Sunday, June 18, 2017

US Health Rankings remain low and #Trumpcare will make them worse!

On many occasions this blog has made the point that, despite frequently-repeated claims that the US has “the best healthcare in the world”, we do not. This point is also made by dozens of other sources, recently including Kaiser Health News (KHN) editor-in-chief Elisabeth Rosenthal in her book “American Sickness”. In my book, “Health, Medicine and Justice: Designing a fair and equitable health care system”, and in many lectures I have given to physicians and students, I have cited the “37th in the world”  ranking the US achieved in the comprehensive World Health Organization (WHO) report of 2000. The report’s Table 10, available as a pdf at that site, indeed lists the US as #37 in Overall Performance, just below Costa Rica and just above Slovenia. On an equally telling scale, Performance on Health Level (measured by Disability-Adjusted Life Expectancy, DALE) the US ranked #72, between Argentina and Bhutan. When many US news media led their stories with “Just ahead of Slovenia!”, the Slovenian ambassador took exception, noting that his country was working hard to improve their people's health status.

But, as I also pointed out in my lectures, this table is old, based on 1997 data, and I use it because it is the last time that WHO released such rankings. I supplement it with newer data, such as the Commonwealth Fund’s “Mirror, Mirror on the Wall” from 2014. This compares fewer countries, albeit appropriate, developed, wealthy, OECD countries. In this study, the US also ranks last overall and in many subscales; I have published this graphic before as well.  

Now, we have new rankings to refer to, the Bloomberg Global HealthIndex from 2017. It would be nice to be able to say that the US had moved up from the 2000 WHO report, but now, at #34 (and still just behind Costa Rica) the change is really insignificant. Slovenia, it might be noted, has moved up, to #27, so maybe their efforts are paying off!

Given the recalcitrance of US health status to improvement, it is obviously important to look at the ”why” as well as the “what could be done?”. This is especially now, given that these ranking do not yet reflect any negative impact that may happen through the repeal of the Affordable Care Act (ACA) and its replacement by a a Republican plan (#Trumpcare). The contents of the bill that the Senate is currently working on, and which Majority Leader McConnell hopes to bring to a vote by July 4, remain secret not only to the public but also, apparently, to many or most senators. Therefore, the bill passed by the House of Representatives, the American Health Care Act (AHCA) remains our best guide to what the final plan may look like.

And it is not encouraging; the Congressional Budget Office (CBO) estimates that 23 million Americans willlose health insurance, about equally from loss of Medicaid expansion and from  cuts to support for the health insurance exchanges set up by ACA. This will unquestionably mean that the overall health status of Americans will go down, both in absolute terms and relative to other nations. Without health insurance, people will not access health care, especially for prevention and “minor” problems (or problems that are not really minor but so far not, or minimally, symptomatic). This means that by the time that their health is so bad that they seek care, they are less likely to survive or do well, and also that the cost of their care will be far higher. This is not a plan to most efficiently use healthcare dollars to maximize the health of the American people.

So what is going on? In a recent blog post (“Pre-existing conditions and profit-taking: the causes of our healthcare problems, May 29, 2017)  I wrote “The AHCA is basically a tax-cut-for-the-1% bill, with the money coming from the health care coverage for the rest of us.” That is true, but the question that still needs to be answered is “why”? Ultimately, it is a question of values: if the goal was to have the best possible health status for the American people, rich or poor, white or black, native born or immigrant, rural or urban, this would not be the system that we have and #Trumpcare would be designed to fix the problems with the ACA, not to exacerbate them. President Trump and the GOP have emphasized, in the campaign and since, that for many the ACA has not made insurance accessible because the premiums are too high. This is a good point, and a solution would be great; unfortunately, the AHCA would make them higher, and price out far more people. The values of the Republican leadership are clearly to maximize tax cuts and other financial benefits to the richest American people and corporations, and this AHCA will do. The perpetrators are not among those at the margins; even those congresspersons and pundits who are not truly wealthy have outstanding health insurance for life, and are certain that they will not be in the marginalized group, and that they will be able to access the “best health care in the world”.

Of course, even when you have great insurance and access to “everything”, it is not always better. Sometimes if you are too well-insured you get too much care, tests and procedures and drugs that can put you at risk of harm. And even in the “best” facilities things don’t always go well – medical errors are common, communication can be poor, and even when there are no screwups bad things can happen. Donald Berwick, head of the Institute for Healthcare Improvement (IHI), and former interim head of the Center for Medicare and Medicaid Services (CMS) talks about the US perhaps having the best “rescue care” in the world. But even that is not so good; many IHI initiatives are focused on changing that system to work better, including improvement capability, patient safety, and population health. Anyone who has been sick, or in the hospital, or had a close friend or relative in such a situation recently, can testify to the failings of our health care delivery system even for the well-insured.

So the situation in the US was not good up until now, and will almost certainly get worse with #Trumpcare. Many of the people who will suffer most are those who voted for the President and the GOP members of Congress. Maybe they think that the bad things will not happen to them and their families, but only to “others”.  But they will, and we need to move up in the rankings, to be closer to other OECD countries.

Maybe the solution for the US is not to mimic France, or Italy, or Canada. But whatever the solution is, it has to pass the empiric “does it make our people’s health better?” test. And clearly #Trumpcare will not.

1 comment:

Anonymous said...

At some point we are going to need to deal with the more fundamental issues underlying poor health, namely poverty. While better access to health care services for the poor is helpful, it will not change the underlying problem of the health gradient. As researchers such as Marmot and Wilkinson have repeatedly shown, countries that have the largest disparities in wealth , the U.S. currently has the largest gap, consistently have the worst overall health measures. As someone who has provided primary care to homeless and desperately poor urban populations for the past 32 years, I am personally tired of trying to figure out how to patch together patients whose bodies have been ravaged by the structural violence of poverty, racism, trauma, and other forms of discrimination. Better access to care will help these patients to deal with the symptoms of structural violence, but the underling disease goes merrily on.

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