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 


Portland, Ore


US health care costs vs industrialized nations:

  • Link (link no longer valid)

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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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  • PA Muennig, SA Glied. What Changes In Survival Rates Tell Us About US Health Care. Health Affairs 2010;29(11):1-9

 International alternatives:

  • Reid TR. The healing of America. Penguin Press, New York 2009

Administrative costs to health care providers to collect from private insurance companies:

VA and Medicare provide better care than private insurance:

  • Arnst C. The best medical in the US. Business Week, July 17, 2006

  • General Accounting Office. Medicare + Choice: Payments exceed costs of fee for service benefits, adding billions to spending. GAO/HEHS-00-161, Washington DC Government Printing Office 2000.

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  • Link

  • Asch SM, McGlynn EA, Hogan MM, Hayward RA, Shekelle P, Rubenstein L, Keesey J, Adams J, Kerr EA. Comparison of quality of care for patients Veterans Health Administration and patients in a national sample. Annals of Internal Medicine 2004;141(12):938-45

  • Link

  • Selim AJ, Kazis LE, Rogers W, Qian S, Rothendler JA, Lee A, Ren XS, Haffer SC, Mardon R, Miller D, Spiro A, Selim BJ, Fincke BG. Risk-adjusted mortality as an indicator of outcomes: comparison of the Medicare Advantage Program with the Veterans Health Administration. Medical Care 2006;44(4);359-65

Excess deaths in the US from inadequate access to health care:

  • Wilper AP, Woolhandler S, Lasser KE, McCormick D, Bor DH, Himmelstein DU. Health insurance and mortality in US adults. American Journal of Public Health, December 2009; Vol. 99, No, 12.

Bankruptcy from medical crises in families with insurance:

  • Himmelstein DU, Thorne D, Warren E, Woolhandler S. Medical Bankruptcy in the United States, 2007: Results of a National Study. American Journal of Medicine, 2009;122:741-6

  • David Himmelstein, et al. MarketWatch: Illness and injury as contributors to bankruptcy. Health Affairs Web Exclusive, February 2, 2005, pp.W5-62  (link no longer valid)

 Medical tourism: 1.3 million out in 2009, six million expected in 2010:


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