The Healthcare System in America Needs an Operation
by M.C. Russell, M.D.
Mr. Jones* came into the emergency department complaining of gastrointestinal bleeding. He reported that it had been going on “for a while.” In addition to blood, he reported a change in his bowel habits and decreased energy. A quick look at his medical records revealed a colonoscopy some twelve months prior showing a tumor in his large intestine. At that time it was recommended that he have an operation to remove the tumor. When asked why he did not follow up on the recommendation, his answer was honest and straightforward. Mr. Jones did not have health insurance, but he did have a family who depended on his income for food, clothes and a roof over their heads. He knew that, at the very least, he would be out of work for six weeks in order to have the extensive operation. More importantly, there would be thousands of dollars in medical costs that he would surely be unable to pay and support his family. He was not an uneducated man; he realized there would be consequences for not having the operation, but like many of the patients at this public hospital, he was trapped and could see no way out. He left the hospital a year ago and only returned because it was now an emergency. Unfortunately, those twelve months will cost him dearly.
This account is based on a true story. As healthcare costs continue to rise, more and more people are falling into the ranks of the uninsured and the underinsured and do not receive the care they need. The opinion that the United States provides the finest healthcare system in the world is robustly challenged by studies showing severe shortcomings in outcome studies, while stories like that of Mr. Jones are more common than anyone would like to imagine.
Changes must be made if the prognosis for America’s healthcare system is to improve.
Surgeon George Crawford asks, “Is it the responsibility of society to bear the costs because someone had a stroke and they are in the hospital?” He thinks the answer is no, but makes sure to add, “It is easy to say that until it is my grandmother.”
The United States is the only industrialized nation in the world that does not offer some form of nationalized healthcare for its citizens. Interestingly, the current structure is an evolution of government regulation that began in the 1940s during World War II (1). Because of a wage freeze, employers began attracting workers by improving benefits. One of these benefits was health insurance. From those beginnings, healthcare in the U.S. grew into the free market, non-government regulated establishment that it is today. Unfortunately, the current industry is fraught with chronic issues that threaten the whole system.
Dr. Crawford explains, “In the late 80s and early 90s, insurance companies and businesses started realizing that medicine didn’t really have a middle man. It was either patient to hospital or patient to doctor. When that happened, you had a lot of businesses coming in and trying to make money off of medicine, and that drove the cost up. Everybody loses but the middle man cashes in.”
There are some 47 million people in the United States today who are uninsured, yet approximately $6,400 is spent per person in the United States on health care, adding up to 16% of the gross domestic product (GDP) (2). By 2015 this number is expected to reach $4 trillion dollars and amount to 20% of the GDP. In comparison, other countries such as France and Germany, which have nationalized healthcare, spend 9.5% and 10.6%, respectively, of their GDPs on health care.
Despite the higher spending in the United States, there is disparity when looking at outcome measures (1). In 2000, the World Health Organization (WHO) ranked the U.S. a dismal 32nd for infant mortality and 24th for life expectancy (3). Another study by the Commonwealth Fund compared outcomes such as mortality, life expectancy and health conditions in the U.S. to those of top countries. They found that the U.S. ranked 15th out of 19 countries in preventable deaths prior to age 75, 40% higher than in Spain, Japan and France. The healthy life expectancy in the United States tied for last at age 60. Finally, the United States ranked dead last in infant mortality when compared to 23 industrialized countries (4).
So why is it that the United States can lead the world in spending and have such poor outcomes in so many areas? For one, the overhead associated with the current system is spiraling higher and higher. In comparison to other countries, administrative and regulatory costs in the US are significantly higher. The Organization for Economic Cooperation and Development (OECD) data for 2003 estimates that the United States spends 7.3% of total national healthcare expenditures on administrative and insurance costs. The next closest country to the U.S. is Germany at 5.6%, while the French only report 1.9%. The administrative overhead for private insurance alone, which covers expenditures such as advertising, marketing, collections and profits was 14.3% in 2005. By comparison, the overhead for Medicare was 1.6-2.1% and less than 1% for Medicaid. This illustrates that costs can be cut from overhead if spending on non-essentials such as advertising and marketing are eliminated.
Another explanation for the increased spending in the United States is the fact that, as a whole, America is a wealthy nation and, as such, can afford to spend more on healthcare. We are quick to adopt the newest technology and the latest drugs, sometimes without proven benefit over older ones. Computed tomography, positron emission tomography, magnetic resonance imaging, cardiac procedures, intensive care units and all the latest advancements are more readily available to people of the United Stated than in other countries, where the waiting time for such services may be as long as 10.1 weeks in Canada for an MRI (5).
Another expenditure is for extreme end of life care. Thirteen to thirty percent (depending on the source) of Medicare’s total expenditure is provided in the final 60 days of life (1). Many nations would refuse to pay for such care. Dr. Crawford suggests, “I would, not so much limit the choices that people have at the end of their lives, but I would empower physicians to make decisions based on logical outcomes” when considering extreme end of life care. Right or wrong, the extreme measures we often utilize at the end of one’s life contribute significantly to Medicare expenditure.
