Bend Over: This Will Hurt

"To practice and prescribe to the best of my ability for the good of my patients, and to try to avoid harming them."
- Hippocratic Oath.

Would you go to a car repair shop which was evasive and opaque with its pricing; persistently overcharged you for simple services and applied usurious costs for necessary repairs; had a history of neglect or incompetence; acted in collusion with regional shops to eliminate competition; and in some instances, were forced to call other shops to repair your vehicle when they further damaged it instead of repairing it?

Well this is the current scenario with the American health care system.

Consider the anecdotal story of Steve Spivey, a 44 year old Texan, who developed breathing problems after spine surgery at physician-owned and for-profit speciality hospital. As a result of there being no physicians on hand (at this physician owned and operated facility), the administrators were forced to call 911 and have him taken to a nearby and regular full-service hospital. He was unfortunately pronounced dead a short time afterwards. What makes this case so galling, is that according to state Medicare records, the same West Texas Hospital, which failed to adequately prepare for the post-surgery complications that Mr. Spivey encountered, called 911 for an ambulance 15 times to transfer patients during medical emergencies since it opened in May 2005. This wasn't an accident; this was a cost-benefit analysis, where a patient's life was jeopardized because the doctors didn't want to invest their time and money in making sure Mr. Spivey would survive their butcher knives.

As an American citizen, Mr. Spivey was not alone in his abandonment by those he ensured with his life and well being. According to studies completed over the past decade, as many as 200,000 people a year could be dying in U.S. hospitals and patient care facilities because of easily prevented errors. For example, 20-30% of patients in American hospitals or long-term care receive incorrect medical care; including incorrect medicine, wrong dosages, lethal infections arising from hospitalization, incorrect surgical operations, and general patient neglect. If listed along with other CDC morbidity indexes, medical errors would rank as the sixth leading cause of death, ahead of diabetes, pneumonia, Alzheimer's disease, and renal disease. In comparison with all other industrialized nations the United States stands out for inefficient care and errors and is an outlier on access/cost barriers.

Public Health

Fifty years ago, Americans used to be amongst the healthiest people anywhere. Today, the nation ranks dead last amongst Western industrialized nations and has been overtaken by some less than prosperous ones. With respect to the general population, life expectancy in America continues to slip, descending to 77.3 at birth, compared to Canada at 79.8 years and the Japanese reigning at 81.9. America is unique among Western nations in that 63% of its population are overweight, with an unprecedented 34% of the general population being obese and as many as six million being morbidly (or super) obese. Additional factors unique to America include that it has the highest homicide rate of all industrialized countries and given its size, is the largest consumer of illegal drugs in the world.

American children like their adult counterparts are also experiencing higher levels of obesity, hypertension, diabetes, and heart disease than previous generations and are likely to impose a severe cost upon any future social security and health care systems. Other less than stellar achievements in the areas of childhood care include the fact that the country has the highest infant-mortality rate, the highest child-poverty rate, the highest teen-pregnancy rate, and the highest child-abuse death rate in relation to its peers.

Dr. Stephen Bezruchka, a senior lecturer in the School of Public Health at the University of Washington in Seattle states, "There isn't a single measure in which the U.S. excels in the health arena…We spend half of the world's health care bill and we are less healthy than all the other rich countries."

Economics

The American health care system as a whole is a behemoth that only as recently as 2004 was spending $1.9 trillion dollars per annum, or 16% of GDP; nearly twice the OECD average. Despite years of bipartisan posturing about reform (including the infamous Bush Medicare donut) this year alone health-care expenditures are expected to account for about 18% of US GDP. President Obama’s Commerce Secretary, Gary Locke, recently opined in the Wall Street Journal that without reform, health care costs will increase to 28% in 2030 and to 34% in 2040 of GDP.

