We are 37th! We are 37th! No, this is not the cheer to be heard this week at a Notre Dame football pep rally. Rather, it is, according to the last rankings done by the World Health Organization, the chant appropriate for the U.S. health care system.
The pressure is building to do something about our broken system.
President Obama says he will not back down — we have to reform our system before more Americans die prematurely or go broke.
Senate Finance Committee Chairman Max Baucus has put forward his Obama-lite plan , which abandons the option of a government-run basic insurance option competing against the private market to get coverage for everyone. Instead, Baucus calls for tax credits for small business, the end of underwriting and a mishmash of government-subsidized insurance plans — co-ops to make health care affordable for all.
The Republicans continue to wring their hands at the prospect of a trillion dollars being poured into a reform plan at a time when government debt has reached the nearly incalculable stage.
Meanwhile, the rest of the world is watching to see if we will really finally do what nearly all of them did decades ago — provide health insurance for everyone. The French, Swedes, British, Canadians, Taiwanese, Singaporese, Dutch, Germans, Spaniards and Italians cannot believe that we plod on year after year with exploding costs and hordes of uninsured.
So what do they know that we don't?
First, we spend more money to insure fewer people than our peer-group nations. According to the Kaiser Family Foundation, we are spending twice as much or more than other comparable countries around the globe. Those spending less per person include Australia, Austria, Belgium, Canada, Denmark, France, Germany, Iceland, Italy, Japan, Singapore — well you get the idea — while covering everyone in their country.
And, the cost gap is getting worse. Our rate of inflation for health care costs is the fastest growing among rich nations on the planet. If you earn more money in the years to come at least half of it will go to cover your out-of-pocket health care costs if the inflation rate is not slowed. Things are so out of control that we have a form of bankruptcy unheard of anywhere else in the world — the inability to cover medical costs is tied to more than 60 percent of all personal bankruptcies in America.
Not only do we lag far behind many nations in terms of how much we pay, we get less for our money. We rank 52nd in the number of doctors per thousand people. Sure, we rank behind the usual suspects: Italy, France, Sweden and Norway. But did you know America also trails Cuba, Uzbekistan, Moldova and Mongolia?
We also limp along behind many nations in the number of babies who die at childbirth, including Singapore, Bermuda, Britain, Sweden and Japan. And they live longer than we do in Singapore, Japan, Israel and Italy, while spending a heck of a lot less for their care.
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All that said, I do not hesitate to use American health care. After all, I have good insurance with access to a world-class academic medical center as a University of Pennsylvania employee. People from all over the world come here to train as doctors because when American medicine is good, we are very, very good.
But when you look at how we do as a nation overall, our health care system is just shy of awful. Being 37th in the world in key health measures, spending a ton more money while leaving a good chunk of our friends and neighbors to fend for themselves or go bankrupt, dying sooner than they do elsewhere and having a less than stellar infant mortality rate only shows that as a national system, American health care is a mess.
As we move toward the end-game for health reform, a quick spin around the globe reveals that No. 37 has a lot to learn from the rest of the world.
The denizens of the Great White North know they do at least two things better than Americans — hockey and health care. There is a lot of talk about waiting lists in Canada but the reality is that there is no delay in getting urgent medical needs attended to and the rich and the poor both get high quality care. Primary care works well. And if you don’t want to wait for elective procedures you can simply buy more insurance or pay out of pocket and get out of the line. Canada has everyone covered and the quality of care is very good.
There is no place more in love with markets and capitalism then this nation. So how do the Swiss handle health care? Surprise — the Swiss have Obamacare!
Health care's fate in grandma's hands?Health insurance is mandatory — mandatory — so everyone has basic health insurance. No one in Switzerland can be denied basic insurance coverage no matter how sick or disabled they or their children may be. The government subsidizes care for the poor but they still have to pay something. This is the Swiss version of a co-op plan. There are private insurers who compete for business above the basic minimal insurance and do quite well.
The Swiss do pay something out of pocket for each health care visit but usually no more than 10 percent of the cost. Those in the subsidized basic insurance system have somewhat restricted choice in where they can go to the doctor. Everyone else can go to any doctor or hospital anywhere they want in the entire nation.
Israel has superb primary care. It is not just that everyone is insured but there is primary care available in nearly every city and town all over the country. This makes a big difference, as shows up in the care of chronic diseases like diabetes.
