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Adam Thompson on August 11, 2008 - 9:36am
US athletes are now showing their mettle, competing against the world in the Beijing Summer Olympics. Since the modern summer Olympics began in 1896, the US has been a force; consistently fielding a dominant cadre of athletes and ranking first, or among the top, in the overall medal count. In the spirit of competition and international comparison, this Stateside Dispatch will look at how well our health care system stacks up against our peers in the international community.
The sobering truth of America's health care system is that it dramatically under-performs. In an August 2008 poll by the Commonwealth Fund, 8 of 10 adults agreed with the statement that the health care system "needs either fundamental change or complete rebuilding". This becomes even clearer when comparing our system with those of our international peers - each of whom guarantee coverage to all residents through a mixture of single-payer or mixed-payer public/private systems. In 2000, the World Health Organization ranked the performance of the US health care system 37th in the world. In this and other international comparisons, despite spending more than twice per capita than our peers, we are beaten on virtually every metric of health care cost, quality and access. In other words, we spend more and get less.
Limited Access and Unfair Financing
The US is the only major industrialized country that does not ensure coverage for all. At least 47 million Americans lack health insurance and at least 25 million more are under-insured, meaning their insurance does not shield them from high health care costs. In the World Health Organization's 2000 comparison of the world's health care systems, a key metric is "fairness in financing"; the degree to which financial contributions to health systems are distributed fairly across the population. On this measure, the US is ranked 54th, the lowest of all major industrialist countries.
The US financing system, which burdens families with out of pocket costs twice the international average, does not protect Americans against the costs of poor health. This has implications for all Americans, but particularly for lower and middle income families.
Without adequate insurance and facing high out of pocket costs, tens of millions of Americans put off care until illnesses become an emergency. In fact, emergency room visits jumped 36% from 1996 to 2006, according to a new CDC report. Additionally, average wait times at emergency rooms have increased to about 56 minutes, up from 38 minutes in 1997. The increases were due to both uninsured and insured Americans being unable to access timely care elsewhere, particularly primary care visits. Higher emergency room use drives up costs overall as emergency room care is more expensive than preventive care; and delaying care results in worse health outcomes overtime.
Poor Quality and Longer Wait Times
Scoring the US health care system on key benchmarks achieved in other countries is about as complex a process as the new scoring system for gymnastics, where the "perfect 10" is now a thing of the past. Yet, in Why Not the Best?, experts at the Commonwealth Fund give the US a score of 65 out of a possible 100, when examining how we compare to other countries on 37 different metrics for a high performing health care system, including life expectancy, preventable deaths, and timely doctors' visits.
Poor Quality - Key measures of an effective, coordinated, and overall highly-performing health system include life expectancy and deaths preventable with timely and effective care ("amenable mortality"). In both areas, the US lags far behind our international peers.
- Life Expectancy - In 2007, according to the US Census Bureau, the US ranked 42nd in life expectancy. If you are a person of color, a low-wage worker, non-English speaking, or live in a low-income community, the picture is much worse. For instance, the life expectancy for African-Americans is 73.3 years, five years shorter than it is for whites. For African-American men, it is 69.8 years, just above averages in Iran and Syria, but below Nicaragua and Morocco.
- Preventable Deaths - In a Commonwealth Fund study comparing amenable mortality rates - or preventable deaths with timely and effective care - in 19 peer countries, the US ranked last. The study looked at 14 Western European countries, Canada, Australia, New Zealand, and Japan, and found that if the US attained even average benchmarks for timely and effective care in the top three countries, 101,000 American lives would be saved each year. While all countries showed improvement over a 5 year period, the US merely inched along. The "amenable mortality" rate in the US dropped 4%, but dropped an even greater average of 16% in all of the other countries studied. Compounding these findings is a 2004 HealthGrades study which estimated that 195,000 patients die each year across the US from preventable hospital errors.
Longer Wait Times - One of the most hackneyed attacks on health care-for-all reform is that it will result in long lines to see a doctor or specialist. But, Americans now are facing longer waits to see doctors and get timely and effective care than other countries that guarantee coverage for all. Of six countries in a Commonwealth Fund comparison of health system performance- Australia, Canada, Germany, New Zealand, United Kingdom and the US - patients here and in Canada reported facing the longest waits to see a physician, waiting six or more days for an appointment when needing care. A similar comparison found that US adults reported the most difficulty - along with Canadian adults - getting care on nights, weekends, and holidays without resorting to emergency rooms. Furthermore, three-quarters of adults in the August 2008 poll by the Commonwealth Fund reported difficulty making timely appointments with doctors, getting advice over the phone, or accessing care after-hours without resorting to the emergency room.