The number of persons sequestered to administer and manage the system has increased between the years 1969 and 1999, from 18.2 percent to 27.3 percent. Compared to Canada, which has a universal health care system, its percentage of the labour force dedicated to health care only grew from 16.0 percent in 1971 to 19.1 percent in 1996. With medical inflation outpacing inflation, American companies continue to reduce the health coverage they offer to employees. The percentage of workers who receive health insurance from their own employer has fallen from almost 70% in the late 1970s to around 50% today. So what we have today is a system that continues to grow without constraint, while providing fewer services and most certainly value to a smaller proportion of the working force.

With decades of growth across a patch-work of state health systems, the Byzantine network of American health care has created opportunities ripe for fraud and corruption. FBI data indicates that between 3-10% of health care funding is lost to fraud. There maybe as much as $75-250 billion dollars being squeezed out of the current Medicare system every year by crooked pharmacies, doctors, HMO’s, and equipment providers. Pfizer Inc, one of the world’s largest pharmaceutical companies, recently agreed to pay $2.3 billion, the largest health care fraud settlement in the history of the Department of Justice, to resolve criminal and civil liability arising from the illegal promotion of certain pharmaceutical products. UnitedHealth Group at the beginning of 2009 was forced to pay a record $350 million to defrauded customers to resolve allegations of price fixing. Similarly, Aetna, the United States’ third-largest health insurance company, agreed to pay $20 million to a non-profit body that would fairly determine rates for patients who use doctors outside the network.

The American Medical Council, a professional group which certifies internists, makes the statement that, "Primary care is on the verge of collapse." They explain that, "Very few young physicians are going into primary care and those already in practice are under such stress that they are looking for an exit strategy."

So unless wholesale and systemic changes are made to the way health care is paid for, delivered, and managed, the entire system is posed to collapse.

Alternatives

What is not in dispute is that America has some of the greatest public health centers in the world. The Mayo Clinic, the Cleveland Clinic, the Johns Hopkins Hospital System, Massachusetts General…etc are world renown institutions that service countless Americans and people from across the world. If you have the finances, the ability, and/or status to pay top dollar for your health concerns, then you will be more than adequately serviced by these hospitals. Although there may be some physicians and hospitals that offer similar treatments elsewhere, the collection of these centers of health excellence are what Americans think about when they say their country offers the best in health care.

The Bush administration deduced that the reason health costs were too high was because people had too much insurance and purchased too much medical care. Their solution was what the population needed were “tax-advantaged health savings accounts tied to plans with high deductibles that induce people to pay more of their medical expenses out of pocket.” Of course as with all things Dubya, this would (again) favour his true base; the rich and the very-rich. The standard Republican line is deference to big-pharma, increase the monopoly power of the insurance companies, and shriek about states rights when it comes to regulation. Yes the public continues to suffer and get taken to the bank (which curiously enough they now perversely own), but I'm sure that's what the founding fathers would have wanted.

Many Democrats, especially economists like Paul Krugman and public health practitioners advocate either a Canadian or European style system. Given that 40% of Americans already receive health care through Medicare, state plans (Medicaid), children health insurance plans (CHIP), Native American health care systems, and/or military/veterans’ affairs, a large minority already have that system in place. From 2000 to 2005, per capita health-care spending in Canada grew by 33 percent, in France by 37 percent, in the U.K. by 47 percent—all comparable to the 40 percent growth experienced by the U.S. in that period. So regardless of the nation or model being used, health care cost everywhere continue to rise at an unstable level and consume larger-and-larger portions of government spending. Furthermore, the United States has a number of cultural and societal attributes, as discussed above, that impose significant limitations towards the successful adoption of any foreign system in the long-term.

The Brookings Institute summarizes the attributes that meaningful reform will need to entail in America:

Reforming our health care delivery system to improve the quality and value of care is essential to address escalating costs, poor quality, and increasing numbers of Americans without health insurance coverage. Reforms should improve access to the right care at the right time in the right setting. They should keep people healthy and prevent common, avoidable complications of illnesses to the greatest extent possible. Thoughtfully constructed reforms would support greater access to health-improving care — in contrast to the current system, which encourages more tests, procedures, and treatments that are at best unnecessary and at worst harmful.