE 30 YEARS
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NEW DISEASES SINCE 1981
Legionnaires
AIDS
SARS
Lassa
Ebola
Hanta
Anthrax
Smallpox
Dave Carlisles Year of Medical School
Graduation
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AIDS on the Rise LA TimesShowing New Cases
and Deaths, US 1981-2002
( In Thousands, Estimated )
Source Centers for Disease Control and Prevention
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AIDS on the Rise LA TimesShowing New Cases
and Deaths, US 1981-2002
( In Thousands, Estimated )
Source Centers for Disease Control and Prevention
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Whats Right about the U.S. Health Care System?

• Extensive Facilities (Hospitals, Equipment)
• Enough Health Care Professionals
• Superb Research
• Sufficient Spending

?
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The U.S. Health Care SystemA Paradox of
Excess and Deprivation

• - Enthoven and Kronick, 1989

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Male Life Expectancy at Birthamong OECD Nations,
1998
The United States Ranks 18th of 29 OECD Nations
Anderson and Hussey, Health Affairs, 2001
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Female Life Expectancy at Birthamong OECD
Nations, 1998
The United States Ranks 20th of 29 OECD Nations
Anderson and Hussey, Health Affairs, 2001
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Maternal Mortalityamong selected OECD Nations,
2002
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SURVIVAL OF MENHARLEM (U.S.) vs. BANGLADESH
NEJM 322173
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Relative U.S. Percentile Rank among OECD Nations
Anderson and Hussey, Health Affairs, 2001
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Relative U.S. Percentile Rank among OECD Nations
Anderson and Hussey, Health Affairs, 2001
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Relative U.S. Percentile Rank among OECD Nations
Anderson and Hussey, Health Affairs, 2001
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How serious an illness can you afford?
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U.S. Health Care Spending 1.6 trillionin 2002

• ( 5,267 per capita and 14.6 of GDP)

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Health Spending per Capitaamong OECD Nations,
2002
The United States Ranks 1st of 29 OECD Nations
In PPP Dollars
Anderson GF, et al, Health Affairs, 24(4) 2005
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Health Spending GDPamong OECD Nations, 2002
The United States Ranks 1st of 29 OECD Nations
Anderson GF, et al, Health Affairs, 24(4) 2005
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Relative U.S. Percentile Rank among OECD Nations
Anderson and Hussey, Health Affairs, 2001
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Current U.S. Health Spending
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International ComparisonsOutcomes vs.
Expenditures
Austria Canada
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WHY IS U.S. HEALTH CARE SO EXPENSIVE?
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High TechnologyU.S. Rank among OECD Nations

• MRI Scanners per million 5th
• (7.6, Japan 18.8)
• CABG Procedures per 100,000 1st
• (223, Belgium 157)
• Hemodialysis Patients per 100,000 2nd
• (74, Japan 147)

Anderson and Hussey, Health Affairs, 2001
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INAPPROPRIATE CARE
(Carotid Endarterectomy 32 - RAND, 1980s)
Commonwealth Fund Quality of Health Care in the
U.S. Chartbook, 2002
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PHARMACEUTICAL SPENDING
Center for Medicare and Medicaid Services, 2002
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ADMINISTRATIVE COSTS(per capita U.S., 1995)
995
248
U.S.
Canada
Woolhandler and Himmelstein, NEJM 329400, 1993
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WHY ARE U.S. HEALTH OUTCOMES SO RELATIVELY POOR?
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Of course, with the position that has the
benefits - medical, dental, etc.. there is no
salary.
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Percent of Population Eligible for Mandated
Inpatient Coverage

• United States
• Switzerland
• Germany
• Canada
• Australia
• Japan
• Sweden
• United Kingdom

• 46.0
• 99.5
• 92.2
• 100
• 100
• 100
• 100
• 100

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U.S. Health Care System47 MillionUninsured(at
any one time)

• Approximately 60 million Americans have been
  uninsured at some point during the past year

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Type of Health Insurance Coverage in the US
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You dont know how lucky you are! A quarter
of an inch either way, and it would have been
outside the area of reimbursable coverage!
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U.S. Health Care System50 MillionUnderinsured

• Insured but would be bankrupted by a major
  illness/accident

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YOUR PILLS ARE READY, MR. WIMBLE TAKE ONE
WHENEVER YOU CAN AFFORD TO.
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Major Health Policy Issues

• Disparities
• Racial/Ethnic, Gender, Income
• Uninsuredness
• Cost of Care
• Quality of Care
• Patient Safety

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BlackWhite Ratio Infant Mortality Ratio
(California Vital Statistics)
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RELATIVE RISK OF DEATH BY INCOME DECILE
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RELATIVE RISK OF DEATH BY INCOME DECILE
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LACK OF PREVENTIVE CARE, INSURED vs.
UNINSURED(Women 45-65)
Not Receiving
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STAGE OF BREAST CANCER AT DIAGNOSISPRIVATELY
INSURED vs. UNINSURED
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6-YEAR BREAST CANCER SURVIVAL BY INITIAL STAGE
AND INSURANCE STATUS
ALIVE
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WHAT SOLUTIONS ARE THERE TO THESE ISSUES?
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Are there several doctors in the house, so we
can have a little managed competition?
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California Health Insurance Legislation

• SB2 (Burton/Speier) Pay-or-Play
• Proposition 72 (defeated 11/04)
• SB 921 (Kuehl) Single Payer
• AB 30 Richman ?Healthy Families

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QUESTIONS?

• www.oshpd.ca.gov
• dcarlisl_at_oshpd.ca.gov
• 916-654-1606

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Per Capita Health Care Spending(OECD 1996)
in U.S. Dollars
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AIDS on the Rise LA TimesShowing New
Infections among Gay and Bisexual Males, US
1994-2002
( In Thousands )
Source Centers for Disease Control and Prevention
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THE UNITED STATES IS THE ONLY WESTERN
INDUSTRIALIZED DEMOCRACYTHAT DOES NOT
PROVIDE HEALTH INSURANCE TO ALL OF ITS CITIZENS