Public Citizen Health Letter
We Americans live in a nation where the medical-care system is second to none in the world, unless you count maybe 25 or 30 little scuzzball countries… that we could vaporize in seconds if we felt like it. – David Barry
Senator John McCain has joined President Bush in declaring that we have “the best system in the world.” A recent survey found that this view is shared by 45 percent of the population and fully 68 percent of those who identify themselves as Republicans. But any mention of “the best” begs the old Borscht Belt question of “Compared to what?”
The fact is that – by practically any measuring stick other than how much money it spends – the United States is lagging compared not only to most major industrialized countries, but also to some developing countries. Different organizations and researchers have devised a variety of ways to measure how United States the is faring vis-à-vis the rest of the world. These provide a sobering and humbling appraisal of health care expenditures and what they buy us.
There are three usual ways to measure health services. We can look at structure, the ingredients that go into providing care; at process, the way services are linked to ensure access and accountability; and at outcome, or health status, most often summarized as the five D’s: disease, death, disability, discomfort and dissatisfaction.
Because structure refers to the country’s medical endowment in terms of personnel and facilities, at first glance the United States would seem to rank high in terms of its health labor force and clinic and hospital infrastructure. Still, the United States does not have more resources available than the average for the countries in the Organization for Economic Cooperation and Development (OECD). In 2004, the United States had 2.4 practicing physicians per 1000 population, while the average for OECD countries was 3.0. Moreover, and most importantly, the country is in the midst of a contracting supply of primary care specialists, and that is expected to worsen in the next decade.
In the absence of a point of entry such as a primary care physician and a source of continuing care, many Americans lack a medical “home.” The result is fragmented care, uneven responsibility and higher expenses, all of which affect the process of obtaining services. Not surprisingly, a cross-national study of seven developed countries found that U.S. respondents reported the highest overall medical error rate of those studied.
The process also leaves a lot of people out, with almost 50 million uninsured and an equally large number having skimpy or inadequate coverage. This means that approximately 100 million people, one-third of the U.S. population, is uninsured or underinsured. And even those “covered” with Medicaid and Medicare cannot count on complete coverage, having to deal with gaps, co-pays and “doughnut holes” that act as barriers to health care. Those without coverage tend to receive fewer preventive services, get late or no care, lack continuity in the treatment they receive and have worse outcomes.
It is therefore not surprising that the United States has worst indicators of health status than many other countries that have fewer resources to spend on medical care. A study published earlier this year ranking 19 industrialized nations in terms of preventable deaths found that the United States was the worst. The top three ranking countries were France, Japan and Australia. While France had 64.8 deaths deemed preventable for every 100,000 inhabitants, the United States had 109.7 deaths. If the United States could reduce these “excess deaths” to the average of that of the three top-performing countries, there would have been 101,000 fewer deaths per year by the end of the study period.
Even when patients are unaware of data such as discussed above, they manifest their dissatisfaction with the system. One 2007 study surveyed 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom and the United States. This found that adults in the United States reported high rates of coordination problems and billing hassles. Moreover, one-third of U.S. respondents said that the health system needed to be rebuilt completely, the highest rate of any of the seven countries.
The Best Health Care System?
What, then, do politicians mean when they say the United States has the best health care system in the world? They are probably referring to the abundance of resources (however poorly distributed) and the intensity and variety of technology (however ineffectively or unnecessarily used). While the United States is a significant leader in medical research, medical education and in the application of new methods of diagnosis and treatment, the benefits of these accrue primarily to selected medical enclaves: those who are better educated, live in metropolitan areas and have generous insurance coverage.