Essays
Is the US Health Care System
Really the Envy of the Civilized World? Rebuttal to Dr. Cossman
This piece
appeared in Anesthesiology News, December 2010 in slightly
different form
Author: Samuel Metz
Date: 11/01/2010
In his commentary, "The Taking" (Anesthesiology News,
October 2010), Dr. Cossman appears to make three points:
1) our current health care system is the envy of the
civilized world (untrue); 2) the new health care law is a
disaster (probably true); and 3) because government-run
health care is the only alternative, we might as well
crawl back in bed with the private health insurance
industry (definitely misleading).
In fact, although our current problems are much worse than
Dr. Cossman suggests, available solutions are more
plentiful than Dr. Cossman imagines.
Let's start with worse: Dr. Cossman's confidence that we
enjoy the "finest health care system in the world" seems
singularly ungrounded. He confuses free access to
emergency rooms with free access to health care. He is
correct that any citizen with heart failure can enter a
hospital in pulmonary edema and leave with a free heart
transplant. However, no citizen gets a free cardiac
evaluation, blood chemistry test, or medication to prevent
heart failure in the first place. Any diabetic can receive
a free amputation and wheelchair when a foot ulcer turns
necrotic, but no one gets free glucose monitoring or
insulin before necrosis begins. Any hypertensive suffering
an acute stroke gets a free stay in the intensive care
unit (no extra charge for the ventilator!), but no one
gets free blood pressure checks or antihypertensive
medications to prevent the stroke. You get the idea.
To be sure, researchers in the United States make
brilliant contributions to medical knowledge. But we do a
lousy job of applying them to care. There are more than 20
other countries where a pregnant woman and her baby are
more likely to survive the pregnancy; where the baby has a
better chance of living to one year old; and where both
have a better chance of surviving the next five years. The
United States ranks 47th in life expectancy; when adjusted
for tobacco, obesity, homicide, traffic accidents and our
immigrant citizens, we look no better.
What Dr. Cossman refers to as "wacky data" from the World
Health Organization that reveals these inadequacies is
corroborated by the Commonwealth Fund, the Kaiser Family
Foundation, the Organisation for Economic Co-operation and
Development and the CIA (okay, maybe the CIA guys qualify
as "wacky").
The United States is nearly alone in allowing illness to
ruin families. Last year, medical crises bankrupted 2
million Americans, most of whom had health insurance when
the illness began. We also take lives needlessly: 44,000
Americans died of preventable causes in 2009 because they
were too poor to afford basic health care. This does not
happen anywhere else in the industrialized world.
Although hundreds of wealthy foreigners fly first class to
the United States to undergo elective operations at
renowned hospitals, 1.3 million Americans left the country
in 2009 to get essential health care unaffordable at home.
That number is expected to exceed 6 million in 2010.
Clearly, many Americans cannot get the health care they
need, even if the health care they need but can't get
might be the best in the world. And Americans pay twice as
much for the health care they don't get as other citizens
pay for the health care they do get.
All this was true before the first draft of the Patient
Protection and Affordable Care Act (PPACA) ever landed in
Nancy Pelosi's in-box.
Dr. Cossman's terror of the U.K.'s National Health Service
has him metaphorically checking under his bed for
government health care bureaucrats. Is the NHS so
terrible? Our Veterans Administration, a near clone of the
NHS, cares for our sickest patients with the best results
at the lowest cost with the highest patient satisfaction
in the country. Even Medicare does better than our
for-profit private insurance companies. Whatever one
thinks about government-run health care, it works pretty
well.
But why ignore alternatives other than a government-run
health system? The world (and the United States) provide a
multitude of financing solutions each of which provides
universal access, better outcomes and lower cost. France
uses employer-sponsored insurance coverage. Germany uses
individually purchased insurance coverage. Taiwan uses a
specific payroll premium dedicated exclusively to single
payer health care. And so on. Every other industrialized
country has found its own way to better us.
Successful health care systems follow three rules:
Everyone is in a single risk pool with a single set of
benefits. There are no impediments to primary care. And no
one profits from financing health care (you can profit
providing health care, just not financing it). We are the
only nation still attempting to finance health care with
private insurance companies that fragment risk pools, deny
primary care, and profit from simply passing money to
providers.
Many would agree that our much abhorred PPACA is a
soul-corroding abomination that enshrines everything
repellent about our current arrangement: insurance
companies selling cheap policies with great coverage to
the young, healthy and employed but expensive policies
with terrible coverage to the old, sick and jobless;
"cost-sharing" policies that pay for neither primary care
to keep people healthy nor the expensive complications
causing bankruptcies; and the $200 billion cost to health
care providers to collect their due from insurance
companies.
Dr. Cossman is spot on when he notes American insurance
companies celebrated this national legislation. After all,
it compelled every American to buy their product
regardless of price. The voices of protesting citizens
were drowned out by the clinking of whiskey glasses in
insurance board rooms around the country. If our Congress
continues to attempt universal health care by forcing
another 45 million Americans to purchase private policies,
our health care expenditures will skyrocket and we will be
no more healthy than we are now. Maybe less.
That Dr. Cossman says he is concerned, frightened and
angry shows an appropriate appreciation for the problems
PPACA poses to us as physicians, patients, taxpayers,
heads of family and socially responsible citizens. Perhaps
with less fondness for our private insurance industry and
more understanding of the many working alternatives, his
next essay will advocate one of the viable solutions.
Samuel Metz, MD
Anesthesiologist
Portland, Ore
References:
US health care costs vs industrialized nations:
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Link (link no longer valid)
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Link
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Link
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Schoen C, Davis K, How SKH, Schoenbaum SC. US health
system performance: A national scorecard. Health
Affairs Web exclusive, November/December 2006; 25(6):
w457-w475
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Link
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Link
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PA Muennig, SA Glied.
What Changes In Survival Rates Tell Us About US Health
Care. Health Affairs 2010;29(11):1-9
International
alternatives:
Administrative costs to
health care providers to collect from private insurance
companies:
VA and Medicare provide better care than private
insurance:
