By Samuel Metz, M.D.
Anesthesiology News, June 2015
In his opinion piece (Anesthesiology News 2015;41[February]:44), Dr. S.J. Slavin takes the proverbial ax to the tree of American health care reform. And he wields it with gusto. Two assumptions animate his swing and both deserve careful attention: 1) Despite its flaws, our U.S. health care system is better than any other, and 2) foreign nations have nothing to teach us.
Such patriotic vigor is understandable. After all, America gave the world Elvis Presley, footprints on the moon and the oil depletion allowance. With such achievements, why shouldn’t we think of ourselves as world leaders in health care?
Unhappily, our success in rock ’n’ roll, technology and finance does not translate to health care. Americans pay twice as much as citizens in the average industrialized nation — our health care is the most expensive on earth. Yet our public health is a disgrace. There are 60 other countries where a pregnant woman and her baby have better chances of surviving the pregnancy.1 American diabetics are more likely to suffer a foot amputation from an untreated ulcer than are diabetics living anywhere else where you can drink the tap water.2
Our infant mortality rates are the highest in the civilized world, as Dr. Slavin noted, even when compared only with other nations that, as Dr. Slavin wrote, do not throw out premature babies and label them “miscarriages.” Our life expectancy ranks 30 to 35 in the world, even after correcting for trauma, traffic accidents, racial disparity and smoking.3 And each year, 44,000 Americans die of treatable diseases because they lack money for treatment.4 Patients in other countries might wait for elective treatment, but Americans might very well die before they get essential treatment. There’s no wait time longer than the rest of your life.
Adding insult to the injury of expensive care and dismal outcomes is that medical debt is the leading cause of personal bankruptcy in the United States. Most of those bankrupt families owned an insurance policy when the medical crisis began — so much for insurance policies protecting access to health care.5 A further insult is that “medical bankruptcy” is an exclusively American disease. In no other country will you lose your home, your foot or your life if you can’t pay for health care.
Our results look bad even when compared only with foreign nations that don’t impose government control on health care (most of them don’t). Socialized medicine or not, every other industrialized nation provides better care to more people for less money than we do. In spite of Dr. Slavin’s caution to turn our backs on these alien, socialist, non-American solutions, we should still pay attention.
Universal Health Care?
The common characteristic of nations with better results at less cost is a universal health care plan. Regardless of how it’s implemented, the administrative efficiency of universal care more than compensates for the added costs of more benefits to more people.
Example: UnitedHealthcare provides private insurance to 24 million Americans, most of them healthy enough to hold steady jobs and wealthy enough to afford high-end policies. The company spends almost 20%6 of its premium dollars paying for 37,000 administrators.7 In contrast, Taiwan’s national health care service, which also cares for 24 million people (employed and unemployed, sick and healthy, rich and poor), spends 1% of its premium dollars paying for 2,900 administrators8 — a 90% reduction in administration, enabling the health service to provide comprehensive coverage to 100% of the population.
In fact, no nation on earth spends more money than we do on health care administration, nor requires as many administrators, nor loses as much money filtering its premium dollars through insurance companies as we do.
This administrative loss doesn’t include the administrative losses of we physicians who spend $82,000 a year — each — desperately attempting to collect our payment from an insurance industry that denies 30% of all first claims.9
Parenthetically, Dr. Slavin mentions Danny Williams, the wealthy premier of Labrador, who flew to Miami for his mitral valve repair rather than stay in Canada. This story is instructive. Mr. Williams’ first option included Canadian hospitals in Ottawa and Toronto that specialize in the operation. He could then have his operation performed at public expense immediately by surgeons who enjoy international reputations.
However, Mr. Williams consulted a college friend in New Jersey who recommended a surgeon in Miami. Miami had the advantage of being close to Mr. Williams’ vacation condominium in Sarasota. Mr. Williams opted to have his operation performed by a less experienced surgeon in another country at his own expense. The operation took twice as long as expected, but Mr. Williams did just fine. He recovered uneventfully at his nearby condo.
This story may or may not reflect quality of health care in the two countries. But it certainly illustrates, as Dr. Slavin might agree, that wealthy people sometimes make medical decisions based on convenience, word-of-mouth and other nonmedical factors, just like the rest of us.
We all share Dr. Slavin’s frustration at the hideous complexity and injustice of our country’s health care system. Yet our despair should not blind us to the single most important lesson that other industrialized nations with better systems (i.e., all of them) can teach us: Start with a universal care plan, and build on that.
Health care reform does not need to be the terrifying specter that Dr. Slavin warns against. It can be the first step toward better care to more people for less money.
A tree bearing that kind of fruit deserves nurturing, not the ax.
- Kassebaum NJ, Bertozzi-Villa A, Coggeshall MS, et al. Global, regional, and national levels and causes of maternal mortality during 1990-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet. 2014;384(9947):980-1004.
- Health Care at a Glance 2009: OECD Indicators. http://www.oecd-ilibrary.org/sites/health_glance-2009-en/05/02/02/index.html?contentType=&itemId=/content/chapter/health_glance-2009-49-en&containerItemId=/content/serial/19991312&accessItemIds=/content/book/health_glance-2009-en&mimeType=text/html. Accessed May 11, 2015.
- Muenning PA, Glied SA. What changes in survival rates tell us about US health care. Health Aff. 2010;29(11):1-9. http://content.healthaffairs.org/cgi/content/abstract/hlthaff.2010.0073v1. Accessed May 11, 2015.
- Wilper AP, Woolhandler S, Lasser KE, et al. Health insurance and mortality in US adults. Am J Public Health 2009;99(12):2289-2295. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2775760. Accessed May 11, 2015.
- Himmelstein DU, Thorne D, Warren E, et al. Medical bankruptcy in the United States, 2007: results of a national study. Am J Med. 2009;122:741-746.
- Committee on Commerce, Science, and Transportation. Office of Oversight and Investigations, Majority Staff. Implementing health insurance reform: New medical loss ratio information for policymakers and consumers. Staff Report for Chairman Rockefeller, April 15, 2010, Table 1, page 4.
- http://careers.unitedhealthgroup.com/why-work-here/our-businesses/unitedhealthcare-employer-and-individual. Accessed May 11, 2015.
- Cheng TM. Reflections on the 20th anniversary of Taiwan’s single-payer national health insurance system. Health Aff. 2015;34(3):502-510.
- Furhmans V. Fights over health claims spawn a new arms race. Wall Street Journal. February 14, 2007: A1. https://www.ppocheck.com/fightsOverHealthClaims.htm. Accessed May 11, 2015.
Dr. Metz is a private practice anesthesiologist in Portland, Ore. He is a member of Physicians for a National Health Program and a founding member of Mad As Hell Doctors, both of which advocate for universal health care.