Friday, July 20, 2007

The US: a nice place to live, but don't get sick

I would like to thank Revere, of Effect Measure, for his open willingness to share his posts per the creative commons licensing, share and share alike. I have chosen to add this license to the writing here as well, the tag can be found in the side bar.

I really appreciate Revere's writings on public health issues. As such, I thought it would be very appropriate to use a post he wrote about the state of health care in the U.S. to get the conversation about universal health care started. I will be adding posts from others on this topic, both pro and con, in the future, along (of course) with my own thoughts. This post was originally posted to Effect Measure, June 19th 2007. . .

From Effect Measure;
The Editors of Effect Measure are senior public health scientists and practitioners. Paul Revere was a member of the first local Board of Health in the United States (Boston, 1799). The Editors sign their posts "Revere" to recognize the public service of a professional forerunner better known for other things.

It's a myth that's hard to bust. The one that says the United States, the country that spends more on health care than any other, has the best medical care in the world to go with it. It hasn't been true for a long time. It doesn't. But it is part of the core belief of most Americans. I wonder who benefits most from that falsehood? But to the facts:

As early as 2000, the World Health Organization made the first attempt at ranking all the world's healthcare systems. The U.S. came in 37th out of 190 nations in the provision of healthcare. (France, according to the June 2000 report, was first.) The report was criticized for using inconsistent comparison measures and for failing to note that some countries deny expensive care to very sick patients. Americans could still reasonably cling to their long-held pride.

But in 2006, the Organization for Economic Cooperation and Development, an international organization that aims to lift living standards by promoting economic development, compared health spending and health statistics in its 30 member nations. Its report was more detailed than the WHO rankings, and had more controlled and consistent measures. The data, taken more seriously than the WHO rankings, left Americans with little to brag about.

And [NIH's Dr. Ezekial Emanuel's] recent commentary [in the Journal of the American Medical Association] was published the day after another report released by the Commonwealth Fund, which supports independent research into healthcare issues, found the United States at the bottom among six industrialized nations on measures of safe and coordinated care.

If all of that doesn't seem damning enough, insurance provider UnitedHealthcare Group took out a full-page ad in the Wall Street Journal on March 19 declaring: "The health care system isn't healthy.... A system that was designed to make you feel better often just makes things worse." One of the very industry giants that critics point to as a cause of the problem was defensively pointing back.

Amid stacks of reports, all with wonky measures of access, equity, efficiency and medical outcomes, two statistics stand out. The U.S. spends more on medical care than any other nation, and gets far less for it than many countries. According to the 2006 analysis by the Organization for Economic Cooperation and Development, the U.S. spends an annual $6,102 per person -- more than any other country and more than twice the average of $2,571. Yet Americans have the 22nd highest life expectancy among those nations at 77.2 years compared with the analysis' average of 77.8 years. People in Japan, the world leader in longevity, live an average of 81.8 years.

The report also found that the United States had about 2.5 times the average years of potential life lost due to diabetes: 101 years per 1,000 people compared with the average of 39 years per 1,000 people. Americans had fewer practicing physicians, or 2.4 per 1,000 people, than the average of 3 per 1,000 people. Infant mortality rates have been falling in the U.S., but are still higher, at 6.9 deaths per 1,000 live births, compared with less than 3.5 deaths per 1,000 live births in Japan, Iceland, Sweden, Norway and Finland. (LA Times)

When Andrew Speaker used subterfuge to fly back to the US for treatment of his XDR-TB an Denver's National Jewish Hospital it was not only to get home to his family but because he believed the care in the US was better than anywhere else. In fact, Italy has the second best health care system by the international comparison rankings and some of the best TB experts in the world. You probably didn't know that. Number 1? France. I'll bet you didn't know that either. You can quibble about the ranking method (if you can claim some expertise), but the only thing everyone agrees the US comes out on top for is cost. Cadillac prices for a high mileage junk car.

