IN the midst of criticism of America's healthcare system over the last decade, Americans held fast to the belief that if you have to be sick, this country is the best place to be. Faced with casual comparisons with Canada or Europe, many were ready with counterarguments: Americans don't have to wait months for bypass surgery, like they do in Canada. Doctors here aren't constrained by government interference. Unlike in England, American patients receive costly treatments such as hemodialysis even if they are old and infirm.
But now, the knee-jerk attitude that the U.S. is the best place on earth to be sick, fueled by the reputations of great institutions like the Mayo Clinic and by America's leadership in drug and technology development, is beginning to be challenged by rigorous international comparisons. There is increasing evidence that, despite justified pride in individual institutions and medical breakthroughs, the world's biggest medical spender isn't buying its citizens the longest, healthiest lives in the world.
It's not just moviemakers and comics saying so. The dire message that the U.S. healthcare system is, by some measures, an also-ran on the worldwide stage is being delivered by doctors, researchers -- even insurance industry giants.
On screen, slamming U.S. medical care is coming of age with Michael Moore's documentary "Sicko." Through the eyes of people who have faced healthcare catastrophes, he tells graphic stories of the problems with America's system. The movie has received Oprah hype, the ear of some in the California state legislature and the support of several national healthcare advocacy groups weeks before its June 29 release.
Considerably more sobering are the warnings from an official at the National Institutes of Health, who declared in the May 16 issue of the Journal of the American Medical Assn. that the U.S. healthcare system is "a dysfunctional mess." So unusual is it for a government official to speak out against the U.S. system that Dr. Ezekiel Emanuel, chairman of the department of ethics at the NIH, emphasizes a point made in print during a conversation. "I'm speaking for myself, not for the NIH or the Bush administration," he says.
As early as 2000, the World Health Organization made the first attempt at ranking all the world's healthcare systems. The U.S. came in 37th out of 190 nations in the provision of healthcare. (France, according to the June 2000 report, was first.) The report was criticized for using inconsistent comparison measures and for failing to note that some countries deny expensive care to very sick patients. Americans could still reasonably cling to their long-held pride.
But in 2006, the Organization for Economic Cooperation and Development, an international organization that aims to lift living standards by promoting economic development, compared health spending and health statistics in its 30 member nations. Its report was more detailed than the WHO rankings, and had more controlled and consistent measures. The data, taken more seriously than the WHO rankings, left Americans with little to brag about.
And Emanuel's recent commentary was published the day after another report released by the Commonwealth Fund, which supports independent research into healthcare issues, found the United States at the bottom among six industrialized nations on measures of safe and coordinated care.
If all of that doesn't seem damning enough, insurance provider UnitedHealthcare Group took out a full-page ad in the Wall Street Journal on March 19 declaring: "The health care system isn't healthy.... A system that was designed to make you feel better often just makes things worse." One of the very industry giants that critics point to as a cause of the problem was defensively pointing back.
Amid stacks of reports, all with wonky measures of access, equity, efficiency and medical outcomes, two statistics stand out. The U.S. spends more on medical care than any other nation, and gets far less for it than many countries. According to the 2006 analysis by the Organization for Economic Cooperation and Development, the U.S. spends an annual $6,102 per person -- more than any other country and more than twice the average of $2,571. Yet Americans have the 22nd highest life expectancy among those nations at 77.2 years compared with the analysis' average of 77.8 years. People in Japan, the world leader in longevity, live an average of 81.8 years.
The report also found that the United States had about 2.5 times the average years of potential life lost due to diabetes: 101 years per 1,000 people compared with the average of 39 years per 1,000 people. Americans had fewer practicing physicians, or 2.4 per 1,000 people, than the average of 3 per 1,000 people. Infant mortality rates have been falling in the U.S., but are still higher, at 6.9 deaths per 1,000 live births, compared with less than 3.5 deaths per 1,000 live births in Japan, Iceland, Sweden, Norway and Finland.
"If a politician declares that the United States has the best healthcare system in the world today, he or she looks clueless rather than patriotic or authoritative," Emanuel wrote in the recent JAMA commentary.
Beacons of excellence
The healthcare picture is certainly not all bad. Emanuel knows, for example, that as an NIH employee, he works for the premier medical research institution in the world. Americans' penchant for raising awareness, consciousness and money have helped the country shine in breast cancer treatment, preventive measures like colonoscopies and world-class institutions like the Joslin Diabetes Center. And America leads the world in the development of new drugs, in part, the pharmaceutical industry says, because there are no constraints here on what the industry can charge for patented medications.
The examples of excellence, of flat-out "best-in-the-world" care, help explain why Andrew Speaker, the Atlanta lawyer who took intercontinental flights knowing he had drug-resistant tuberculosis, risked worldwide shame to get to Denver's National Jewish Medical and Research Center, and why he didn't just stay put in Italy, No. 2 on the WHO's rankings of best health systems.
America's medical system is nothing if not spotty -- and care for rare, drug-resistant TB is one of its spots of excellence. "It's true, there are pockets that are great," says Emanuel.
