Rational Arguments

How many times can you say the same thing?

You can look at the WHO report.  Or OECD data – pick a year, I don’t care.  Or past Commonwealth studies.  Or the most recent one:

Despite having the most costly health system in the world, the United States consistently underperforms on most dimensions of performance, relative to other countries. This report—an update to three earlier editions—includes data from seven countries and incorporates patients’ and physicians’ survey results on care experiences and ratings on dimensions of care. Compared with six other nations—Australia, Canada, Germany, the Netherlands, New Zealand, and the United Kingdom—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. Newly enacted health reform legislation in the U.S. will start to address these problems by extending coverage to those without and helping to close gaps in coverage—leading to improved disease management, care coordination, and better outcomes over time.

Here’s the money shot:

Just to be clear, we did win the Health Expenditures/Capita category.  Unfortunately, that’s not really a win.

Last in efficiency.  Last in equity.  Last in long, healthy, productive lives.  Last overall.

Next to last in quality care.  Tied for last in access.

I challenge you – tell me where the good news is here.  What makes us the best in the world?  And this isn’t some biased organization judging from outside the system, this is based on the reports of patients and physicians themselves.

One of my biggest gripes with the Affordable Care Act (and I have many of them regardless what some people think) is that it will do so very little to change any of the results in this chart.  It’s not focused on quality.  It’s not going to do enough about spending.  And while it will likely help with access and equity, we’re so in the hole, we likely won’t move up at all.

The system is broken.  Band-aids aren’t enough.

More on this after I fully digest the full report.

One of the most commonly heard memes when it comes to the high cost of health care is that somehow the United States population is predisposed to be more expensive.  Somehow, we are inherently more costly.  Or we do stuff to make us unhealthy.  It’s just not true.

Here are some more slides I use when I talk about quality.  Again, this is OECD data, and I will show you eight of hte 10 richest countries in the world with all data available since 1993.

Can we agree that the elderly cost more?  So a population that consists of more elderly people would inherently be more expensive.  Here is the percentage of the population age 65 or older:

Huh.  So the United States has the lowest percentage of expensive elderly people.

Conversely, kids are cheap.  They are much healthier and have fewer chronic illnesses.  The more kids you have in your population, the cheaper it should be to care for:

Hmm.  So the United States has a higher proportion of young people than any of the other countries.  It seems like – if anything – the United States is predisposed to have the lowest health care costs by age.

But wait!  We do stuff to make ourselves unhealthy- like smoke.  Right:

Wrong.  The United States has almost the lowest tobacco use of any of these countries.

It must be alcohol then:

Nope.  Turns out that people in the United States have some of the lowest rates of alcohol consumption.

Don’t despair.  We are more overweight or obese than those other countries:

But come on, our percentages are barely higher than the United Kingdom, which costs less than half as much per person as our system.

So, yes, we are heavier than those other countries.  But that alone can’t account for the extremely high cost of health care in the United States, especially given that we smoke less, drink less,  and have a higher percentage of cheap kids along with a lower percentage of expensive elderly.  There must be another reason health care costs so much in the United States.

There is.

Back from my vacation/trip.  No surprise – nothing has changed.  Lots of bluster, lots of politics, little substance.

But one bit of data caught my eye while I was away.  It has to do with life expectancy.

Before I show it to you, let me say that I know life expectancy is not a perfect metric of quality in a health care system.  There are other factors that can effect the life expectancy of a population.  That said, you would expect that we would do better than this:

That’s a slide I made using OECD Data that use regularly in talks about health care quality.  You’re looking at the expected life expectancy of the total populations (at birth) of 8 of the richest 10 countries in the world.  The United States not only has the lowest life expectancy, it has had the lowest consistently for a long time.

But this weekend, I saw something even more striking:

Here, you are looking at health care spending per person (on the left) versus life expectancy (on the right).  Here are the take home points:

1. The United States spends WAY more per person on health care than any other country.
2. The United States has a pretty poor life expectancy, especially when you see how much we’re spending.
3. The United States is the only country (besides Mexico) without universal health coverage.
4. The United States has some of the lowest average number of doctor visits a year.

Can someone justify this for me?  What’s the money for?

Whenever I speak about the quality of the US health care system, I talk about a handful of indicators that organizations use to compare different systems.  Inevitably, someone chooses one of them, and then starts to scream that because THAT one indicator is flawed, everything I said is a lie.  The biggest one people like to pick apart is infant mortality.

My response is always the same:

To be honest, there is some truth in what you are saying.  Bottom line, [insert measure here] is flawed.  All measures are.  That’s why you will never hear anyone who is serious about this issue use [selected measure] as the only measure to promote single payer.  It is one of many.  As I usually say, “it doesn’t matter which metric you pick, life expectancy, infant mortality, maternal mortality, levels of vaccination, continuity of care, access, cost, or most importantly, preventable years of life lost – the US is middling at best and often worst when compared to comparable nations.”

That said, you would hope that we wouldn’t place LAST in [selected measure] when compared to other countries, and with all the spending we do on our health care system, it certainly isn’t getting us the quality you expect.

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