National Health Insurance Quiz

John R. Battista, M.D.

President, Connecticut Coalition For Universal Health Care

http://cthealth.server101.com

Prepared for the Connecticut League of Women Voters, March, 2007 

Here is your chance to assess how much you know about national health insurance.  Please mark every correct answer.

1.     Which of the following industrialized countries does not guarantee health insurance to its citizens?

A.   Taiwan

B.   Israel

C.   Spain

D.   The United States

E.    South Africa

D. The United States is the only industrialized country not to guarantee health insurance to its citizens.  Over 15% of Americans are uninsured.

The Following Set Of Questions Address the Issue of Whether the United States Has the Best Health Care System In The World

2.     Infant mortality and life expectancy are the two internationally accepted means of evaluating the effectiveness of national health care systems.  Where does the United States rank on these two measures relative to other industrialized nations?

A.   First

B.   In the top third

C.   In the middle third

D.   In the bottom third

E.    Last

D. The United States ranks in the bottom third of all industrialized countries in terms of life expectancy and infant mortality.

3.     Efficiency is a second means of evaluating health care systems.  Efficiency measures the performance of a health care system relative to the dollars spent.  When the World Health Organization assessed all the countries in the world in terms of efficiency in the year 2000 where did the United States rank?

A.   First

B.   23^rd

C.   46^th

D.   72^nd

D. The United States ranked 72^nd, the poorest of all industrialized countries. 

4.     Satisfaction is a third way to assess the performance of a health care system.  Where does the United States rank relative to other industrialized nations in terms of citizen satisfaction with their health care system?

A.   First

B.   Top Third

C.   Middle Third

D.   Bottom Third

E.    Last

E. The United States ranked 40^th in the world according to the World Health Organization study, the lowest in the industrialized world.

5.     When the World Health Organization ranked the overall functioning of the health care system of every nation in 2000 using an aggregation of efficacy, efficiency and satisfaction where did the United States rank?

A.   First

B.   Thirteenth

C.   Twenty-fourth

D.   Thirty-seventh

E.    Fifty-fifth

C. The United States ranked 37^th, the lowest of all industrialized countries. France ranked first.

Conclusion:  There is no basis for asserting the United States has the best health care system in the world, although the best health care in the world is available in the United States for people who are able to pay for it.  On the other hand, one could reasonably assert the United States has the worst health care system among the industrialized nations because it is least efficient and results in the poorest satisfaction while delivering outcomes in the lower third of industrialized nations. 

The Following Set of Questions Seeks To Address Why the American Health Care System Performs Poorly Relative to Countries with National Health Insurance

6.     Which of the following factors explain why the United States ranks in the bottom third of industrialized nations on basic health statistics?

A.   The large number of uninsured

B.   The high incidence of smoking

C.   The limited access to health care characteristic of Medicaid programs

D.   Managed care

A, C and D.  The large number of uninsured is the main reason the United States fares poorly relative to other industrialized countries.  Problems with access to health care in the Medicaid population contributes to the poor US health care statistics.  Managed care programs perform more poorly than unmanaged care programs on all quality of care indicators.  No other industrialized country utilizes managed care.

7.     The uninsured contribute to poor health statistics because?

A.   They seek less preventative health care

B.   They tend to seek medical care later in the course of illness when it is less effective to treat

C.   They are disproportionately people of color

D.   They are disproportionately poor

A and B.  The uninsured contribute to poorer health care statistics because they do not seek routine, preventative care and seek medical care later in the course of an illness when it is more difficult to effectively treat.  As a result the uninsured are in poorer health and die earlier than the insured population.  At least 18,000 yearly deaths occur in the uninsured population which would be prevented by national health insurance. 

8.     The inefficiency of the American health care system relative to other industrialized nations is explained by which of the following factors?

A.   High administrative expenses

B.   High cost of prescription medications

C.   The high number of uninsured

D.   Increase cost for services with for-profit health insurers

All of the above.  At least 25% of total health care costs are spend on administration in the United States .  Other industrialized countries spend less than 10% on average.  This is due to the high number of insurance programs in the United States and the high administrative costs of for-profit insurance companies due to their marketing expenses, high salaries, profits, and expensive managed care programs.  Prescriptions medications cost almost twice as much in the United States as other industrialized countries due to the lack of negotiating the cost of prescription drugs with pharmaceutical manufacturers in many parts of the American health care system such as traditional Medicare, where it is prohibited by law.  The uninsured contribute to the high cost of American health care due to increased costs associated with treating illness later in its course, the failure to prevent illness, and the increased utilization of emergency and inpatient services.  About 50% of emergency room visits and hospitalizations by the uninsured would be prevented by national health insurance.  For-profit health insurance companies increase cost for services.  The same services delivered in for-profit Medicare cost on average 19% more than if they had been delivered under traditional Medicare.  The same procedure in the same hospital the year after for-profit conversion costs 15% to 30% more. 

