George W. Bush claims that "we have fabulous health care" when compared to "other systems around the world." What he fails to mention is that U.S. health care has already been systematically compared to other systems around the world. He omits these facts:
I ask - can we claim to possess the most fabulous health system in the world if our quality isn't the best, if our cost is the highest, and if one out of every six Americans can't even afford to access our so-called system?
Bush made these remarks during a Q & A session after his speech to the Rotary Club in North Fredericksburg, Virginia, this past Monday:
We have fabulous health care in America... Before people start griping about the health care system here... compare it with other systems around the world. (George Bush, December 17, 2007)
You and I know that Bush is trying to bluff us into believing in his make believe world, again. But let's look past his bluster and review the facts. Let's do a little unpacking of some health care realities...
Bush's home state of Texas has the highest number of uninsured.
A report issued by the U.S. Census Bureau in August 2007 shows that Texas again ranks No. 1 with the highest percentage of uninsured residents in the nation. Based on the three-year average from 2004 to 2006, Texas had an uninsured population rate of 24 percent. New Mexico and Louisiana had the next-highest rates, each topping 20 percent. Looking at the total number of people, Texas has about 5.7 million without health insurance coverage.
Dan Stultz, M.D., FACP, FACHE, president of the Texas Hospital Association (THA) released a statement last week, pointing out:
"A surprising 82 percent of the uninsured are from working families, and only 53 percent of Texas employers provide health coverage to their employees. Employer-sponsored insurance decreased 5.5 percent in Texas from 2000 to 2004...
"Unfortunately, in order to compete in a global economy, Texas businesses have no choice but to continue to drop health benefits or pass the costs on to employees, who often can't afford the premiums...
"Texas hospitals strongly believe that health care coverage needs to be accessible and affordable, so that all Texans have access to basic health care services.
"If we achieve this goal, then we can eliminate unnecessary health problems such as babies born with deformities because their mothers did not get prenatal care; uncontrolled diabetes and asthma and their associated costs; and women not getting mammograms, even though 11 percent of Texas women will get breast cancer in their lifetime."
The Center for Public Policy Priorities, an Austin-based research group, called the state's uninsured problem embarrassing. The organization also called on U.S. legislators to continue the State Children's Health Insurance Program (SCHIP), which provides coverage for children under age 18 - the same bill that Bush vetoed in October and again last week. SCHIP has been particularly important to Texas because Bush's home state has 1.5 million uninsured kids (1 out of every 5 Texas children), the highest percentage of uninsured children in the country.
So. Texas has the highest uninsured rate in the nation - 24.5% in 2006. The U.S. average is still high at 15.8% or almost 47 million people that are uninsured nationwide. But, Texas is the highest. Over 5.7 million Texans have no health insurance.
Too many Texas children live in families that earn too little to afford private health insurance.
One wonders why President Bush's fabulous system isn't serving all these uninsured Texans in his own home state.
Americans spend far more on health care than their counterparts abroad - but they don't actually receive more care.
By several measures, health care spending in the U.S. continues to rise at the fastest rate in our history.
In 2006, employer health insurance premiums increased by 7.7 percent - two times the rate of inflation.
In 2005, the United States spent 16 percent of its gross domestic product (GDP) on health care. It is projected that the percentage will reach 20 percent in the next decade. In contrast with other industrial countries that have universal healthcare, health care spending accounted for 10.9 percent of the GDP in Switzerland, 10.7 percent in Germany, 9.7 percent in Canada and 9.5 percent in France, according to the Organization for Economic Cooperation and Development (OECD).
The annual premium for an employer health plan covering a family of four averaged nearly $11,500. The annual premium for single coverage averaged over $4,200.
Health care spending is 4.3 times the amount spent on national defense.
Even for those that do have insurance, it's becoming both increasingly unaffordable and most insurance plans have begun to deny or refuse to reimburse for medical care services that would be covered by other industrialized nations and their health systems.
Even though we spend more per capita, one out of every six Americans is unable to access health care services at all.
