Friday, December 14, 2007

Thinking through US Health Care


"We cannot live under the idea that we can give everybody all the health care they need. Rationing of health care is inevitable because society cannot or will not pay for all the services that modern medicine can provide. People in this state must search their hearts and pocketbooks and decide what level of health care can be guaranteed to the poor, the unemployed, the elderly, and others who depend on publicly funded health services" Oregon Health Decisions, 1988

Since this blog is largely about finding ways to stay healthy in a responsible way, I thought it would be good to post a snapshot of US health care. I believe that many of the readers of this blog may not be from the US-- this one's for you! Looking forward, this post sets the stage for my next two posts:

(1) What it might take to see a different picture in 2012, a picture where everyone has good, appropriate care without ever having to worry about how they will afford the care, or if they will lose insurance.

(2) What might have happened if the opposite had taken place and we're looking at a disaster in 2012: costs spiralling out of control, more people uninsured, the nursing shortage further deteriorating, etc.

The Snapshot

47-60 million without insurance and some 150 million under-insured
1.7 trillion (that is, 1.7 000 000 000 000) in yearly costs, or 16% of national spending.
"The United States spends more than twice as much on health care as the average of other developed nations, all of which have universal coverage"^ yet
Comparing Japan, Sweden, Canada, France, Australia, Spain, Finland, the Netherlands, the United Kingdom, Denmark, Belgium, the United States, and Germany, the United States ranks*:
- 13th(last) for low-birth weight percentages
- 13th for neonatal mortality and infant mortality overall
- 11th for postnatal mortality
- 13th for life expectancy at 1 year for females, 12th for males
- 10th for age-adjusted mortality.

20-30% of patients receive inappropriate care.
An estimated 44 000-98 000 people die each year as a result of medical errors.


Many readers will compare the US system to the South African system. I would like to do the same in a future post. I think it may be useful for thinking about health improvement in both countries. The South African system recognizes health care as a Human Right, which the US system does not. Yet people in the US generally receive much better care.

So, let's look at the "Human Rights" aspect of health care. The limitation of the "human rights" language of health care is that one can never guarantee health. We all get sick and we all die. As one professor at BU School of Public Health says, this fact means that health care has a 100% failure rate. As a result, it's really difficult to measure what is a reasonable amount of care. Some people will need far more resources than others. Yet the right to care is also one of the most fundamental-- it's a life and death issue.

In the U.S., patients and health care providers are uncomfortable with the idea of rationing. Surely everyone should get the best possible care that is available? Unfortunately, the answer is "no". Particularly when what is available is often extremely cutting-edge and therefore expensive, as in Boston, there has to be a limit. The challenge is drawing a line between one type of care and another. The challenge is saying no to some types of really expensive care. As a result, US health care spending is spiralling out of control.

As in the South Africa, socio-economic inequality is a root problem in the health care system. People are not guaranteed care. Worry becomes an intricate part of any visit to the ER, specialist, or primary care physican.

I argue that the deeply fragmented nature of health care is a major source of waste and of poor care. Health care is not a commodity like any other, so it cannot be treated as a common commodity in a free market. In a free market there are always people who lose everything, but losing money is one thing, and losing one's health is another.

^The Physicians' Working Group for Single-Payer National Health Insurance, Proposal of the Physicians' Working Group for Single-Payer National Health Insurance. JAMA August 13 2003, 290 (6)
*Starfield, Barbara. Is US Health Really the Best in the World? JAMA, July 26, 2000 26(4)

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