INTRODUCTION

During the last election cycle, there was some significant discussion about health care reform. A large number of individuals queried stated that access to health care / insurance was a major concern of theirs. Indeed, prior to the economic downturn – recession ? depression ? disaster, for sure – one of the most common causes of individual bankruptcy was health care costs. Additionally, prior to the health care reform passed by Congress and signed into law by Mr. Obama, about 50 million of us were without access to health care, and despite spending more than any other country per capita on health services, our quality metrics are reasonably poor.

One might be forgiven if, over the past 18 months, all of this has been forgotten. We are more concerned, it appears, with Mr. Obama’s birth certificate, and the “socialist takeover” of our country. Indeed, if one believes the multiple news reports, there was never an issue with health care, before or during the election, and the American people are simply irritated with Mr. Obama’s government for interfering with the private sector in which medicine resides.

If, that is, one believes what are broadly termed “news reports”. In fact, reality – that evidence based entity that no amount of obfuscation can eliminate or alter – shows that we are and have been in some trouble as regards our health system. The health insurance reform act that passed in March of 2010 will not eliminate this problem, but it does go a long way toward moderating some of the worst elements facing us.

What I have done below is to draw broad outlines of the situation of the American health system prior to March 2010. Then, in the second part of this discussion, I analyze the health reform bills and the consensus bill to suggest what the face of our health system might look like in 2014. I include references so that the reader can check for him / herself whether I have interpreted the extant data with fidelity.

Finally, I have no power of prediction beyond that of any other reasonably sane human. I can no-more see into 2014 that can you. My descriptions of what might exist are based upon my reading of the bills.

WHAT DID WE LOOK LIKE BEFORE MARCH 2010 ?

Despite evidence to the contrary, strong evidence, the American health system underperforms those of many of our neighbors. It is not that we cannot do things well; that is not so. This health system episodically delivers extraordinary care – think of heart transplants and the care of individuals with severe traumatic brain injury. It is, however, the routine delivery of indicated care that is so often problematic.

While I will expand upon this below, it is not a process that is without cost. In terms of dollars per capita spent, we are the most expensive – not the best, the most expensive – in the world. This is shown in the following figures.

The first figure ( 2010/08/slide15.gif ) shows that between 1970 and 2000, for both the United States and the nations making up the Organization of Economic Cooperation and Development (OECD), as the gross Domestic Product (GDP) increases, so, too, do expenditures for health care; this might be considered almost a “law”. Of particular note is that while the slopes of the lines are approximately the same, they are offset by 2% in 1970 and 6% in 2000.

When the data are broken down by country – as shown in the next three figures labelled health expenditures and GDP per capita (1998 [ 2010/08/slide2.gif ], 2004 [ 2010/08/slide3.gif ]. 2005 [ 2010/08/slide4.gif ] ) we see that as the GDP per capita increases, the health expenditure per capita increases, as well, in an almost linear fashion. The exception is our country; for each of these plots, we are off of the curve. We spend more than would be expected based upon our GDP. If this expenditure resulted in vastly improved outcomes, we could be induced to accept it as the price for excellence. But is this so ?

While these figures might suggest that we are spending more on our citizens and doing well by them – that is, our outcomes as measured against other OECD nations are better – this does not always appear to be the case. While the data are not as bad as has been suggested, they do speak to the fact that – for whatever reason[s] – some of our quality of life outcomes ar not as good as our sister nations in the OECD.

For example, we are number 20 of 27 nations in terms of life expectancy of the total population at birth ( 2010/08/slide5.jpg ), with Japan being the best and Turkey the worst. When these data elements are separated by gender, we see that for men we are 19 of 27 ( 2010/08/slide7.jpg ), and for women we are 19 of 27 ( 2010/08/slide6.jpg ). Perhaps more disturbingly, we have the third highest infant mortality (deaths per 1,000 live births), behind only Turkey and Mexico ( 2010/08/slide8.jpg ).

While these data are of great concern, and they are part of the reason that health care reform is still needed, there are some bright spots that must not be ignored when one discusses the effectiveness of our health care system.

As one can see in the several data slides that follow, for colonic ( 2010/08/slide10.jpg ), breast ( 2010/08/slide11.jpg ), and cervical malignancies ( 2010/08/slide13.jpg ), our outcome statistics are better than many of our sister countries. Our cervical screening ( 2010/08/slide14.jpg ) and mammography rates  ( 2010/08/slide12.jpg ) and, for diabetics, retinal exam rates ( 2010/08/slide17.jpg ) are well above average for the OECD nations. Unfortunately, our hospital admission ( 2010/08/slide15.jpg ) and death rates ( 2010/08/slide16.jpg ) for asthma are quite high.

These data all speak to the fact that we can do better at prevention. It is to this, as well as improving access and reining in health costs, that the health reform was to address.

It remains to be seen if the health insurance reform that was passed will impact these outcome data in a positive manner. The questions to be addressed in part two of this discussion will relate to why – if our outcomes are poor, the costs are so high. This is as complex as one might think.

While we have superbly trained nurses, physicians, and other members of the health care team, our health care system in the United States is simply not the best in the world. There are serious problems with access, resource utilization, organization, and, as I have briefly and incompletely shown, outcome metrics.

The question we all must ask is: Is this is the best we can do ?