9.     Dissatisfaction with the American health care system relative to the national health insurance programs of other industrialized countries is related to which of the following factors?

A.   High cost

B.   Financial insecurity

C.   Lack of insurance continuity

D.   Frustration with accessing care

All of the above.  The high cost of health insurance and health care is an almost universal source of dissatisfaction with the American health care system, where total costs are twice that of other industrialized countries on average.  Cost is the main reason over 15% of Americans are uninsured.  Financial insecurity about health care is common in the United States because 25% of the insured population are underinsured to the extent that a major medical illness is likely to cause bankruptcy.  50% of all bankruptcies in the United States involve medical bills.  Lack of insurance continuity is a major source of dissatisfaction among the large percent of families whose medical insurance is employment based.  When employers changes health insurers this requires changing medical providers 25% of the time resulting in dissatisfaction with the lack of continuity of care and increased time and cost involved.  In addition, because people with medical conditions find it difficult and expensive to obtain medical insurance if they leave their job, particularly if they have medical illnesses, about 25% of employed Americans are locked in unwanted jobs to sustain health insurance.  Frustration with accessing care is a source of dissatisfaction among Americans who seek to access care through a managed health care insurance programs due to limited provider networks and difficulties in receiving the care their health care provider recommends due to pre-approval requirements and limitations on their health insurance coverage.  Dissatisfaction in higher in managed care insurance programs than in unmanaged programs.   

Conclusion:  High administrative costs, the failure to negotiate prescription drug prices, the uninsured, for profit insurance companies and managed care are the main reasons the American health care system is ineffective, inefficient and unpopular relative to the health care systems of other industrialized countries.

The Following Set of Questions Address the Forms of Universal  Health Insurance Which Could Be Utilized By the United States

in Developing Universal Health Insurance

10.                          Universal Health Insurance Could be Obtained in the United States through which of the following programs?

A.   Publicly funding a national health insurance program for all citizens.

B.   Premium support for people who have trouble paying for health insurance leaving our current system intact.

C.   Medical savings accounts to make the purchase of health insurance more affordable while leaving our current system intact.

D.   Mandating the purchase of private health insurance by all Americans who are not covered by public health insurance.

A and possibly D.  The public funding of national health insurance is utilized by most industrialized nations.  Switzerland and Germany mandate the purchase of health insurance through sickness pools and subsidize the cost of health insurance for people of limited income.  A variant of this model was proposed for the United States under the Clinton administration and has recently been enacted in Massachusetts . International experience suggests that in order to obtain true universal health insurance under this model there must be very strong government control of the private insurance industry and substantial government support for individuals with limited means.  Premium support without a mandate will decrease the number of uninsured but will not result in universal coverage.  Medical savings accounts will do little to decrease the number of uninsured because most of the uninsured can not afford to take advantage of the benefits of medical savings accounts.

11.                          Which type of national health insurance program is less costly?

A.   Publicly funded universal health insurance

B.   Mandated universal health insurance with public assistance for families with limited means

A. Publicly funded universal health insurance is less costly because it is more efficient to have all citizens in a single health care insurance program with a single payer.  Mandated universal health insurance with private insurers is the most expensive approach to universal coverage among other industrialized nations but is about 30% less expensive than the United States due to the savings which result from not having an uninsured population in combination with much tighter controls on private insurers including provisions they be run not-for-profit and avoid managing care.

12.                         Are public funded universal health care systems socialized medicine?

A.   Yes

B.   No

C.   Sometimes

C. Sometimes.  Some publicly funded systems such as Canada keep the private fee-for-service system of medicine and the private ownership of hospitals intact.  They are not socialized medicine.  Some publicly funded systems such as Great Britain and Spain utilize national health services in which health care providers are salaried employees of the government and hospitals are publicly owned and operated.  National health service systems are socialized medicine in a way which is similar to the VA System and Kaiser in the United States .