Speaker no doubt erred in timing his trip and choosing his mode of transportation, but he may well have been justified in believing he should get his sick lungs to Colorado.
That's because after tuberculosis began to succumb to the wonders of antibiotics in the 1960s, most sanitariums closed. The Denver center continued to treat tuberculosis, and it was poised with singular expertise as a multi-drug-resistant strain took hold over the last decade. National Jewish became the nation's de facto referral center as well as a worldwide consultant for patients with the disease. Its surgeons, radiologists, clinicians and laboratories became the most experienced and sophisticated in the nation and world in treating the disorder.
There are certainly other pockets of greatness in U.S. healthcare, both within institutions and for specific diseases. Wealthy people come from all over the world to go to the Mayo Clinic, Johns Hopkins Hospital, Massachusetts General Hospital and others.
Breast cancer survival rates are highest in the United States, compared with Britain, Canada, Australia and New Zealand, according to a 2004 study by the Commonwealth Fund. The U.S. holds its own in other cancers as well. And a higher percentage of American patients received some common cancer preventive measures compared with the other five nations in the most recent Commonwealth Fund study. "We're first on Pap tests and mammograms," says Karen Davis, president of the fund and lead author of the study.
Slightly fewer Americans than Canadians die after a heart attack, according to a 2004 study in the journal Circulation that reported that five-year mortality rates were 19.6% for American patients compared with 21.4% among Canadians. Although the study didn't explain why, it was the first to show an American advantage between the two countries.
Far too many gaps
For all the sources of pride, the U.S.' overall healthcare delivery system has enough gaps to make patients feel they can't quite count on getting the best across the board.
For starters, the American system doesn't measure up worldwide in controlling chronic diseases, such as diabetes or hypertension. Payment systems reward doctors for doing procedures, not for managing those chronic conditions, so a world-class center -- like Boston's Joslin Diabetes Center, which is supported by philanthropy -- stands in stark contrast to results seen by regular doctors treating the disease in average patients.
Kidney disease patients on dialysis have a higher risk of death in the United States. By an act of Congress in 1972, all end-stage renal disease is covered by Medicare, even for patients younger than 65. But because of Medicare funding cuts, patients on dialysis receive less time on dialysis than patients in Europe and Japan. That helps explain why Americans on kidney dialysis have a mortality rate of 23% compared with 15% in Europe and 9% in Japan, according to a May 2002 report in JAMA.
Probably the area in which the U.S. uniquely falters by comparison with developed nations is in assuring that anyone who is sick can receive care. The Commonwealth Fund study found that half of Americans didn't fill a prescription or skipped a medical test because of cost, compared with 13% in Britain; and 26% went to an emergency room for a condition that could have been treated by a regular doctor, compared with 6% in Germany.
"People with unlimited amounts of money can fly to the Mayo Clinic, or Johns Hopkins or the Mass. General [three top-rated U.S. hospitals]," says Emanuel. "But for the average person, that's not the case."
That's the rub -- treating average, chronic diseases in the average masses. Insured or not insured, Americans can't always count on the best, the most appropriate, the most error-free, or the most coordinated care.
Stories of missteps have entered the collective consciousness. A doctor operates on the wrong leg, a nurse hangs the wrong IV medication, clinicians don't wash their hands. Such events fuel the belief that the system is broken.
A June 2006 survey by the Commonwealth Fund found that 75% of 1,000 adults questioned thought the U.S. healthcare system needs fundamental change or complete rebuilding. Respondents were concerned about costs, about getting timely appointments when they needed care and about paperwork complexity. Forty-two percent said they had had duplicate tests ordered, had received care that involved a mistake, believed their doctor recommended unnecessary care, or were frustrated that one of their caregivers failed to provide needed medical information to other clinicians.
Insurance is key
There's plenty of blame to go around, some of it landing squarely on the shoulders of people who eat too much and refuse to get off the couch.
But the biggest reason for the failure of the nation to measure up on the world stage can be chalked up to the fact that 46 million people in the U.S. lack insurance, meaning they don't have ready access to a doctor and often get healthcare later in the course of disease. All other industrialized countries cover all their people. "The main thing that stands out is that we're the only country that doesn't have a universal health insurance system," says Davis, author of the foundation's most recent study, which compared the U.S. with Australia, Canada, Germany, New Zealand and Britain. "So problems of access, cost, failure to get needed care are easily explained."
That doesn't explain why the American medical system fails to do some fairly simple things right, she says. "Like diabetes and hypertension. Those aren't as glamorous as things you go to the Mayo Clinic for," Davis says. "But controlling them makes a huge difference in whether someone is going to have a stroke or a heart attack."
One reason why those disorders aren't well controlled in American patients, she says, is that insurance payments reward physicians more for procedures such as heart surgery and leg amputations than for preventing those complications.
Another reason for America's poor showing defies explanation. As much as Americans pride themselves on innovation and change, the U.S. healthcare system is notoriously behind the curve in information technology. In the political debate over how to change the system, there is near universal agreement that American medicine needs to make progress in this area. Yet it isn't happening. Davis speculates that, in countries with universal healthcare, the government pays for or coordinates computerized systems. "In the U.K., the government just paid for it," she says. "In Denmark, physicians pay for their own software, but the government provides the central record-keeping."