Although the United States spends more on health care than other industrialized nations, those other countries provide health insurance to ALL their citizens. In contrast, 47 million Americans are uninsured and are unable to avail themselves of health promoting services like mammograms, flu vaccines, health checkups or physicals. When they get really sick, they are denied access to lifesaving procedures like heart surgery, chemotherapy, blood pressure medications or antibiotics.
Services that you and I may take for granted are simply not available to one out of every six Americans. Risa Lavizzo-Mourey, president and chief executive officer of the Robert Wood Johnson Foundation, a New Jersey-based think tank focusing on health-care issues simply points out:
"When millions of hard-working men and women do not have health insurance themselves and cannot cover their children, it raises serious clinical, economic and moral concerns about how we as a nation will meet the needs of our people."
The uninsured rate rose among the employed because fewer people are covered at work! The uninsured rate among all other rose because the cost of healthcare insurance has skyrocketed - rising much higher and faster than the inflation rate - and not keeping pace with wages.
People with low incomes are much more likely to be uninsured. Some 25 percent of people with incomes below $25,000 were uninsured in 2006, almost triple the 8.5 percent rate among people with incomes over $75,000.
The percent of full-time working adults who lack health insurance rose to 17.9 percent in 2006, up from 17.2 percent. The number of full-time working adults who are uninsured climbed by 1.2 million, to 22.0 million.
You will sometimes hear it said that these people (the ones without insurance) can just go to their local hospital emergency rooms for that care. That's an urban myth and it's time we told the truth. The truth is that people without insurance cannot get their mammograms, vaccines, antibiotics or chemotherapy in American's emergency departments. Those services are just not available in ERs.
The citizens of France, Germany or Canada aren't treated like that. They aren't discriminated according to income in their nation's hospitals and clinics. In those countries, all the citizens have access to health care - equally. According to a World Health Organization (WHO) report in 2000:
In North America, Canada rates as the country with the fairest mechanism for health system finance - ranked at 17-19, while the United States is at 54-55. Cuba is the highest among Latin American and Caribbean nations at 23-25.
If by chance an uninsured person in the U.S. lands in an ER, say as a result of a tornado or train wreck, the ER may treat the person on an emergency basis but will not provide any sort of follow-up. And, furthermore, that ER care will not be charity.
The uninsured person WILL be billed for that expensive emergency care and, if the uninsured person does not pay the bill in a reasonable time (say, three months), then the bill will be turned over to collections. That's when the uninsured citizen's life goes from sad to devastating. That collection agency will pull out all stops to collect the money. All too often, this means that the uninsured American will end up in bankruptcy, lose his house, lose his credit standing and may end up on the streets.
Dr. Brundtland, Director of the WHO, said this in 2000:
"The poor are treated with less respect, given less choice of service providers and offered lower- quality amenities. In trying to buy health from their own pockets, they pay and become poorer."
About 50% of all personal bankruptcies in the U.S. are a direct result of medical problems. A Harvard study performed in 2005 and published in the respected peer reviewed journal for health policy, Health Affairs, showed that these "medical debtors" (who end up in bankruptcy) are primarily middle class and employed and were demographically typical prior to becoming sick. While many were insured, they blame high copayments and deductibles for their financial ruin. Following their bankruptcy filings, about one-third of debtors continued to have problems paying their bills. Medical debtors reported particular problems making mortgage/ rent payments and paying for utilities, eventually leading to home foreclosures, evictions and, for some, even homelessness.
To our surprise, half said that illness or medical bills drove them to bankruptcy. So each year, 2 million Americans -- those who file and their dependents -- face the double disaster of illness and bankruptcy.
But the bigger surprise was that three-quarters of the medically bankrupt had health insurance. (Washington Post)
It's also a fact that 3 out of ever 4 uninsured Americans live in employed households, and almost 50% of all uninsured Americans are employed adults. Children make up 30% of the remainder of the uninsured.
That is, these uninsured people are working, playing by the rules, staying out of trouble - and, still cannot afford health insurance or access medical care for their families. And, they are going broke trying to do it.
The quality of the U.S. health care is simply not the best in the world.