Some Progress - In its national scorecard, Why Not the Best?, the Commonwealth Fund notes exceptions to US stagnation, or declines, in health system performance. The US has made notable improvements in quality metrics that have been the focus of national campaigns or public reporting, such as safety measures to reduce hospital mortality rates and provider incentive programs to improve care for diabetes and high-blood pressure. This demonstrates that assertive, coordinated, and public campaigns to improve the quality of care can have swift results.
Quality and Cost - The quality of health care has a direct impact on the cost of care. For instance, the Institute of Medicine estimates medical errors in the US cost $17 billion to $29 billion each year. And, a staggering 78% of all health care costs are for people with chronic conditions, like diabetes, heart disease, lung disease, and depression. With higher rates of obesity-related chronic diseases in the US than in peer countries, our system falls short in comparison to other countries in helping Americans stay healthy. Developing a system that ensures high quality, effectively coordinates coordinates care and helps people stay healthy will achieve the dual dividends of better health and lower overall costs.
Spending More, Getting Less
Over the past 40 years, US health care spending has grown on average between 1.3 and 3.1 percent faster than the overall economy, according a 2007 primer on health care costs produced by the Kaiser Familiy Foundation. 16.3% of the gross domestic product is consumed by health care. What's frightening is the constant upward trend. By 2017, the federal agency that directs Medicare and Medicaid projects US health care spending to double to more than $4 trillion, accounting for one of every $5 dollars and 20% of the GDP.
Other industrialized countries with above average per capita national income like the US and systems that cover all residents, spend about half what we spend per person. In 2004, our per capita spending was just over $6,000. France, Germany and Canada each spent roughly $3,100 per person and the UK spent less at $2,560. Yet, in terms of quality and access, each of these countries outperform the US.
Inefficient Administration: US athletes excel at efficiency - whether perfecting a swim stroke to limit drag and preserve energy for a strong kick at the end of the 1500 meter free, or extracting every bit of energy and power from each stride of the 100 meter sprint in track and field. The same, however, cannot be said of the US health care system. Our health care system treats efficiency as if it were a communicable disease, avoiding it at all costs.
Economist Henry Aaron calls the US health care system an "administrative monstrosity, a truly bizarre melange of thousands of payers with payment systems that differ for no socially beneficial reason." According to the Commonwealth Fund, US administrative costs - as a share of total health care spending - are 30% to 70% higher than other countries, including those with mixed public/private systems. In Why Not the Best?, the Commonwealth Fund found that we would save $100 billion in administrative costs if we reached top efficiency benchmarks achieved elsewhere. Within the US system, administrative expenses for private insurance are two and a half times as high as for public programs.
Conditions resulting from this administrative inefficiency include wasteful, fragmented, and inappropriate care. According to the Commonwealth Fund, US patients report having duplicate tests or that medical records or tests were not readily available three to four times benchmark rates in other countries. Furthermore, the August 2008 Commonwealth Fund survey of US adults found high instances of poorly coordinated, inefficient or wasteful care and administrative hassles dealing with medical bills and insurance.
An indication of how far ahead of the US are leading countries in implementing systems to improve efficiency and coordination of care is the use of electronic medical records. According to the Commonwealth Fund, 98% of all physicians in benchmark countries use electronic medical records to improve care, compared to only 28% of physicians in the US.
Every major industrialized country guarantees health care for all residents, excluding the US. Even though we spend far more per capita, we lag behind our international peers in terms of quality, health attainment, and over-all health system performance. We spend more and get less.
It is clear that in a more coordinated system that guarantees coverage for all and provides incentives for quality care, we can have a health care system that outperforms the world - a lesson we can learn from our Olympic athletes. Yesterday, after failing to capture gold in the past two Olympics in men's swimming's 4x100m freestyle relay, the US team coordinated a dominating performance and out-touched the favored French team - who were unable to turn their pre-swim hubris into a win. But, in health care - according to its number 1 ranking by the WHO - France still has bragging rights as the gold standard.