When I was in medical school the prestige specialties were internal medicine and psychiatry. That's what the brainy students chose. Not any more. Why? Because you don't get to do "procedures" in those specialties. Doctors get paid for "procedures." Handsomely paid, I might add. Managing chronic disease? Sorry. No procedures.

For starters, the American system doesn't measure up worldwide in controlling chronic diseases, such as diabetes or hypertension. Payment systems reward doctors for doing procedures, not for managing those chronic conditions, so a world-class center -- like Boston's Joslin Diabetes Center, which is supported by philanthropy -- stands in stark contrast to results seen by regular doctors treating the disease in average patients.

Kidney disease patients on dialysis have a higher risk of death in the United States. By an act of Congress in 1972, all end-stage renal disease is covered by Medicare, even for patients younger than 65. But because of Medicare funding cuts, patients on dialysis receive less time on dialysis than patients in Europe and Japan. That helps explain why Americans on kidney dialysis have a mortality rate of 23% compared with 15% in Europe and 9% in Japan, according to a May 2002 report in JAMA.

The US, alone among the industrialized nations, has no universal health care. Let me correct this. The average US citizen doesn't. Members of Congress already have their health plan. Even the CongressThings so adamantly opposed to "socialized medicine" are not giving up their government health plans. They'd rather hold the average American hostage to their ideological pecadillos.

Meanwhile, those of us who can afford to, pay. And pay. And pay. But we don't get our money's worth.

And those who can't afford it? You supply the answer.


Beth said...

From reading this, my overall feeling is that we need to do more about preventative measures to be healthier, that doesn't require universal health care, that requires people taking responsibility for minimizing their own health risks first and foremost. We have more obesity and are a less active nation, let's get to the heart of the issue here. Also, if we have fewer doctors, we need to look at why people don't want to be doctors in the first place. Is it the cost, the stress, the fear of malpractice suits? We can solve health care problems without getting the government involved.

DuWayne Brayton said...

The heart of the issue here, is that no matter how much one does to take care of themselves, they still need access to health care. Without it, a minor illness or injury can become something catastrophic. Without access to medications, quality of life, for even minor problems, becomes intolerable. Mental problems, including depression, that can be made manageable with medications, spin out of control, spiraling a person into a need for hospitalization.

The problem is, that a lot of problems that would cost little to deal with and keep a person on track with their life, end up costing the tax payers, costing paying health care consumers and costing the patient and their family, exponentially more because they wait until the problem is accute. Under the current system, the only care many people can receive, is in the ER, when it becomes serious. I have been there innumerable times and will probably be again.

The cost has been immense. The cost to other, paying health care consumers, has been close to twenty thousand dollars. Some of that was probably picked up by the taxpayers. The cost to me has been substantial as well. Instead of getting timely care, I have probably lost, collectively, months of work. Not to mention the emotional tole. All of that, and still, to this day, I am without medications to help manage stress and anxiety.

All in all, I'm lucky for a person lacking access to health care. Others have far worse problems to deal with. In many cases, it isn't even a lack of health insurance, that is responsible for the lack of access to care, but the restrictions placed by the insurance companies themselves.

The system is beyond broken and beyond salvage. Even health insurance is no guarantee for essential access to care. The best preventative measures, many of which can be costly in themselves, are unlikely to prevent the need for some care, it certainly won't help protect one from accidental injury. Nor are a healthy diet and exercise a guarantee that one won't have a heart attack, stroke or cancer.

If you think that we can solve the health care crisis without getting the government involved, I'm all ears. So are the 45 million plus Americans without any health insurance and the millions more who's insurance doesn't actually provide the care they so desperately need. So are the employers who are going into bankruptcy trying to keep up with providing care for their employees. Easy enough to say we can solve the problems, so where are the solutions?

Beth said...

A solution that involves a huge beaurocratic governmental agency is not the answer. I would propose many other fixes to health care instead. First, have health insurance be made available like home or car insurance, where consumers have insurance companies competing for their business. Medical insurance should be there for the catastrophic times, just as you wouldn't use car insurance for an oil change you wouldn't use health insurance for a checkup. So insurance wouldn't be so expensive.