Comment: The greater efficiency of publicly funded national health insurance in combination with the public’s aversion to socialized medicine has led most national health insurance advocates to support a Canadian style national health insurance program for the United States.  This approach is given form in HR 676, introduced by Representative John Conyers,  which is currently under consideration by the United States Congress.  It has 60 co-sponsors and has been endorsed by the Green Party, a wide variety of health care provider groups, health care advocacy organizations, labor unions, faith groups, and local governments. The following set of questions address concerns about what might occur if a Canadian style national health insurance program along the lines of HR 676 were to be enacted in the United States .

The Following Questions Address the Concern that Canadian Style National Health Insurance will Result in Poorer Quality of Care than our Current Health Care System

13.                        Since Canada passed publicly funded national health insurance over 30 years ago their health care statistics relative to the United States   have?

A.   Gotten much worse

B.   Deteriorated slightly

C.   Remained the same

D.   Improved slightly

E.    Improved very significantly

E. Improved very significantly.  Infant mortality and longevity were poorer in Canada than the United States when Canada passed national health insurance over forty years ago.  Current Canadian health care statistics are much better than those of the United States to the point that the poorest third of Canadians have better infant mortality than the average American and Canadians live significantly longer than Americans.

14.                          When the United States health care system is compared to the Canadian health care system in terms of treatment outcomes for acute illness such as pneumonia, myocardial infarction, appendicitis, sepsis, and spinal meningitis the United States outcomes are?

A.   Clearly superior

B.   A little superior

C.   About the same

D.   A little worse

E.    Clearly inferior

C. They are about the same.  Medical practices are quite similar in all industrialized countries for the treatment of acute illness and the outcomes are similar.

15.                          Which of the following are significant factors in accounting for why universal health insurance countries have improved health care statistics relative to the United States ?

A.   Increased preventative health care

B.   Increased office visits

C.   Increased hospitalization days

D.   The lack of uninsured

E.    Lack of managed care

All of the above.  There is more preventative health care, increased office visits and increased days in hospitals in industrialized countries relative to the United States despite decreased cost.  Each of these is believed to improve health care outcomes.  Managed care, characteristic of the United States , has been shown to provide poorer outcomes than unmanaged care.

Conclusion:  Quality of care in the United States and health care outcomes are likely to improve in the United States under a Canadian style national health insurance program due to increased access to health care and doing away with managed care which has been shown to result in poorer quality of care. 

The Following Set Of Questions Seek To Address the Concern That Universal Health Insurance Will Be Even More Costly Than Our Current System and Result in Escalating Costs Through Time

16.                        When Canada passed National Health Insurance over forty years ago it spent the same amount per capita on health care as the United States .  Today, Canadian spending on health care relative to the United States is?

A.   About one-third of what the United States spends.

B.   About one-half of what the United States spends.

C.   About two-thirds of what the United States spends.

D.   About the same as what the United States spends.

E.    About one-third more than what the United States spends.

B. Per-capital spending in Canada is approximately half of the per-capita spending in the United States .  The percent of gross domestic product spent on health care has doubled in the United States relative to Canada since passage of the national health insurance in Canada .

17.                         If the United States were to enact a Canadian style national health insurance program the total cost of health care in the United States would?

A.   Decline by around 50%

B.   Decline by around 10%

C.   Stay about the same

D.   Increase by around 10%

E.    Increase by about 50%

B or C.  Studies by the General Accounting Office, Harvard University and many additional studies all predict savings in the neighborhood of 10%.  However, increased demand as the result of universal insurance coverage may make the cost about the same in the short run.

18.                          Short-term, decreased costs in a Canadian style health care system for the United States would result from?

A.   Decreased administrative expenses

B.   Decreased cost of prescription drugs as a result of negotiation

C.   Decreased fees for health care providers

D.   Managing medical care

E.    Decreased emergency services

A, B and E.  Short term savings would result from decreasing administrative expenses from 25% to less than 10% and negotiating the price of prescription drugs saving an additional 5% of total health care costs.  Additionally savings result from decreased demand on emergency services and avoiding hospitalizations through outpatient intervention.  Health care provider fees would not be significantly changed.  There would be no managed care.

19.                         Long-term decreased costs in a Canadian style health insurance system relative to the United States result from which of the following?

A.   Decreased utilization of emergency services

B.   Increased preventative health care

C.   Prevention of hospitalizations

D.   Earlier intervention in the disease course

E.    Cessation of treatment for the terminally ill.

A, B,C and D. Long term savings from universal health insurance result from increases in preventative care and earlier treatment intervention.  Increased utilization of outpatient services would result in decreased utilization of emergency services and the prevention of many hospitalizations.

