The Real Story About American Healthcare
For many years the American healthcare system has been under fire for not only being the most expensive worldwide, but, also, sub-par when compared to other healthcare systems – especially those in Europe. Critics have always pointed to the European healthcare models as what we, here in the United States, should be copying in order to bring our healthcare costs more in line with the rest of the world.
Many of these articles point to certain statistics such as infant mortality and life expectancy, both of which, are worse here in the United States when compared to other industrialized countries. Unfortunately, as is so often the case, statistics without a basic understanding of how those numbers are achieved is erroneous and very misleading.
It is the purpose of this article to give the reader a better understanding of healthcare, here and abroad.
One recent article by Robert Frank entitled, “What Sweden Can Tell Us About Obamacare”, published in the New York Times on June 15th 2013, wrote how superbly the Swedish healthcare system worked compared to that in the United States. Besides being less than half of the annual cost here in the United States, mortality for 16-35 year olds is lower in Sweden and infant mortality is much higher in the United States compared to Sweden. Though both statistics are true, there are legitimate explanations for both comparators. If they had been published in the article, it would have shed a more favorable light on healthcare here in the United States.
First, mortality of 16-35 year olds in both Sweden and the US has very little to do with healthcare. This is because the leading cause of death in that age group is injuries due to accidents and violence. In the CDC report, “Injuries and Violence are the Leading Cause of Death: Key Data & Statistics”, (last updated 11/22/2013) concluded that ¾ of all deaths among young people are the results of violence and injuries. The report goes on to site that the leading cause of death for those ages 5-34 is MVA’s. Considering the fact that there are more vehicles per capita here the US compared to Sweden, which was also mentioned in the article, it is understandable how mortality is higher for that age group here in the US compared to Sweden.
The report goes on to show what kind of financial burden injuries to young people are here in the United States. In 2007, nearly 183,000 persons died of injuries and nearly 3 million persons were hospitalized for an injury. At the same time nearly 30,000 persons were treated for nonfatal injuries in ER’s throughout the US. The cost for this type of care was an estimated $406 billion dollars in 2005 when medical, work loss, hospitalizations and ER visits were taken into consideration.
Statistics on infant mortality are a bit more complicated, but are still misleading. In trying to rank infant mortality nationally worldwide the WHO (World Health Organization) has defined a live birth, “as any product of conception that shows signs of life at birth, with no consideration for birth weight or gestational age criteria”. According to the British Medical Journal’s article published in 2012 entitled “Influence of Definition Based vs Pragmatic Birth Registration on International Comparisons of Perinatal and Infant Mortality: Population Based Retrospective Study”, found that despite this definition being unchallenged, some countries have widely varying regulations for registration of birth that range from definition to pragmatic. For instance, stillbirths in the United States begin at twenty weeks gestation, whereas in Sweden, a still birth begins at 28 weeks gestation and not at 20 weeks as in the US, thereby increasing infant mortality for the United States. The BMJ article goes on to conclude that because of these differences, it compromises the validity of international rankings of perinatal and infant mortality.
Similar findings are found in the CDC’s report from November 2009, “Behind International Rankings of Infant Mortality: How the United States Compares to Europe” finding that it is difficult to rank nationally due to varying criteria. The article goes on to show that:
- Infant survival for preterms is higher here in the US than in most European countries; however, infant mortality rates for infants born at 37 weeks of gestation or more, is higher in the United States than in most of Europe.
- One in eight births here in the US were born preterm compared to one in eighteen births in Ireland and Finland.
- If the United States had Sweden’s distribution of births, nearly 8,000 infant deaths would be averted each year and the US infant mortality rate would be one-third lower.
- The main cause of the United States’ high infant mortality rate compared with Europe is the very high percentage of preterm births in the US.
Risk for preterm birth is multifactorial and goes way beyond healthcare. Though socio-economic issues and education, or the lack there of, play an important role in creating risk for premature births, other factors need to be considered. Other factors that contribute to preterm births include: extreme age – younger and older, substance abuse, cigarette smoking, diabetes, obesity, stressful and long hours at work.
Clearly healthcare costs for preterms can be expensive. According to a recent report from the CDC on preterm births, it was estimated that the US spent over 26 billion dollars on preterm births in 2005. Unfortunately, the European Foundation for the Care of Newborn Infants (EFCNI) in November, 2011, found that the availability on data for preterms in Europe as far as risk factors, management and outcome has not been consistent and statistics are scarce. Despite the lack of quality data on preterm births in Europe there appears to be an increase in prevalence for preterm births in all EU countries except for Sweden. The EFCNI concluded in its report that there needs to be:
- An increase in the standard of care across Europe
- Allocation and prioritization of funding to improve neonatal care
- Support for post-graduate training of physicians and nurses in this area. All of these things have already been accomplished here in the US.
