Part 1 (857 words)
“There are those that look at things the way they are, and ask why? I dream of things that never were, and ask why not?”
Those over a certain age will remember this phrase from then Presidential-candidate Robert Kennedy’s 1968 speech. I use it here purposefully, to begin a series on health systems and health. We hear repeatedly – I’ve said this – that our system is inadequate, expensive, unresponsive; a Rube Goldberg system that results in high-cost and poor outcomes. This price is not just in dollars: it is lives lost, potential wasted, opportunities destroyed.
I have been extremely critical of the so-called “Repeal and Replace” or “Just Replace” process that Representative Ryan, Senator McConnell and Mr. Trump attempted to institute; that it unwound is a plus for our citizens. This does not mean that what we have in the Affordable Care Act (ACA) is optimal, or even just ok. Thus, I dream of what could be and say: Why not?
What is Health?
More than the absence of disease, health has been defined – certainly since the end of WW II and the World Health Organization’s founding – as:
“…a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”
Using this definition, health is a larger political project, not only the responsibility of doctors and nurses; it is a project, I argue, in which we are failing.
We can likely agree upon the meaning of “physical well-being”: We are well fed but not obese; have access to adequate and appropriate health services so that our “genetic life potential” – the potential we have given the good, as well as bad, genes inherited from our families – is met; can access high quality, patient/family centered curative health care when something goes wrong; and know that our end-of-life wishes will be met, because we have had discussions about them with family and our physician.
Mental and social well-being may be a bit more difficult. In his 1941 State of the Union Speech, President Roosevelt enumerated the four freedoms: Freedom of speech, freedom of worship, freedom from want, and freedom from fear. These are – even if imperfect – elements needed for the components of health that relate to mental and social well-being.
Do we, in the United States and with our presently-existing health system, meet these basic standards? It is not enough to simply reply ‘yes’ or ‘no’; there are data upon which we are obliged to base the response. These data come from national and international health organizations – the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), for example; we will not discuss ‘fake facts’ or ‘alt-facts’ here. There is a physical reality to our world, whether or not we wish or choose to believe it; the information below belongs to the really-existing world. Let us now review some of the information needed to answer the question posed: Firstly, do we meet the basic standard of health?
There are multiple methods to evaluate physical well-being, revolving around what are termed indexed deaths: the number of deaths per 100,000 population, per 100,000 live births, or even per 1,000 live births. This methodology allows comparison of different countries and their health systems. Because of reporting and analysis delays, this kind of statistical data always lags one or two years; thus, most of the data here is from 2014 and 2015.
The death rate for women giving birth – indexed per 100,000 live births – should be low, because women of child-bearing age are usually young and healthy. For 2015, the last year for which data are presently available, the global average was 216 maternal deaths per 100,000 births. The maternal death rate is worst on the African Continent, with an average of 542 deaths. In the Americas, Canada is the best, with 7 deaths, followed by the United States, with 14, twice as many maternal deaths per year.
Comparing ourselves with our peers in the European Union – spending an average of 10% of their gross domestic product (GDP) on health – our numbers look even worse. Thirty-four countries – including Kazakhstan and others that are in Europe but not part of the EU – have maternal death rates lower than ours. Indeed, of the 50 countries designated by the WHO as “Europe” for the purposes of evaluation of maternal deaths, 14 of the 16 worse than the US are former Soviet Republics or allied states.
We spend more than any other country in the world on health care (2014: $ 9,403 per person), yet for the Maternal Death metric, we are bested by Canada (2014: $ 5,300 per person). Even though we spend about 65% more on health care – as a percentage of our national economy (GDP) than do our Canadian neighbors (Canada – 10.4% versus US 17.1% in 2014), we do worse on this metric than do they, and than do 34 of 50 countries in Europe who spend less than do we on health, both as a percentage of GDP and per capita (2014: $ 3,612 for the EU; $ 4,135 for those in the Euro Zone).
More on this in the next column.
PART 2 (1,047 words)
(Continued from the last column)
Childhood Mortality – Deaths Before 5 Years of Age
The health of young children depends upon the adults caring for them. Children need love, affection, food, shelter, preventive health care, and safety; when ill, they need medical care. One method of determining if these elements are present is to measure the number of children who die before they reach 5 years of age, indexed per 1,000 live births.