Other industrial countries, like France, Germany or Canada, have something to teach us about the formula of combining top quality of care, equity of care, and cost of care.
Despite the fact that we spend more money per capita, per GDP and per inflation than any other industrial nation, we cannot say we have the highest quality of care.
We can only say that we have the most expensive care. Not the best.
Even though America has the most expensive health-care system in the world, the best high tech medical equipment that money can buy and the best emergency care in the world, we're ranked only 37th of all nations in health care system performance, according to the World Health Organization.
How does America's health care system stack up to our neighbor to the north, Canada, who has universal health care? Surprisingly, WHO ranked the overall health of Canadians 35th and Americans a pitifully low 72nd. And Canada ranks 30th in overall health care -- slightly higher than the U.S. at 37th. Obviously, Canada must be doing something right by not having a for-profit health-care system like America's. By the way, only two other Organization for Economic Cooperation and Development (OECD) countries in the entire world, Turkey and Mexico, don't have universal health care.
We often hear about Canada's waiting lists. Yes, it's true that Canada has a waiting list for many of its less critical elective procedures, but, so do we here in the United States. When is the last time you tried to make an appointment with an endocrinologist and had less than a sixty day wait time. How about less than forty-five days for an orthopedic specialist or a urologist? Here in the United States, let me remind you, if you don't have any insurance - it's possible that you will NEVER see an endocrinologist or orthopedic surgeon. They just don't have to see you and they just might not. And, if they do see you, they probably won't agree to do your special procedures for you.
If you have an urgent need for care in Canada, there will be no waiting time. This is not necessarily true in the United States.
There's no waiting list problem in either France or Germany.
A Commonwealth Fund survey of 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States (updated in 2007 here) showed some true comparisons between civilized countries:
All the countries surveyed, except the U.S., have universal health insurance systems. Despite arguments that such systems result in long waits for care, or even rationing, half or more adults in Germany, the Netherlands, and New Zealand reported having rapid access to physicians. Yet in the U.S., only 30 percent of adults said they could get same-day appointments with their doctors when sick.
But, you say, many people DO have great health care in our nation. You have many anecdotes and stories of those you know and how their lives have been improved, saved or lengthened due to the great quality of care they received.
Yes, I know. I, too, have those stories that I can relate. But, if our health care system is not serving all of us the same, can it really be a great health system? Can we stack it against the universal health systems of other countries?
In America, we have a substantially lower life expectancy and higher infant-mortality than most other advanced countries. Although we spend so much more for healthcare here in America, the quality does not translate into either better customer service or better health.
Often, in the U.S, we boast of all our biomedical machines and how much they cost. We somehow equate the number of assets we own with the quality of care we provide by owning them.
Is that really the way to assess the quality of a healthcare system? If we own the most MRI machines or heart catheter labs, then, we must have the best quality of care. Right?
That's faulty logic. What you own doesn't equal what you produce. Nor do your possessions indicate whether or not you are producing what's needed. If you are not producing what's needed, then, are you providing the best service possible?
Perhaps to increase our overall health, what we really need is more nurse practitioners providing more health check-ups and fewer overall MRI tests.
The cost and quantity of supplies and equipment do not translate to quality of care.
Rather than measuring life expectancy or customer satisfaction, health outcomes have often been estimated or assessed simply in relation to the existence of inputs such as the number of doctors or hospital beds per unit of population.
This approach indicates what these inputs actually produce, but it tells little about the health system's potential - what it could do if it used the same level of financial resources to produce and deploy different numbers and combinations of professionals, buildings, equipment and consumables.
The question for any health system today is, given the country's human capital and the resources devoted to its health system, how close has it come to the most that could be asked of it?
A large percentage of our neighbors who are not uninsured are actually "under-insured" - meaning that they may know that there are great services and tests available, but their own health plans don't "cover" them.
If the plans won't pay, well, then not only can't the citizens afford them but the hospitals and clinics probably will not allow them to get the services in the first place. We live in a "pay to play" America, even in health care.