Secondly, reform malpractice litigation by capping the amount of punative damages. I can see compensating for actual losses, but these lawsuits (where the lawyers make the most out of it) are out of control.

Third, the cost of prescritions is high partly because other countries (those with socialized medical systems btw) refuse to pay for R&D of new drugs. So of course their health care costs are going be lower than the USA for the same drugs, while guess who has to pick up the costs for R&D...Americans do. This is unfair, and something should be done about it.

IF the government needs to get involved to help those who truly cannot afford health care, then I could only endorse it done at the state level. The bigger the programs get, the more inefficient and less personal they are, which is not a good thing when it comes to your health.

And goodness, you talked in another comment about being "wards of the state" if the state limits what we can do with our bodies, yet you want them to have full access to your medical records?

Lastly, the issue was brought up in the post here about the lack of doctors, and I do not think a government run health care system is going be an incentive for people to go into the health care field. If anything, it will discourage them from wanting to be doctors.

While universal health care seems like the answer, all you are doing is taking the problems and shifting them to an entity that I feel I give enough of my money to through taxes, and don't really want to give them anymore.

nbm said...

Universal health care or health insurance (two different things) is found in all industrialized countries except the USA. There are almost as many different systems as there are countries. I'm familiar with the Norwegian system. GPs are key. There aren't many specialists or tests one can access without going through one's GP and the GP gets back reports from all of them. In certain, well-defined circumstances the GP must give personal info to other parts of the system, for example on hospitalization or when a patient is applying for a disability pension. Lots of other info is reported for statistical purposes, but not by name. I agree that just anyone in government shouldn't have access to personal info!

Almost all GPs and many specialists have contracts with the government, with rates negotiated by their unions. Patients choose any GP who has capacity on her/his list; it's voluntary, but 98% of us are on a GP's list. The GP is paid by the government a certain sum for each patient, even patients who never go to the doctor. The patient pays any doctor specified (subsidized) fees for appointments and tests up to a ceiling for the year, after which care is "free". ("Free" but we pay in our taxes, of course.) All hospitalization is "free".

The government also decides how many doctors we will have by limiting access to medical school, which is free.

I'm very happy with the Norwegian system except for a few things which aren't included such as adult dental, eyeglasses and physical therapy. Dental is free for kids up to 18, for nursing home patients and a few other categories. I think it will be included for everyone before too long.

One major advantage over the US "system" is that, except for on-the-job injuries, there is NO connection between health care and employer.

DuWayne Brayton said...

Hi nbm and welcome. First, I wanted to ask if you would email me, my address is in my profile. I wanted to discuss sleep disorders v ADHD and also how they can integrate.

One quibble I would have with the Norwegian system, is that I do not really want to see the government become the provider. I am supportive of single payer, in a multi-tier system. I.e. there is and never can be, a requirement that one use the public insurance, or has the allowance to pay more than the baseline for care, whether through additional insurance or straight out of pocket. I think this would be an ideal application for HSA (health care savings accounts), which provide untaxed accounts to be used only for health care - including preventative care and things that the UHC does not cover.

As I am ADHD, I have mutliple posts in the works, one of which specifies how I think an ideal American system would look. In short, I think that there needs to be a baseline for care that everyone has access to and the ability to supplement beyond that. But then, I also think there needs to be a baseline minimal standard of living across the board - food, shelter, clothing and toiletries. Nothing remotely fancy or even very comfortable, minimums should be minimums. Just a baseline that everyone can work up from.

nbm said...

As I understand it, "government as provider" is like the present VA system. The doctors there are salaried, not fee for service, right? And I don't know whether you can count on getting the same doctor twice in a row. That's not what the Norw. system is like at all.

I don't rightly see how there can be single payer without it being a government agency, on a line with Social Security or perhaps Medicare.

(I have sent you an e-mail.)