20.                         The cost to the average American under a Canadian health care style system as per HR 676 would be?

A.   Increased by more than 20%

B.   Increased by less than 20%

C.   About the same

D.   Decreased by less than 20%

E.    Decreased by more than 20%

E. Decreased by more than 20%.  Although the total cost of the American health care system would initially be the same or decreased by up to 10% , the cost to the average citizen would be decreased by much more than 20% due to the way in which health care insurance costs would be paid for and the lack of co-pays for health care under this comprehensive insurance package.  For example, there would be no out of pocket expenses for prescription drugs, hospitalizations or long term health care.  Under HR 676 health insurance would be paid for by existing government programs combined with a 4.75% tax on payroll and self-employment income, a 1/3rd of 1% tax on stock transactions, a 5% increased income tax on the top 5% of  Americans and a 10% increased income tax on the top 1% of Americans.  Although taxes would increase, close to 95% of Americans would save money and an average citizen would save above 50%.    

Conclusion:  A Canadian style national insurance program is likely to cost about the same as our current system in the short term.  In the long term, increases in health care spending are likely to be constrained by about 50% from what they would be if our current system were to continue.  The cost to the average person would be substantially less in both the short term and long term due to the fact that the cost of health insurance would be tied to income and out of pocket expenses would be eliminated.

The Following Questions Address Concerns About A Canadian Style National Health Insurance Program for the United States In Terms of Government Control And It’s Impact on Business

21.                         If a Canadian style national health care insurance system were enacted in the United States through HR 676 which of the following would be true?

A.   Americans would have to select their health providers from a limited government approved panel

B.   Americans would have to get pre-approval of prescriptions by the government before they would be covered

C.   Elective surgical procedures such as knee replacements would require pre-approval before they could be scheduled

D.   There would be waiting lines for elective surgery and diagnostic procedures similar to Canada

None of the above.  There would be no managed care under HR 676.  Because the American health care system would be fully funded to cover all current medical care there would be no lines, just as there would not be lines in Canada if it were funded at American levels, twice the health care spending of Canada.

22.                         If  a Canadian style national health insurance program were to be enacted in the United States through HR 676  which of the following statements about its impact on business would be true?

A.   International American corporations would become more competitive because of decreased health care costs for their employees

B.   The private health insurance industry would be severely curtailed

C.   A significant drop in medical innovation and drug development would occur

D.    Profits of the pharmaceutical industry would increase due to expanded insurance coverage

A and B are correct.  The cost of health insurance for international companies for major international corporations such as General Motors would be significantly lessened making them more competitive internationally.  The private insurance industry would be severely curtailed.  There is no evidence that national health insurance would significantly impact medical innovation.  Currently the majority of new medications are developed in countries with national health insurance and the American government would continue to fund a significant part of the research involved in medical innovation and drug development.  The payments to pharmaceutical companies for prescription medications would be reduced and although demand may increase pharmaceutical profits would likely decrease.

Conclusion:  Americans would experience greater freedom of choice and less insurance control under a Canadian style national health insurance program than our current health care system.  Most businesses would be strengthened by a Canadian style system, although the pharmaceutical industry would become somewhat less profitable and the private health insurance industry would be severely constrained.

The Following Question Addresses The Reasons Why National Health Insurance Is Unlikely To Be Enacted In The United States In The Immediate Future

23.                          Which of the following factors is significant in making it difficult to pass national health insurance for the United States ?

A.   The strong influence of the insurance and pharmaceutical industries on elected officials

B.   The lack of publicly funded elections

C.   The lack of public support

D.   The irrational belief that private for-profit health insurance is more effective and more efficient than not for profit and publicly administered health insurance

A, B and D.  The insurance and pharmaceutical industries are leading contributors to the campaigns of public officials and vastly outspend advocates of national health insurance in lobbying against national health insurance legislation.  For this reason, most health care advocates support the public funding of elections and the strict regulation of lobbying as the surest way to pass national health insurance.  For some years there has been majority support among Americans for a Canadian style insurance system for the United States .  The most recent poll, a February 2007 poll conducted by the New York Times, revealed 64% of Americans believe the government should guarantee health insurance for all American citizens.  When the Citizen Advisory Board was established by the government to obtain input from citizens about health care reform, a Canadian style health care system was by far and away the leading reform supported by the public.  However, the irrational belief that for profit health insurance is more effective and efficient than not-for-profit or publicly administered health insurance continues to sway elected officials and some of the public despite the vast, well documented data which shows this belief to be without factual basis.