Some say as many as 100 to 150 million of Americans are under-insured. Most who are under-insured won't find out they lack adequate coverage until the day comes when they actually need to access particular services or tests. Another 47 million of us have no health care at all. Altogether, a lot of us just don't have enough care, fabulous or not.
As New York Times columnist Paul Krugman once noted, American health care "at its best is the best in the world," but for millions of Americans, "it's all too easy to fall through the cracks in our system."
Can a health system be a "fabulous" system if it is not a "fair" system? Can it even call itself a "system" if it doesn't provide care for the population in any sort of systematic way? Not according to the World Health Organization:
A good health system, above all, contributes to good health. But it is not always satisfactory to protect or improve the average health of the population, if at the same time inequality worsens or remains high because the gain accrues disproportionately to those already enjoying better health.
The health system also has the responsibility to try to reduce inequalities by preferentially improving the health of the worse-off, wherever these inequalities are caused by conditions amenable to intervention. The objective of good health is really twofold: the best attainable average level - goodness - and the smallest feasible differences among individuals and groups - fairness. A gain in either one of these, with no change in the other, constitutes an improvement, but the two may be in conflict.
The logic is somewhat parallel to that concerning the distribution of income in a population. It is desirable to raise the average level, to reduce inequality, or both, and sometimes to judge the relative values of one and the other goal (with the difference that there is no argument for taking health away from anyone - health, unlike income or nonhuman assets, cannot be directly redistributed).
The distinction between the overall level and how it is distributed in the population also applies to responsiveness. Goodness means the system responds well on average to what people expect of it, with respect to its non-health aspects. Fairness means that it responds equally well to everyone, without discrimination or differences in how people are treated.
The distribution of responsiveness matters, just as the distribution of health does. Either one is valuable by itself.
In contrast to the objectives of good health and responsiveness, there is no overall notion of goodness related to financing. There are good and bad ways to raise the resources for a health system, of course, but they are more or less good primarily as they affect how fairly the financial burden is shared. Fair financing, as the name suggests, is concerned only with distribution. It is not related to the total resource bill, nor to how the funds are used.
While it is unambiguously preferable to have better health or a higher level of responsiveness, it is not always better to spend more on health because at high levels of expenditure there may be little additional health gain from more resources...
To assess a health system, one must measure five things: the overall level of health; the distribution of health in the population; the overall level of responsiveness; the distribution of responsiveness; and the distribution of financial contribution...
Health is the defining objective for the health system. This means making the health status of the entire population as good as possible over people's whole life cycle, taking account of both premature mortality and disability...
As with health status, it is not only overall responsiveness that matters, if some people are treated with courtesy while others are humiliated or disdained. A perfectly fair health system would make no such distinctions, and would receive the same rating of responsiveness on every element, for every group in the population. In almost every country where key informants were surveyed, the poor were identified as the main disadvantaged group. In particular, they were considered to be treated with less respect for their dignity, to have less choice of providers and to be offered poorer quality amenities than the non-poor...
Fair financing in health systems means that the risks each household faces due to the costs of the health system are distributed according to ability to pay rather than to the risk of illness: a fairly financed system ensures financial protection for everyone. A health system in which individuals or households are sometimes forced into poverty through their purchase of needed care, or forced to do without it because of the cost, is unfair...
For this reason, financial fairness is best served by more, as well as by more progressive, prepayment in place of out-of-pocket expenditure. And the latter should be small not only in the aggregate, but relative to households' ability to pay...
In sum, the way health care is financed is perfectly fair if the ratio of total health contribution to total non-food spending is identical for all households, independently of their income, their health status or their use of the health system. This indicator expresses the trenchant view of Aneurin Bevan, that "The essence of a satisfactory health service is that the rich and the poor are treated alike, that poverty is not a disability, and wealth is not advantaged."
A Commonwealth Fund survey of primary care physicians and patients in five other nations - Australia, Canada, Germany, New Zealand, and the United Kingdom - finds that the U.S. health care system ranks last or next-to-last on five dimensions of a high performance health system: quality, access, efficiency, equity, and healthy lives.