Using data from 2015, in the Americas, Canada has the best childhood mortality rate, with 4.9 deaths before 5 years of age per 1,000 live births, followed by Cuba with 5.5 and then by the United States with 6.5. Cuba, embargoed and blockaded for decades, has a childhood mortality rate lower than ours and one of the best in the hemisphere; this shows what a country can do with limited resources if those resources are strategically used with an end – in this case protecting children – in mind.
If we look at the WHO European Area, 35 of 53 countries have childhood mortality rates lower than ours; Luxemburg and Iceland are the best, with rates of 1.9 and 2, respectively. Of the remaining 18 with higher rates of childhood death, all but one (Turkey) are former Soviet Republics or allied states. Once again, we spend more per person on health care than any of these countries.
Life Expectancy at Birth
Perhaps the most important indicator of a country and its’ health and social systems – not just hospitals and doctors, but things that provide for mental and social well-being as well – is life expectancy at birth. The numbers given are “healthy life expectancy”: that is, years of life minus those years with chronic diseases. The numbers in parenthesis are the life expectancy at birth, not excluding the years with chronic disease.
Here again, we are not the best: In 2015, our life expectancy at birth for both genders was 69.1 (79) years; Cuba was 69.2 (80); Costa Rica 69.8 (80); Germany 71.3 (81); Israel 72.8 (82), Italy 72.8 (83); the highest was Japan at 74.9 (84). It appears that the last 10 years of our lives, no matter where we live, are marked by decline.
Amenable mortality refers to diseases that, if untreated, will cause early death; proper and timely treatment prevents death. The WHO definition of amenable mortality is both specific and the one used throughout the world. The diseases that fall into the ‘amenable to treatment’ category include tuberculosis, measles, diabetes, hypertension, coronary artery disease, pneumonia, peptic ulcer disease, influenza, appendicitis and 24 others. In a 2011 report, using data from 2006 – 2007, France was the best, with about 58 amenable deaths per 100,000 population between the ages of 0 – 74 years; we came in last, number 16 of 16, with about 95 amenable deaths.
More recently, using 2015 data, the probability of dying from diseases in the ‘amenable to treatment’ category (cardiovascular disease, cancer, diabetes, chronic respiratory disease) between 30 and 70 years of age – a slightly different way of looking at the data than noted above – for those living in the US was 13.6%; for every 100 people with these diseases, between the ages of 30 and 70 years about 14 will die. This makes us the 6th best in the Americas, bested by Canada, Costa Rica, Chile, Peru, and Ecuador. When comparing ourselves to our European peers, of 50 European nations, we are bested by 22, and those with worse performance are all – the one exception being Turkey – former Soviet Republics or allied states. In this way of looking at health, Iceland is the best in Europe with an amenable mortality for these diseases of 8.3%; the only other country in the world this good is the Republic of Korea, also at 8.3%.
Homicide, the intentional killing of one human by another, is another form of ‘amenable mortality’, although not reported as such. It is clearly impacted by multiple influences, such as a society in chaos, drugs and alcohol, weapon availability, and so forth. While about 80% of homicide victims are men, women are the most common victims of intimate partner homicide.
In the Americas, we have the 6th best mortality rate due to homicide, bested by Canada, Chile, Argentina, Antigua, and Cuba. Our rate is 5.3 deaths per 100,000 population, that of Canada is 1.8. The regional average is 18.6, heavily influenced by countries in which our country has had significant police and military involvement – Honduras (85), El Salvador (63.2), Columbia (48.8), Guatemala (36.2).
Of 50 European countries, 8 have homicide rates higher than ours, all former Soviet Republics or allied states.
Mental and Social Well-Being
Freedom of speech, freedom of worship, freedom from want, and freedom from fear. These imperfect descriptors of the components of health relating to mental and social well-being are never-the-less of importance. Asking how we might meet them requires us to ask how we define mental and social well-being.
Mental Well-Being is, according to the National Association of Social Workers, a state of mind in which mental health predominates. Qualities like gratitude, joy, forgiveness, humility, optimism, curiosity, and a sense of humor are all signs that we are well mentally. The American Psychiatric Association notes that mental health involves the ability to be productive, have healthy relationships, and adapt to change and cope with adversity.
Related to Social Well-Being, the WHO comments in a 2008 Report: “The social determinants of health…are the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life. These forces and systems include economic policies and systems, development agendas, social norms, social policies and political systems.”
