Saturday, May 2, 2009

Health disadvantages of Americans compared to Europeans

I have written often about the absurd non-system of health care and health insurance that exists in the United States, and unabashedly argued for (and, I hope, supported these arguments with data) a single-payer health system such as that that exists in Canada. I have also addressed the inequities that this creates for our people, with great disparities in health outcomes between the rich and poor and between the insured and uninsured. I have cited studies and other data that shows that, despite spending more than twice as much as any other developed country on health care, our outcomes are worse – our infant mortality and maternal mortality rates, our life expectancy, our years of productive life lost and disability-adjusted life expectancy, along with virtually every other measure.

The March 2009 issue of the American Journal of Public Health contains an article by a group from the Netherlands entitled “Health disadvantage in US adults aged 50 to 74 years: A comparison of the health of rich and poor Americans with that of Europeans”.[1] The goal of the study was to look at the health differences that exist between Americans and Europeans and assess whether wealth is a factor in those differences, and whether there are differences in Europe as well. In other words, it looked at both the difference in health between wealthy and poorer Americans and Europeans (comparing “tertiles”, top, middle and bottom thirds of wealth within each country, to minimize the impact of differences in wealth between countries) as well as the overall difference between Americans and Europeans. The study examined 9,900 Americans aged 50-74 and compared them to 6,500 English and 17,000 mainland Europeans of the same age range. To exclude the effect of racial disparities (why? see my comment below), only non-Latino white US adults were included in the study.

The results?

1. The rate every disease examined was higher in the US adults than in either the English or European groups.
Rates of cancer in the US were 11%, while 6% in England and 5% in Europe. Heart disease rates were 18% in the US, 12% in Britain, and 11% in Europe.
2. In all groups the rate of disease was higher in the poorer than in the wealthier groups. Except for cancer, apparently an equal-opportunity disease
3. The difference between rich and poor were much greater in the US and England than in Europe.
Example: Risk of stroke of poorest third of Americans compared to richest was 1.9; in England 2.08 (not a significant difference) but in Europe 1.36; for heart disease the numbers were 1.94 for the US, 2.13 for England and 1.38 for Europe.

The exclusion of all but non-Latino whites from the US sample is hard to justify because 1) these people are Americans and the explanation often heard that it is minorities who have poorer health as if this was an excuse or OK, and 2) the growing numbers of racial minorities in Europe were not excluded. Amazingly, however, even with this exclusion, health was much worse in the US. Including all Americans, the non-white and Latino who in fact often are on the “short end” of health disparities, would make the differences even greater!

And what about the fact that the wealth/class differences in England are at least as great as in the US? In part of this can be explained by the fact that, although they have a National Health Service it was until recently very underfunded (remember, there is a difference between how much money is spent per capita and how it is distributed) and that wealthier Britons can “buy out” and purchase private care. However, it is important to note the context: while the odds of having heart disease in the poorest vs the richest third in England was 2.13, slightly more than the 1.94 in the US, the overall rate of heart disease was only 2/3 of that in the US (12% vs 18%), thus all English groups are doing significantly better than their US counterparts.

What will it take to convince Americans that we do NOT have the “best health care system in the world”? At best, many Americans get the best health care available much of the time (and even the most privileged often suffer from getting too much care), many others get less than the best care, and yet others get almost none. As far as “system”, we have none; it is, in Ferrer’s words a “non-system”.[2] The data is clear, consistent, replicable, and unimpeachable. Virtually all other first-world countries with health systems and universal coverage (whether from single-payer, national health service, or highly regulated non-profit insurance companies) have far better health outcomes for their people at far lower cost.

We can no longer plead ignorance of the facts (although the ignorance of many of our leaders, willful or otherwise, should not be disregarded). Our policies, our insistence on having a bad system (or non-system) that spends huge amounts of money with poor outcomes and our resistance to a change that will improve both, represents either an ideological commitment to bad ideas, or complete corruption in selling out to those insurance companies, pharmaceutical and device makers, and providers who pocket the huge amount of money we call “health care expenditures” but are really a gift of profit from us all at the expense of our health.

[1] Avedano M, MM Glymour, J Banks, J Mackenbach, “Health disadvantage in US adults aged 50 to 74 years: A comparison of the health of rich and poor Americans with that of Europeans”, Am J Pub Health Mar09; 99(3):540
[2] Ferrer RL, “Within the system of no-system”, JAMA 2001;286:2513-14

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