 Thank you so much. I'd like to thank the Frank Bryant Memorial Lecture in Medical Ethics and Dr. Ruth Bergeron She is thank you for inviting me here this evening to talk to you about single-payer national health care And it's not every day that a person like me gets to sit around this table. So I appreciate that Mark Peterson from UCLA wrote all of us in the field should at a minimum demand that Participants in the debate know what they're talking about So I hope this talk will help inform you about single-payer To that end I will attempt to define single-payer, which is easier said than done And in an effort to be as balanced in my bias as possible Consider the merits and the demerits of single-payer Explain financing of single-payer and finally discuss current legislation on the floor of Congress for single-payer Now in the August 2009 publication of the Journal of Health Politics policy and law out of 11 papers No fewer than six felt obligated to define single-payer Invariably all of them proffering different definitions Probably a reflection that there are as many definitions of single-payer as there are countries using it and possibly Health policy experts writing about it Now single-payer is a healthcare financing system where all citizens within a given geographic area are members of a single funding pool These citizens make mandatory contributions to the single pool and finally most commonly Where all medical and hospital care is covered this kind of financing system is found in Canada Sweden Denmark Great Britain Australia Finland Ireland Italy New Zealand, Portugal and Spain and US Medicare and With a single-payer definition properly understood it must be recognized that US Medicare with its 44 million Participants is the largest single-payer system in the world And I include Great Britain and Spain which are socialized healthcare systems because they're financing systems really are single-payer Most simply it can be defined as a publicly funded system whose delivery system can be public private or mixed Now according to Deborah Stone Single-payer is a way to talk about distributing the financial burdens of something that we all need without mentioning taxes Solidarity or that most vicious American slur socialism In other words, we are talking about distributive justice Single-payer is about financing health care in the most equitable way possible so that we might all enjoy the right to health care Now single-payer is not exclusively public Nor is it socialized although in some countries such as in England and Spain the delivery system is Socialized that is the providers are paid by the government or many of them are Nor is it exclusively national for example in Canada. There are 13 sub national provincial single-payer systems It is not as we've discussed a delivery system It is not devoid of private health insurance or even employer health insurance nor is a devoid of gaps Canada which is known as a prototypical quintessential single-payer system While funding for hospitals and physicians is almost 100% from public sources The share of private finance in the Canadian health care system as a whole is 30% In about two-thirds of Canadians have private health insurance mostly through their employers Covering amenities for hospital care such as private care or private rooms drugs dental care eye care and whatever falls outside of the Canadian Medicare system and Finally, yes single-payer is not perfect Now according to Adam Oliver from the London School of Economics Compared to competitive Multi-payer system single-payer is a system most effective at ensuring the whole population Can avoid market failure and alleviate equity related problems It's better designed to control total health care expenditures and administrative costs in particular It carries high consumer satisfaction in fact a survey of Canadians last year found that 82% of them rate their own Medicare system very high or high and Rationing is based on available resources rather than on the ability to pay and it lends itself because of its centralized nature to priority setting practices We have a somewhat natural experiment in the United States in that we can compare the largest single-payer system in the world which is Medicare with private insurance and We've talked about this several times tonight already And it just gives you an idea of what you can do with statistics many analysts Including the CBO believe that Medicare's financing difficulties can be viewed as a reflection of the trends in the national in the nation's overall health care costs since the 1970s national health care spending has on average grown 2.5 percentage points faster than the economy a trend which unfortunately is expected to last However, Medicare's average annual growth of 8.9 percent is lower than private practice insurance average annual growth of 9.8 percent So taken cumulatively from 1969 to 2005 the total growth for Medicare has been about 2,000 percent compared to private insurances of 3,000 percent over the same time The major driver of Medicare spending is the overall growth in health care spending and most recently Medicare Part D and Medicare Advantage Even the federal employees health benefit program which covers all federal employees from the president To the mailman has costs that are growing faster than Medicare's It is important to note that 100,000 federal workers are uninsured because they cannot afford the premiums and my guess is that our elected officials are not among them in 1991 then chairman John Conyers of the committee on government operations requested from the GAO a report on health care Canadian health insurance That is this is what the GAO found And you can see this from the graph measured either on a per capita basis or a share of GNP Health care costs have risen at a dramatically slower pace in Canada than in the United States The difference reflects Canada's low administrative costs control on hospital budgets and on the acquisition of high technology Equipment and fee controls for physician services Now hospital billing and administration in the US are three times that of single-payer Canada as our physicians buildings and office expenses Private insurance exists in countries outside the United States although it is highly regulated and plays a much less prominent role We can see the insurance overhead in the US far outpaces that in other countries, and this is the per capita insurance overhead Finally if we look at aortic aneurysm repair costs in the United States and a single-payer system like Canada we see that costs are much higher in the United States and When you look at the clinical cost, which