Our country is not a high performer with either mental or social well-being. The WHO definition notes that social well-being includes housing, food security, early childhood development, education, employment/job security, income and income distribution, presence or absence of social exclusion, and gender equality; we do not do well with these metrics of social well-being. Housing and food insecurity exists, we do not have centers/pre-school for children that need them, education is – to say the least – an ongoing problem, we have one of the most unequal income distributions in the world, and gender inequality/social exclusion remain a serious problem.
PART 3 (733 words)
(Continued from the last column)
What Does This All Mean?
The summarized data are a broad critique of the Health System of the United States, a system in which my adult life has been spent; I do not relate these facts with joy. Even in the Americas, we are rarely in second place, more likely 5th or 6th or 7th place. Compared to our European peers – a more appropriate comparison – we are worse, 34th or lower.
Does this mean we do nothing right? Of course not! We remain a research/development power-house. We do remarkable things remarkably well; it is just that routine care, things that really matter – preventive medicine – where we fall down. Unfortunately, we spend more money to be 2nd best, or 34th best, than does any country in the world.
Why? Why is it acceptable that, in some of our cities, or in rural West Virginia, children die at rates similar to some of the worst parts of Africa? How do we call ourselves civilized, humane, kind, and loving, yet allow this to occur? How do we look in the mirror each morning, knowing that our unwillingness to organize health services – this is NOT about money, there is more than enough money – simply ORGANIZE health services in an efficient manner will cost our children, our brothers and sisters, their lives? Since when did we become a country that doesn’t care about our neighbors? A country that would rather see neighbors suffer than receive help from our Government, the Government of the United States?
We are surrounded by excellent models of health care delivery, they just happen to be local or regional, rather than national. We will climb out of 34th place, or 16th place – depending upon which metric you look at – but, to do so, we first must look at our starting point and determine rationally – not emotionally – how we got here and then determine what we need to do to improve.
With this in mind, let us look at the broad organization of our health system, compared to those of our peers, and begin the discussion of what might be a better method of organization.
Organization of Health Systems
The UK’s National Health System (NHS)
Ranked # 1 in the Commonwealth Fund’s 2014 study of 11 industrialized countries, Britain’s NHS spends 9.6% of its GDP on health care (public and private funds). The metrics used to measure this ranking were quality of and access to care, efficiency of the health system, equity of care, and “healthy lives”; the latter is a measure of mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60. While there has been criticism that the “trade off” for the NHS is long waits for health care by specialists, this is not the case, as noted in the 2014 Commonwealth Study of Health systems. There is, at this time, a vigorous discussion on whether the level of funding for the NHS is appropriate.
The outcome measures – life expectancy and infant mortality – are roughly the same as in the US and lag the high performers, such as Japan. Of 191 countries evaluated for health system performance by the WHO, the UK ranked 18th while the United States ranked 37th.
The UK’s NHS, launched in 1948, was born of the ideal that good healthcare should be available to all, regardless of income. Everyone in the UK is covered and, as the system is financed from taxes, care is provided without additional payment, with the exception of some eye and dental services. The NHS is managed by the Department of Health, working with 27 agencies and public bodies.
At its founding, hospitals, pharmacists, physicians, nurses, opticians, and dentists were all brought under the NHS umbrella; since the 1990s, the system has been decentralized in an attempt to improve local control. Presently most primary care practices are privately owned, while most hospitals are publically owned.
About 11% of the UK population buys supplementary insurance for more rapid or convenient access; cost sharing (co-payments) is almost entirely related to prescription drugs (maximum of $ 147 per year) and medical appliances. The poor, elderly, pregnant and children are exempt from drug cost-sharing.
Although not without challenges, this system is internationally recognized as an excellent one. The per capita costs of the NHS are about one-third the cost of the US health system (2011: $ 3,405 versus $ 8,508).
PART 4 (892 words)
(Continued from Last Column)
The Swedish National Health System
Ranked # 3 in the Commonwealth Fund analysis, the Swedish health system is an example of shared financing and governance. The system, consuming 11% of Sweden’s GDP, is funded by national, county and municipal taxes – primarily general tax revenue raised by the counties; about 1% of expenditures are covered by private insurance in the form of a supplement that allows quicker access to specialists and elective treatments. There are fees paid by patients, but these are capped at $ 123 (health services) and $ 246 (drugs) per person annually; cost-sharing exemptions exist for people under 18, the elderly, and pregnant women.