All the countries surveyed, except the U.S., have universal health insurance systems. Much of this under-performance is attributable to the lack of universal health insurance in the United States.
The U.S. ranks last overall with poor scores on all three indicators of healthy lives. The U.S. ranks last on indicators of patient safety, efficiency, and equity. New Zealand, Australia, and the U.K. continue to demonstrate superior performance, with Germany joining their ranks of top performers. Despite having the most costly health system in the world, the United States consistently under-performs. A 2006 report of patient surveys shows:
U.S. health care leaders often say that American health care is the best in the world. However, recent studies of medical outcomes and mortality and morbidity statistics suggest that, despite spending more per capita on health care and devoting to it a greater percentage of its national income than any other country, the United States is not getting commensurate value for its money...
The findings suggest that, if the health care system is to perform according to patients' expectations, the U.S. will need to remove financial barriers to care and improve the delivery of care. Disparities in terms of access to services signal the need to expand insurance to cover the uninsured and to ensure that the system works well for all Americans. Based on these patient reports, the U.S. should improve the delivery, coordination, and equity of the health care system.
Experts agree that our U.S. health care system is riddled with inefficiencies, excessive administrative expenses, inflated prices, poor management, and inappropriate care, waste and fraud. This international report also describes problems in the U.S. with a high rate of medical errors, medical mistakes and illnesses that are not treated:
Among adults in the seven countries, U.S. adults reported the highest overall error rates, including lab and medication errors. One-third of U.S. patients (32%) with chronic conditions reported a medical, medication, or lab test error in the past two years, compared with 28 percent of patients in Canada, 26 percent in Australia, and fewer patients in the other countries. Patient-reported errors were highest in every country for those seeing multiple doctors or with multiple chronic illnesses.
In the U.S., 37 percent of all adults surveyed -- and 42 percent of those with chronic conditions -- skipped medications, did not see a doctor when sick, or did not obtain recommended care in the past year because of the cost. These rates are well above those found in the other six countries. Few people in Canada, the Netherlands, and the U.K. reported skipping care because they could not afford it.
These problems significantly increase the cost of medical care and health insurance for employers and workers and affect the security of families.
Mr. Bush, your characterization of our health care system is just plain wrong. Our health care is not fabulous and I'm not sure we can even define it a system. Not yet. Our neighbors are dying out here. Your fabulous mirage doesn't match the harsh reality on the ground.
We don't have fabulous health care in America if two out of every six of us are under-insured and can't get the services we want or need, and, when one out of every six of us cannot access it at all.
We cannot make our nation better by lying about the conditions our citizens are facing. Pretending that we have great health care doesn't cause great health care to somehow magically materialize. This is not something that we can be bluffed into believing.
As a nation, we must be honest about our failures in health care and face up to the task of fixing our broken or non-existent system.
Like it or not, we're all in this together - and we will all benefit the most by looking out for each other while we look out for ourselves. We can do a much better job of it.
Medical care is not a luxury. It's a necessity. High quality health care is a human right - not a privilege.
In our nation, health care quality is stagnant and inconsistent while costs are spiraling out of control. Thousands of working Americans lose their health insurance every day. Millions of insured Americans are one illness away from bankruptcy.
Others are choosing to die too soon to avoid creating debt for their families.
Health care does not have to be regarded as a free spirited scarce resource subject only to the economic forces of an unpredictable and uneven free enterprise system. Health care can instead become a renewable resource that can be increased and delivered broadly and with better efficacy - for all.
In a modern, civilized society, health care should be every citizen's right.
We simply can do better.
(Pam Pohly, EverydayCitizen.com)
If you believe that today's health care system falls far short of the needs of our patients and communities; if you believe that significant health care reform is needed now; if you believe that we all must be active in the fight for universal health care; and if you want to make a difference in the movement to achieve health care for all, then take the next step and be active! Here are some ideas to consider:
If you want your own copy of the Census Bureau's report on Income, Poverty and Health Insurance, you can download it here.
More information about our health care crisis in America:
We just have got to find a way to make healthcare affordable for all Americans - available to all Americans. The answer is universal health care.