Though the two categories discussed help demonstrate some of the expenses for healthcare here in the United States, the most expensive challenge facing our healthcare system today is the significant and growing number of Americans coping with more than one chronic condition. According a report published by the Robert Wood Johnson Foundation titled, “Chronic Care: Making the Case for Ongoing Care”, published in 2010, it found that nearly 2 of every 3 dollars spent on healthcare in the US is directed towards care for 27% of Americans with multiple chronic conditions.
Chronic care is very different from acute care in several ways. With acute illnesses there is usually an abrupt onset with a single cause. In most instances acute illnesses are accurately diagnosed and effectively treated with the possibility of a cure. However, patients with chronic disease are more complex and usually have a gradual onset that, more likely than not, will have an indefinite duration, multiple and changing causes and less likely to have a cure. For example, treating cellulitis (skin infection) of the foot of a twenty year old that is healthy, and the cause being due to some traumatic event, is much easier to treat than cellulitis of a middle-aged diabetic with peripheral vascular disease.
Though far from optimal, the United States healthcare system has a much better handle on dealing with multiple chronic diseases when compared to the rest of the world. Consider Sweden for instance. In a recent report on healthcare quality review of Sweden 2013 the Organization for Economic Co-operation and Development (OCED) found that an aging population with growing chronic conditions and requiring more complex health services is testing Sweden’s ability to continue delivering high-quality care. The report states that Sweden is still quite good at delivering care for single illnesses such as asthma. However, the report goes on to state that less than half of patients with diabetes and high blood pressure have their blood pressure controlled. More startling is that only one in six stroke patients in Sweden have a follow-up with either a doctor or nurse specialist.
Worldwide chronic, non-communicable diseases have reached epidemic proportions according to a report prepared for the European Chronic Disease Alliance input to the Reflection Process on chronic disease entitled, “Optimizing the Response to the Epidemic of Chronic Disease.” It stated in its introduction that by 2030 non-communicable diseases would cost $47 trillion worldwide. It also went on to state that Europe currently has the highest number of deaths and disabilities in the world due to these diseases. Considering how the healthcare in the United States has been portrayed to many Americans, this last statistic can be eye opening. In simple terms it’s expensive to keep this group alive and Europe does a poor job of it. Confusing the issue is life expectancy. If the United States does a better job at managing patients with multiple chronic diseases, then why isn’t life expectancy higher in the United States? The answer is that there are more deaths early in life here in the United States. Between young people dying from violence and injuries, and, of course, the increase in infant mortality due to an increase in premature births, these statistics contribute to the decrease in life expectancy here in the US.
Policy makers in Europe are concerned about the growing prevalence of this problem and are looking to the United States for guidance. This was evident in the London School of Economics and Political Science Research Note: Chronic Disease Management in Europe prepared for the European Commission in 2008. It found that the US chronic disease management models may not reduce healthcare costs, but they do seem to improve quality and may improve health outcomes. It goes on to conclude that, “European countries are essentially tinkering with their health care systems rather than considering a complete overhaul of how primary and secondary care is conducted. The rising problem of co-morbidities implies that policies aimed at specific diseases are likely to fall short of comprehensive and continuous care, particularly because multiple sets of provider teams may treat the patient.”
The same findings were echoed in the Eurohealth article, “Chronic Disease Management in Europe,” published in 2009. One conclusion from the article was that policy makers need to clarify their positions on the authorization and reimbursement of highly effective, but costly and personalized medications. It also concluded that since cure rarely occurs in chronic disease conditions, research is needed to assess both interventions and treatment of these disease states.
Ironically, critics of the US healthcare system look to Europe because of the costs spent there, as compared to here. Yet European policy makers are looking to the US healthcare system because of our better understanding of dealing with the chronic disease state compared to Europe. In comparing healthcare in the US to healthcare in Canada, a WHO report from 2000 found that Canada ranked higher than the US for the level of responsiveness and fairness of financial responsibilities – Canada ranking 30th and the US ranking 37th out of 191 countries studied. However, the study also found that the US was number one in quality of service in individuals receiving treatment to Canada’s number seven ranking. Canada also has a slightly higher life expectancy as compared to the US. The reason being is that Canada has less of an obesity problem than does the US and ethnically, the Canadian population is not as diverse as is the United States, once again making it extremely difficult to compare health outcomes on an equal basis. Also cigarette smoking and alcohol use are both higher in the US. Another contributor to increasing healthcare costs here, as opposed to Canada, is the higher prevalence of illicit drug use with its associated violence and illegal immigration – both of which are higher in the US as compared to Canada.
In conclusion, the United States healthcare system is expensive, but there are legitimate reasons other than too many CT scanners and unnecessary and costly procedures as some would have you believe. Also, healthcare in the United States is not as bad as it is made out to be. Is there room for improvement? Yes. Going to a single payer system or reducing the number of CT scans isn’t it. The United States population is too diverse for a one-size-fits-all healthcare system.
With unique populations such as preterms, injuries and accidental deaths of our young people which brings down life expectancy, ethnic diversity, and people having multiple medical problems, it is understandable where the money goes and how we stack up with the rest of the world, especially Europe and Canada.