By Andrew Quint, M.D.
Columbia (MO) Daily Tribune, May 30, 2017
I would like to respond to Luke Davis’ recent commentary in the Tribune. Having worked as a primary care physician at Family Health Center, a federally qualified community health center, serving medically underserved patients in Columbia since 1997, I have experienced firsthand the inequality, inefficiency and warped incentives of our healthcare system.
Davis writes that treatment in a single-payer system “tends to be lower in overall quality.” For example, he cited a recent study of the Canadian health care system that found the average wait time for medically necessary treatment after seeing a specialist was 9.8 weeks. Davis’s citation of this study leaves out a critically important caveat: It was a survey of wait times for elective treatment — by definition not medically urgent care. While a longer wait time for this type of treatment is frustrating, it does not mean the Canadian system produces meaningfully lower quality care. Moreover, my uninsured patients often don’t ever get to see a specialist. One patient had a kidney stone that wouldn’t pass; he experienced pain and blood in his urine for three months. Only when he got insurance through the Affordable Care Act could I get him in to see a specialist to have the stone removed. Uninsured patients are not counted in these statistics on wait times because they often don’t even get referred to specialists.
Davis says that in the United States, “government programs and regulations also guarantee that a certain baseline level of care is provided to all residents.” This is not true unless one believes that access to an emergency room constitutes a “baseline level of care”. If you are bleeding or having a heart attack, you can go to an emergency room and be treated even if you don’t have health insurance. But emergency rooms do not provide preventative care or treat chronic diseases such as diabetes and do not provide the vast bulk of medical care that people need to avoid ending up in an emergency room with a heart attack or stroke.
The infant mortality rate in the United States is 6 per 1,000 live births; in Canada it is 4.8. Life expectancy in the United States at birth in 2012 was 81.2 years for females, 76.4 for males. In Canada it was 83.6 for females and 79.4 for males. We have higher rates of premature death for all leading causes of death than comparable countries on average. Our rates of all-cause mortality, premature death, death amenable to healthcare, and disease burden are not improving as quickly as in other comparable countries during the past 10 years. We have better short-term outcomes after treatment for certain conditions, such as 30-day mortality post-heart attack and ischemic stroke. Five-year survival rates for specific cancers (like breast and colon cancer) are higher here. But we lag behind comparable countries in prevention and other measures of quality. We have relatively higher hospital admission rates for many preventable conditions, including congestive heart failure, asthma and diabetes complications. And we have higher rates of medical errors than comparable countries.
Our per capita spending on health care is double that of other developed countries. In 2016 the United States spent $9,024 per capita on health care; Canada spent $4,506. Despite our high cost, with a few exceptions, our outcomes are generally worse than in those countries. We excel at high technology high cost care. We do not perform nearly as well on lower cost preventative care. The economic incentives in our system favor high cost medications and procedures rather than low cost educational interventions and prevention.
A colleague of mine attended a lecture on research to develop a drug to promote the growth of new blood vessels around arterial blockages. Instead of heart surgery, a patient could take this drug to grow a bypass. When it was pointed out to the speaker that exercise promotes the growth of new blood vessels around blockages, he replied “Yes, but we don’t get paid for that.”
Single-payer systems in other countries are cheaper, provide better access to care, and allow those countries to improve the financial incentives that make their health care systems more rational, with more focus on prevention of diseases and their complications.
Andrew Quint is medical director at the Family Health Center in Columbia.