In the U.S., lots of visits to emergency rooms are related to diabetic ketoacidosis — people becoming faint, feverish and dehydrated because their insulin is out of whack. The condition is very serious and costs a bundle to treat in hospital ERs.
In Israel, very few cases make it to the hospital. There is readily available primary care and diabetics are closely monitored by their doctors. As the Israeli system becomes increasingly computerized, something Obama has been calling for here, it becomes easier to see which diabetics are having problems and to proactively intervene to make sure their disease is being properly managed at home so they don’t wind up costing a fortune in the hospital. The big lesson out of Israel is that ready access to good primary care will save money.
The Brits have something very important to teach us about health care. And it is not just the all-in national health system that they so staunchly defend. It is about the value of prevention.
They have developed a system of caring for newborn babies that the U.S. should have instituted long ago. In America, mom has a baby and goes home. You are on your own even if you don’t have a clue about how to breast-feed or what to watch for in terms of your or your baby’s health problems. Not so in the National Health Service in the U.K.
When you have a baby in Britain, a midwife will come to your house to check on you and the child at least a few times for 10 days after the birth. Then a community nurse will visit at least once over the next month or two. You can then go to see a midwife or a doctor for as long as you wish if you are having problems breast-feeding or for any other concerns for five more years. The Brits not only have a smart preventive focus on newborns, they are making smart use of non-physician health care personnel. Taking full advantage of nurses, midwives, pharmacists, physician-assistants, and social workers has to be a key part of our health reform.
Everyone must be insured in Japan but there are many private insurance plans. One especially interesting feature of health care in Japan is that insurers are prohibited from advertising. So all the money wasted here on ads, TV campaigns, marketing and sales gimmicks goes to the actual delivery of care.
Any citizen of Japan can visit any primary care physician with or without an appointment and will be seen, albeit briefly, within an hour or two. They will pay a fixed fee of about $50 for which their insurance pays 70 percent. Why is this possible? Because doctors are not drowning in paperwork or on the phone arguing with insurance companies or managed care bureaucrats. One fee everywhere with a small co-pay means the doctor will see you now.
One other interesting feature of universal health care that has not gotten much attention is its connection to tort reform. Japan, like all other nations with universal coverage, has nothing like the malpractice crisis that we do. Most doctors pay about $1,000 per year for malpractice insurance. There are only a tiny number of lawsuits every year. One major reason is that if a mistake happens you don’t have to sue to get your medical costs covered — they already are. Plenty to be learned from the land of the rising sun.
Two interesting features about health care in Oz. First, they pay much less than we do for their prescriptions. Why? Because the government won’t pay without some demonstration of cost/benefit analysis involving efficacy, safety and a fair price from the drug company.
Emergency room visits are free, but they make sure to push primary care. Visits to a primary care doctor are heavily subsidized, costing on average about $20. While the U.S. has great specialty care for many of its citizens, what gets the best return on the health care dollar is, as the Aussies, as well as everyone else outside the USA seems to know, primary care.
The French are recognized around the world as having a fabulous health care system. Not only do outsiders admire what they have, the French report the highest satisfaction rates of any country in the world with their health care. The government provides easy access to primary care and insures that every person can utilize a full array of specialty services by keeping a close eye on where new technology and services get placed. In fact, the French have better access to most forms of high technology care than do Americans.
Two features in particular stand out about the French health care system. In 2002, France instituted a national no-fault insurance scheme for medical errors and mishaps. As a result, people who are injured in a hospital or nursing home receive prompt payment and there are nearly zero lawsuits.
The other remarkable feature is that medical school in France is free. This means more doctors are willing to practice primary care unlike American doctors who, saddled with huge debt from their time in medical school, head toward specialties in droves. And since medical education is free, salaries and fees paid to French doctors are far more reasonable then they are in the USA.
The bottom line
A lot of what the President is calling for is reflected in the health care of these nations. An emphasis on having widely available primary and preventive care is the key to controlling cost and getting better outcomes. Covering everyone will help reduce malpractice costs. Getting rid of paperwork will give doctors time to actually see you. And giving non-physician providers a bigger role in basic health care management is the key to handling chronic illnesses and pre and postnatal care. There are many places doing better than we are. We can and should change that.
Arthur Caplan, Ph.D., is director of the Center for Bioethics at the University of Pennsylvania.
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