Monday, September 7, 2009

A Tale of U.S. Health Care Compared to Other Nations

It was the best of times, it was the worst of times, it was the age of wisdom, it was the age of foolishness, it was the epoch of belief, it was the epoch of incredulity, it was the season of Light, it was the season of Darkness, it was the spring of hope, it was the winter of despair, we had everything before us, we had nothing before us, we were all going direct to heaven, we were all going direct the other way - in short, the period was so far like the present period, that some of its noisiest authorities insisted on its being received, for good or for evil, in the superlative degree of comparison only.

Charles Dickens, A Tale of Two Cities
English novelist (1812 - 1870)

The Dicken’s quote sprang to mind as I was listening to a Brian Lamb interview on C-Span with T.R. Reid, author of the Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care (Penguin, 2009). Reid, reporter, documentary film makers, and author of ten books, , spent the last three years touring the world, looking at the health systems of leading industrialized nations.

Best in Some Ways But Unfair

Reid concluded we have the world’s best trained doctors and best equipped hospitals but the world’s most “unfair” health system. It is unfair, he says, because the U.S. culture has not embraced the moral imperative of providing universal coverage of the same quality for rich and poor.

As far as our health system goes, we live, in short, in the best of times, but the worst of times. It is an age of the best of medical technologies, but an age of social foolishness. It is an epoch of belief in medical wonders, but an epoch of incredulity that we do not evenly apply these wonders to all. It is a season of scientific Light, but is a season of social Darkness. It is the spring of hope in that universal coverage may be upon us, but it is a winter of despair in that it may not happen. As the world's richest nation, we should have the best of everything before us. With the recession, we may have nothing before us. We are all going to heaven if we do the right thing, i.e, providing universal coverage, but we all seem to be going the other way. In short, it is like Dicken’s time in which the noisiest authorities say we suffer, for good and evil, when compared to other cultures.

More Complicated Than Lack of Morality

It is more complicated than the U.S. being morally deficient. Our history as a culture, more than our lack of morality, complicates universal coverage and fairness. America was founded 233 years ago, in 1776, on the notion that a weak government is the best government, that government should not intrude on individual freedoms, and that equal opportunity trumps equal results for all.

Reid makes the mistake of equating the health of nations with their health system. Health systems contribute only about 15% to health outcomes. The rest is due to life styles, the homogeneity of its culture, obesity, family cohesiveness, factors such as domestic violence and automoble fatalities, and socioeconomic conditions.

In the U.S. health system, a culture of individualism plays a role. We believe strongly in individual rights – the right to live as one pleases within limits, the right of assembly, the right to speak out, the right of a free press, the right to pursue opportunity , the right to become rich, and the right to bear arms. These traditions pose problems.

Uneven Results

The U.S health system produces uneven results. It sometimes discriminates against those without means. It often does not provide care for non-citizens. It is noisy and argumentative, as demonstrated in town hall meetings. It leads to lousy health statistics. If one were to take the health outcomes of 20% of us who are recent immigrants, legal and illegal, and a 100,000 or so of us killed on the streets and highwaysl out of the equation, our outcome statistics would surpass those of most other nations. It is decentralized and comprised of many subsystems – private and public. It resists a command and control centralized decision making.

To sum up, the U.S. health system is sometimes messy, and sometimes unfair. It does not lend itself easily to a homogenous health system covering all and treating all equally. This is not an excuse. It is an explanation.

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