Coverage is universal and automatic for all legal residents; undocumented adults can receive unsubsidized care, but asylum seeking and undocumented children have full access to health care services. While the national government sets standards, responsibility for care provision rests with county and municipal governing bodies. There is no nationally defined benefits package and, because organizing and financing resides with the counties and municipalities, services vary throughout the country; medications and dental care are subsidized. Mental health care is an integrated part of the NHS. Long-term care is also a part of the Swedish NHS, although patients incur a fee of up to $ 199 per month for these services; home care is prioritized over institutional care.
Primary care clinics are mixed public (60%) and private (40%); hospitals are almost all public, although there are some private institutions, both for-profit and not-for-profit. Innovation related to quality, more rapid access to specialty care, and patient’s rights are priorities. The per capita health expenditure for Sweden is a little less than half that of the US (2011: $ 3,925 versus $ 8,508).
The French National Health System
The French system ranked # 9 in the Commonwealth Fund’s 2014 study. The major reasons for this low ranking were difficult access, timeliness of care, lack of patient centeredness, and coordination and effectiveness of care. Eleven percent of the French GDP is consumed by health care, of which 76% is publically financed; the Ministry of Social Affairs, Health, and Women’s Rights defines national health strategy and, increasingly, controls health expenditures.
Coverage, universal and compulsory, is provided all citizens by non-competitive health insurance. Insurance eligibility is through work or granted as a benefit; the State covers insurance costs for the unemployed, and undocumented immigrants applying for residence; visitors not from the European Union are covered only for emergency care. Supplementary insurance (Voluntary Health Insurance) covers co-payments, which are minimal, ranging between $ 0.60 for medications, to $ 22 for each hospital day.
Primary care clinics are private, while most hospitals are public; there are some private for-profit hospitals. Mental health services as well as end of life and medical costs of long term care are covered; families are responsible for the housing costs of long term care, about $ 1,809 per month. Care is safe and France has the lowest rate of preventable deaths of all countries studied. Per capita expenditures in France (2011: $ 4,118) were about half that of the United States (2011: $ 8,508).
The Dutch National Health System
Ranked # 5 in the 2014 Commonwealth Study, the Dutch system is of interest as it is more like our present ACA-based system than the French, Swedish or British systems.
The system is run through the Ministry of Health with private insurance universally mandated; the insurance companies are both subsidized and regulated by the national government, and may not reject anyone who applies. The system is financed through payroll taxes and general tax revenues; the insurance premiums are community-rated, meaning that everyone pays the same premium, regardless of age or health status. Even for undocumented immigrants, acute care and obstetric care are funded by the Dutch people; otherwise these patients are obliged to pay out of pocket. There are separate policies for asylum seekers; permanent residents and visitors must purchase coverage unless their home insurance policies cover them in the Netherlands.
Benefit packages are set by statute; 84% of the Dutch buy supplementary insurance for co-payments as well as for items not covered by the by the standard package, including dental care, alternative medicine, eyeglasses, and contraceptives. There is no cap on co-payments, but most people do not pay over $ 455 per year; primary and pediatric care are exempt from co-payments and there are premium subsidies for low income citizens.
The Dutch Health System has the third lowest rate of amenable mortality, and only 3% of the population needing specialty care waited 2 months or longer for the appointment, tying for best performer with Switzerland. The Dutch are the third best performers – behind Germany and New Zealand – for getting same-day/next-day appointment when sick.
Primary care practices are mostly private as are most hospitals. There is no mandatory registration with a primary care physician (PCP), although most Dutch do this anyway; a referral from the PCP is required for specialist care. Mental health care is provided. A significant portion of long term care, uninsurable medical risk, and costs that are “not reasonable for an individual to bear” are funded through the Long-Term Care Act. The Dutch spend 12% of their GDP on healthcare; most of this comes from public financing. In 2011, the Dutch spent $ 5,099 per capita annually as compared to the US $ 8,508.
Part 5 – END (963 words)
(Continued from the last column)
The US National Health System
We ‘know’ our health system simply because we live in our United States. What follows relates to the US health system after the implementation of the ACA; I will not delve into what would have befallen us had this law been repealed, as enough ink has been spent on that for the time being.