As the healthcare costs continue to rise the American employer is less willing to foot the bill. The proportion of people covered by employer-based health insurance decreased in 2006 to 59.7%, down from 63.6% in 2000. During this same period, those covered by Medicare/Medicaid increased from 24.7% to 27% and the number of uninsured people increased to 16% (2, 6). Between 2000 and 2005, health insurance premiums increased an incredible 58% for families and 50% for individuals. This far outpaces the increase in income. As the costs of health insurance rise, fewer employers are offering health benefits and more are increasing the financial responsibility passed on to their employees. As a result, the United States has more and more people falling into the “underinsured” group.
There are an estimated 50 million additional people who are in this underinsured group. This sector of people have insurance for major disasters, but either have too high a deductible or expensive co-payments that prohibit routine doctor visits and access to medications that allow them to take care of themselves.
The fact is, however, that just being uninsured increases the risk of death by 25%, even after adjusting for age, gender, smoking and education. Being uninsured, or even underinsured, disrupts the continuity of care enjoyed by those with more adequate health coverage.
For example, diabetes is a disease that can be managed by medical supervision including frequent monitoring of blood glucoses and hemoglobin A1c, urinalyses to monitor for proteinuria, visits to the ophthalmologists, and controlling comorbidities like hypertension and cholesterol. Those that are uninsured or underinsured are less likely to strictly manage this disease and prevent subsequent complications such as cardiovascular disease, kidney complications and eyesight problems as those with more adequate insurance.
So, what about the safety net that President Bush and others claim serves as a surrogate for healthcare to the uninsured?
“To illustrate, in a speech on health reformin Cleveland, Ohio, on July 10, 2007, President Bush casuallyshrugged off the plight of the uninsured with the remark, ‘Imean, people have access to health care in America. After all,you just go to an emergency room’—with nary a concernexpressed over how these emergency rooms will cover their costs” (6).
Unfortunately this is the attitude of many.
The emergency department, however, is a place for emergencies, not a place to be used for primary care and preventative medicine. The emergency room is not going to screen patients like Mr. Jones for colon cancer; this is the job of primary care and preventative medicine. As such, those that rely on the emergency department to be their primary care doctor present more advanced cancers, more complications of treatable diseases and generally poorer heath outcomes, all of which are not only really bad for the patient, but also cost the health system more in the long run.
The cost of taking care of patients in the emergency department is much higher than to do so in clinics and primary care offices. The emergency department physicians are often charged with the task of taking care of a patient that has basically dropped from the sky into his/her care only to disappear after the visit. These patients are notoriously poor historians due to the fact that they are not seen by physicians on a regular basis; they also will have no follow-up after the emergency visit. This means that a patient presenting a stomach bug may end up getting a CT scan simply to make sure that it is nothing worse. Whereas if the patient had a primary care physician with whom he had a relationship, the physician could follow the patient by serial exams and appointments (relatively inexpensive) and only do the big, expensive and probably unnecessary test if the patient did not improve. The emergency department is the most expensive and inefficient primary care imaginable, yet that is where people like the President want the 47 million uninsured Americans to get their routine care.
The United States spends too much on healthcare yet cannot provide access to it for all Americans. Quality of the care has also eroded as is evidenced by the United States’ rankings in key outcome measures. Finally, the rosters of the uninsured and the underinsured continue to grow.
The country needs to act quickly to find ways to fill in the existing healthcare money pit and implement changes that will curb costs, promote accountability to quality of care, and help the millions of Americans struggling to get access to healthcare they desperately need. While government regulation and oversight is not the only answer, it is one of the levers to pull in seeking an overhaul of a system that is hurting badly. It is time for a move toward a standard for the millions of people who have no access to basic care and also for a drastic reconstruction of the health insurance business.
1. Sarpel U, V. B., Divino CM, Klotman PE. 2008. Fact and Fiction, Debunking Myths in the US Healthcare System. Annals of Surgery 247:563-569.
2. Income, poverty and health insurance coverate in the United States. In Bureau of the Census. U. S. D. o. Commerce, ed.
3. The World Health Report 2000 - Health Systems: Improving Performance. W. H. Organization, ed. World Health Organization, Geneva.
4. Schoen C, D. K., How SK, et al. 2006. U.S. health system performance: a national scorecard. Health Aff (Millwood) 25:w457-w475.
5. 2007. Wait times for surgery in Canada at all-time high: study. CBCNEWS.ca.
6. Ginsburg, J. A., R. B. Doherty, J. F. Ralston, Jr., N. Senkeeto, M. Cooke, C. Cutler, D. A. Fleming, B. P. Freeman, R. A. Gluckman, M. Liebow, R. M. McLean, K. A. Musana, P. M. Nichols, M. W. Purtle, P. P. Reynolds, K. M. Weaver, D. C. Dale, J. S. Levine, and J. W. Stubbs. 2008. Achieving a high-performance health care system with universal access: what the United States can learn from other countries. Ann Intern Med 148:55-75.