is the the pink bar those are pretty equal But but overhead costs which are the yellow bars accounts for most of the differences in costs Now the most serious charge against single-payer is that it is politically infeasible Now I find it interesting that in the same breath that economists denounce the possibility of single-payer in the United States They talk about the feasibility of reform that subjects health insurance to regulations that ensures all are covered and that pools and Redistributes funding it isn't clear to me why economists believe that the latter to be politically feasible any more than the former Now lack of choice would not be for doctors or hospitals But lack of choice for insurance carrier, which probably doesn't make a whole lot of difference Undoubtedly there would be displacement of individuals working in health insurance related employment, which probably numbers about 2 million and As with every system there is rationing rationing is not a choice. It is inevitable Thus a system can ration by price Increasing the amount paid a point of service such as co-pays as you find in in France By waiting lists and by value for money meaning that you pay only for those services which have evidence to improve outcomes Now waiting lists are not inevitable Much of this rationing disappears as funding is increased and in fact the National Health Service in England would have no waiting lists If they spent as much of their GDP as the US does is my guess except they would still cover all of their residents But who wants this well Americans do and a majority of Americans surveyed since 1940 have consistently favored national health care funded by taxes and What about physicians? Well, this is a study that was published in annals of internal medicine of April last year And this is a random sample of 5000 physicians from the AM a master file doesn't mean that they belong to the AM a but They're in the master file almost 60% of physicians supported government legislation to establish national health insurance Which is a 10% increase in support since 2002 when they did this the previous study This increase represents over 80,000 physicians Distributed among almost all medical specialties who have changed their minds in support of national health insurance over the past five years For the first time in American history Single payer will be debated in Congress and voted on this month the Wiener amendment one of the many many Amendments to HR 3200 Replaces the language of 3200 with a language of HR 676. Let's go over some of the highlights of this bill HR 676 is called the United States National Health Care Act or the expanded and improved Medicare for all Act It is a bill to provide for comprehensive health insurance coverage for all US residents improved health care delivery and for other purposes and It's only 30 pages long Anybody can read it So who is eligible all residents of the US and her territories how well you fill out a two-page application at your local health care provider You receive a US national health insurance card in the mail Present that card at any participating provider and voila. You are automatically eligible The benefits are all medically necessary Services which will include primary care and prevention inpatient outpatient and emergency care prescription drugs long-term care Mental health services dental services vision hearing and so forth You get your benefits whether you're employed or not if you change employment or if you move from state to state So it is perfectly portable. There are no deductibles co-pays co-insurance or other cost-sharing You will have free choice of physicians clinics hospitals and all other participating health care practitioners All private physicians private clinics private not-for-profit hospitals continue to be private Non-profit HMOs who deliver care in their own facilities and employ clinicians on a salaried basis can't participate But all investor ownership is prohibited as is any private health insurance that duplicates the benefits under the program However, there is no law against selling private health insurance to cover all those benefits that are not covered under the plan Congress will appropriate amounts for the net for the annual budget for the program Regional offices then will be provided with the annual funding allotments to cover costs for each region's expenditures To pay for the health care providers under a negotiated fee schedule To pay for global budgets for health institutions Capitation for capitated groups program administration quality control and health care planning And what about prescription drugs and durable medical equipment? Well, all prices will be negotiated by the program annually unless Unlike the current Medicare Part D There will be a prescription drug formulary system with frequent formulary updates and petition rights by patients and physicians and promotion of generics Now to finance single-payer health care. We eliminate private insurance Shurs except to cover uncovered services role all federal funding in Increase add an employee and employer payroll tax that is estimated to be about five or six percent of payroll And an income tax in the top five percent earners the CEO sorry the CBO is currently costing this right now And basically you would replace the portion of health care spending currently paid as an implicit Regressive tax by individuals and businesses in the form of premiums co-pays and so forth with a system of explicit progressive contributions Since the money already exists in the system the two point five trillion dollars We do not need to spend one more penny than we're already spending and there are many ways the contributions could be organized All this means that costs will be controlled long-term so that benefits are sustainable Now physicians for national health program estimates that it will take about 20 billion dollars To retrain and place the 2 million workers whose jobs will be eliminated by the national health care And so what what this bill does is it sets aside enough funds to To play to retrain place and then salary parity for two years up to a hundred thousand dollars a year Exactly one year after the enactment of the act the US would have single-payer national health insurance and would cover every resident in the United States Unfortunately almost 45,000 uninsured Americans will die that year and Every year waiting for enactment We have what it takes. We have excellent hospitals Excellent physicians empty beds well-trained professionals superb research technology infrastructure Enough money in the system Now what is stopping us? Thank you very much