Ours is a mixed public and private system, with the US Government providing Medicare for those 65 and older, and for some disabled; Medicaid, a partnership between State and Federal governments covers some low-income citizens and with the expansion is now the insurer for many more of us. Private insurance is available through State-level exchanges or individual policies, with income-based subsidies to make this affordable.
Medicare is funded by payroll taxes, insurance premiums, and federal tax revenue; Medicaid through federal and state taxes. Private voluntary insurance covers about 66% of our population; the Medicare supplement is also through private insurance.
While co-payments are ‘capped, it is at a high level: in 2015, individual value was $ 6,600 and for families it was $ 13,200.
The ACA increased access to health services and attempted to improve quality; it was a first step, not the journey’s termination. Under the ACA, all health plans are required to cover 10 essential categories of health services: ambulatory patient services; emergency services; hospitalization; maternity and newborn care; mental health services and substance use disorder treatment; prescription drugs; rehabilitative services and devices; laboratory services; preventive and wellness services and chronic disease management; and pediatric services, including dental and vision care.
Hospitals are paid for services through a number of methods: bundled, per-case, per-service, or per-diem payment. Physicians are paid separately, by utilizing one of several thousand codes; access to mental health care, an essential benefit, was improved with the ACA. Long-term care remains a problem as families must ‘spend down’ all or most of their assets to qualify for assistance, usually Medicaid.
The US per capita health expenditure was $ 8,508 in 2011 and hit $ 10,345 in 2016; 17.8% of our $ 3.2 trillion GDP in 2015 is consumed on health care. In 2014 33 million of us (10.4% of the US population) were uninsured; this should decrease to about 9 million by 2018 if the ACA is maintained. While not perfect, it is light years ahead of where we were in 2009.
Not-withstanding our expenditures and the decreasing number of uninsured, our outcome metrics are some of the worst in the industrialized world. We rank last (# 11 of 11) in healthy lives (mortality amenable to medical care, infant mortality, and healthy life expectancy at age 60), equity (inability to get appropriate care because of cost), efficiency (administrative cost, avoidable Emergency Room use, laboratory testing), and access; we are in the middle of the pack as regards quality.
What is to be Done?
Toward a Patient and Family Centered, High Quality/Safe Health System
The data we have reviewed suggests that our health system is inadequate in many ways. We are unsatisfactory in terms of quality/safety, equity, and meeting the needs of our citizens. A system failing to meet the needs of the most vulnerable of its’ citizens will likely fail most citizens.
While there is no one system which, if implemented, will make everything better, learning from our European and Canadian peers, adopting best practices implemented at home (regionally) and abroad, and focusing on the experiences and outcomes of the most vulnerable populations will help make us the best in the world. What might this look like?
We could make changes to the ACA in which a single payer option – Medicare for All – becomes available. Incorporating other elements of the Dutch system, for example, would bring us along nicely in our quest to improve our health system.
My system, were I able to begin this process again, would be a single payer system funded through progressive income taxes and fees on financial transactions. Drug prices would be decreased to EU levels through negotiation; administrative costs would decrease to between $ 0.05 and $ 0.07 per premium dollar because we would eliminate the armies of people insurance companies hire to try to NOT pay and the armies hospitals and physicians hire to ensure they ARE paid. For-profit insurance companies could be a part of the market for supplemental insurance, if needed, for co-payments.
Women’s health – including birth control and, when needed, abortion – would be covered; we would minimize abortion through sex education and birth control. We must understand that prohibiting abortion means only one thing: women will die due to back-street abortions. This issue must be handled sensitively and compassionately.
There would be no issue with pre-existing conditions limiting access to the single payer system because our citizens would be universally and automatically enrolled. The services covered and fee schedules would require discussion and would, no doubt, be contentious. Long-term care and mental health would be covered and every attempt would be made to ensure that long-term care is provided in the home rather than in nursing homes.
We would begin a national discussion on end-of-life care, sex education for our adolescents, and how to be healthy, not just “disease-free”. How to be healthy includes a discussion of our eating and exercise habits, on the safety of our streets, on our infrastructure including – remember Flint, Michigan – our water and transport systems.
These are very difficult issues; we will not agree with one another on everything. As long as we can see, really see, the decency and humanity in those with whom we disagree, we will be ok. Remember, we are Americans. We will get to the right answer after trying all of the wrong ones. I think we have tried those, let’s get this right.