8th January 2008 The new year started controversially. With my colleague Ellen Nolte we have been working for some time on the concept of avoidable mortality – identifying deaths that should not occur if health systems are working well. We all know that the US health care system is not working, but how bad is it? In a paper published in Health Affairs, we calculated the death rate from these causes in 19 high income countries, looking at how they had changed between the late 1990s and the early years of the 21st century. Most countries did well, with falls in death rates of about 17%. There was, however, one not entirely unexpected exception – the USA. It had improved hardly at all, going from near the bottom of the list to the very bottom. Many of the reasons are obvious:
a) the lack of universal coverage,. There is now a wealth of evidence that people who are without coverage delay seeking timely care and as a result are sicker when they do make it, often quite inappropriately to Emergency Rooms. There is also a lot of evidence that people with insurance face sever barriers to care because of the many obstacles put in their way by their payers.
b) a fragmented system, with high tech specialist care prioritised over family medicine. Barbara Starfield from Hopkins has been showing the problems this creates for the US for years
c) cost of drugs - the Commonwealth Fund has shown how US citizens are much less likely than those in other countries to fill prescriptions. One factor is the complexity of some pharmaceutical benefit plans such as Medicare. Another is the very much higher cost of drugs in the US than elsewhere because the US government is unwilling to impose price controls like almost everyone else does.
d) the sheer cost of getting care because of the inefficiency of the system. Multiple payers, high profits by payers and providers, the cost of malpractice insurance etc. all combine to make care far more expensive than in Europe, meaning that in a system where there are no guarantees of coverage, people cannot afford care.
Unsurprisingly, our findings revealed markedly differing views (with intensive discussions on the bulletin boards). Many people felt that our findings confirmed their own experiences. Given their comments, Michael Moore could make a sequence of sequels to his film Sicko. However, others totally rejected our views, questioning our motives (more anti-Americanism from those awful Europeans…).
The experience of reading the blogs and online comments was fascinating but extremely depressing, as we read once again of the many stories of individuals who have been unable to get timely and effective care but also we saw the total inability of a significant number of people who are totally unable to see that, for many people, the American dream is really a nightmare.