There is no such central medical record-keeping in the U.S., and most individual practices still have floor-to-ceiling shelves full of folders with hand-written records. "Only 18% of American physicians said they sent computerized medical reminders to patients," Davis says. That compares with 93% of physicians in New Zealand and 83% in the United Kingdom. In Britain, 88% of physicians can click a mouse and print out a list of all medications an individual patient takes. In the United States, only 37% of doctors can perform that technological feat.
That means fewer American patients get nudged to come in for a blood pressure check, and fewer physicians get a computer-generated safety check on potentially toxic drug interactions.
It will take more than a round of outrage over a heavily promoted documentary to make change happen.
But "Sicko's" emotional slap in the face might be a conversation starter, similar to Jonathan Cohn's recent book, "Sick." Subtitled "The Untold Story of America's Health Care Crisis -- and the People Who Pay the Price," the book has been hailed as an eye-opening look at the failures of the nation's system.
Like a heavy drinker standing up at an AA meeting and declaring, "
Many of the major presidential candidates have proposals for improving America's healthcare system -- widely divergent in depth, scope and payment schemes, but reflecting the understanding that the problems can't be ignored. Audiences will no doubt get riled up when they see, in "Sicko," an unemployed carpenter deciding between having his severed ring finger reattached for $12,000 or his severed middle finger, for $60,000. They may look enviously at the systems Moore shows in Canada, France -- even Cuba -- where everyone is assured healthcare.
Hundreds of members of the California Nurses Assn. showed up last Tuesday, chanting "Sicko, Sicko, Sicko," on the Capitol lawn in Sacramento as Moore spoke to legislators about universal coverage. Oprah, who called the movie the one film her audience must see this year, has a "Sicko" message board.
Unfortunately, unlike emotional documentaries and comedic punch lines, political solutions to America's healthcare problems are complicated, controversial and deadly dull. "A movie like 'Sicko' [is an] important way of communicating that the system is not working, and that it takes a human toll," says Emanuel. The documentary is packed with dramatic human stories of how the healthcare system has failed, and harmed, people. Such stories trigger outrage -- but don't point to solutions.
"The public has to be willing to engage in more than stories," says Emanuel. "Solution language is more dry. It's abstract policy talk." For anything to change, he suggests, Americans have to stay awake and pay attention to what the policy wonks are saying.
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How we measure up
The United States recently ranked last among six industrialized nations on measures of safe and coordinated care, according to the Commonwealth Fund, although it spent the most per person.
*--* COUNTRY AUSTRALIA CANADA GERMANY NEW ZEALAND BRITAIN U.S. Overall ranking 3.5 5 2 3.5 1 6 (2007) Quality of care 4 6 2.5 2.5 1 5 Access 3 5 1 2 4 6 Efficiency 4 5 3 2 1 6 Equity 2 5 4 3 1 6 Healthy lives 1 3 2 4.5 4.5 6 Health expenditures per capita (2004) $2,876* $3,165 $3,005* $2,083 $2,546 $6,102
*2003 data; Source: The Commonwealth Fund
Overall rankings on safe and coordinated healthcare as calculated by the Commonwealth Fund:
3.5 ...New Zealand
6 ...United States
Healthcare: where the candidates stand
Most 2008 presidential candidates address healthcare on their websites, but the amount of detail varies considerably. Here's some basic information from the sites of candidates -- and potential candidates.
Would "expand health insurance for children and relieve families and businesses of the burden of expensive catastrophic cases."
Hillary Rodham Clinton
www.hillaryclinton.comSays "America is ready for universal health care."
www.chrisdodd.comWould "ensure universal affordable quality coverage by creating a Health Care General Fund (HCGF) to serve all Americans. Then, require employers to either cover their employees or contribute to the fund."
johnedwards.comOffers a detailed plan for "universal health care through shared responsibility."
www.gravel2008.usAdvocates "a universal health-care voucher program in which the federal government would issue annual health care vouchers to Americans based on their projected needs."
kucinich.usSupports "a plan for a universal single payer, not for profit healthcare system."
www.barackobama.comGives a plan for "providing affordable, comprehensive and portable health coverage for every American" and "modernizing the U.S. health care system."
www.richardsonforpresident.comWould "open up existing sources of affordable, portable coverage to more Americans."
Advocates "increased consumer choice, consumer control and real competition."
www.gilmoreforpresident.comHealthcare isn't listed on "The Issues" portion of his site.
Healthcare isn't listed on the "On the Issues" portion of his site.
The site doesn't have an "issues" component.
Doesn't list healthcare under "Issues."
Doesn't list healthcare under "On the Issues."
Doesn't list healthcare under "Issues."
Recommends "extending health insurance to all Americans, not through a government program or new taxes, but through market reforms."
Says "tort reform and immigration enforcement would save the system billions."
www.tommy2008.comWould place "the uninsured in state-by-state insurable pools, allowing private insurers to bid on their coverage."
For quotes and voting records from various candidates, go to Ontheissues.org.