U.S. health care system - The Litany

We’ve all heard the litany of problems – skyrocketing health costs. Large medical bills forcing people into bankruptcy, U.S. manufacturers paying twice as much as foreign counterparts, problems with health care quality, 47 million Americans without insurance, too many specialists and not enough primary care physicians (in particular, family docs). We spend more on health care than any other country in the world, and what do we have to show for it? Bupkis!

Allan Wille, MD, Forum on Health Care Reform, February 3, 2009

Spare me the grim litany of the “realist.” Give me the unrealistic aspirations of the optimist any day.

General Colin Powell

I, for one, question the the value of the litany of U.S. health statistics comparing us to other nations. Yet the litany is repeated so often that it has become political folklore among progressives. It is never questioned, just taken for granted.
The litany appears , in the March issue of the HBS Alumni Bulletin, which I receive because I once spent 8 weeks in one of the Business School’s advanced management programs. The litany is part of an article, “Model Patient,” with a subheading that reads “Massachusetts Landmark Health-Care Reform Law is Drawing the Attention of Many Observers, include the Obama Administration. Could It Work On a National Scale?”

Here is the litany.

"There can be no doubt that America’s health-care system is in critical condition. The cost of U.S. health care not only hampers its citizens’ well being and the country’s ability to compete globally, but it also draws funding from other sectors, such as education, where increased investment could strengthen society and enhance competitiveness. Total health care spending as a percentage of GNP is 16 percent, compared with Canada’s 10 percent and Japan’s 7.6 percent. U.S. per capita health –care expenditures are the highest in the world. Versus Canada’s $3,912 or Japan’s $2,690. Meanwhile the United States ranks 34th in the world in life expectancy at 77.9 years. Half the U.S. population does not receive standard preventive care such a cancer screening, blood pressure checks, or vaccinations. A 2007 McKinsey study found that compared with the average for the thirty countries of the Organization for Economic Co-operation and Development (OECD), Americans pay significantly more per unit of health –care services consumed, seven though they see doctors less, take fewer pills, and have shorter hospital stays. Americans are ‘paying more, despite using less and doing worse,’ concludes Health Connector executive director Jon Kingsdale.”

A Flawed Litany

So what is wrong with the litany? One, it is overly pessimistic. Two, it continuously compares U.S. health care to that of other nations. Three, it misuses statistics to portray U.S. health care as an abysmal failure. Four, it implies that health care alone is responsible for the health of a nation. Five, it ignores the unique characteristics of U.S. culture.

The U.S. health system has roots in our national culture. Since our founding more than 230 years ago, Americans have:

• distrusted centralized federal power

• reveled in virtues of self-improvement

• sought freedom of choice

• believed in equality of opportunity, not results, for all citizens.

These beliefs may explain why Americans:

• prefer a multipayer to a single payer system

• reject federally mandated universal insurance

• want to make their own health care decision

• Seek immediate access to new medical technologies

• Allow market-based and public-based institutions to compete and co-exist

These roots and beliefs may be regrettable, but they help create a climate of freedom and opportunity that draws millions of the world’s immigrants to our shores. Our population is now nearly one-third African American, Hispanic, or of other ethnic origins. We consider diversity a good thing. However, interacting variables among various cultures - insufficient education, lower socioeconomic status, fear of being exposed and exported as an illegal immigrant, violence in the streets, mayhem on the highways in our car-rich country, language barriers, and lack of health care access- are beyond the reach of health care professionals, and negatively skew health care statistics and increase costs through delay of care, crowded emergency rooms, and wards of patients with behaviorally-induced disease.

Take one unfortunate but realistic example of what’s different about American health care and why our longevity statistics lag behind other countries. Colonel John Holcomb, the army’s top trauma surgeon is fond of quoting the statistic, that, among U.S. civilians, trauma leads all diseases in terms of life-years lost, more than heart disease or cancer. That’s useful statistic to keep in mind when comparing national health systems, for if one takes trauma and violence into consideration, U.S. longevity statistics are comparable to any other country.

Ethic origins play a role in our longevity statistics compared to other countries.


Ethnic Origin Total Populations Life Expectancy

White 197 million 81.0

Black 36 million 73.6

Hispanic 39 million 74.0

American Indian 2 million 75.5

Asian 12 million 75.2

Interracial Marriage 4 million 75.0

Source: Abstract of the United States, 2000-2004

Now it may well be that some sort of universal coverage would improve health statistics. But the facts are not encouraging. Dr. Leonard Sagan, a Stanford –based epidemiologist, wrote in The Health of Nations: True Cause of Sickness and Well-Being (Basic Books, 1987) that health care systems had little to do with reducing death rates or extending life expectancy. He says social, family, and personal factors play larger roles than health coverage. And Snatcher and Pamies in Multicultural Medicine and Health Differences (Basic Books, 2006) estimate that medical care accounts for only about 15 percent of the health status of any given population, life style for 20 percent to 30 percent, and other factors – poverty, inferior educations, income differences, and lack of social cohesion – for the other 55 percent.

None of this, of course, is to say that U.S. health care could not be improved by a reformed system, but such a system would probably would not fundamentally change our health statistics, except perhaps for our infant mortality rates which hinge more on access to prenatal care. Still, reform is in the air and is worth a try.
Meanwhile we should not forget Mark Twain’s famous remark about Richard Wagner’s music, “It’s not as bad as it sounds.” This applies to U.S. health care, too.