U.S. Health: First in Spending but Last in Results…Why?

America’s top clinical talent and mega-investments in “health services” do not correlate to better overall health compared to other countries. Learn why.

Let’s get the good news out of the way first.

If you are going to get sick and have great insurance or lots of money, there is no better place to do so than in the United States. We excel at taking care of really sick people.

Medical miracles are performed daily through an amazing pool of talented clinicians who have access to the best technology, facilities and pharmaceuticals.

In this regard, we are the envy of the rest of the world. But there remains a most vexing question: Why do we invest more in healthcare than any country on the planet to have the “best of the best”, only to come in last compared to other countries in success measures like outcomes, longevity, quality and access?

Simply put, America’s mega-investment in “health services” does not correlate to better overall health.

The Commonwealth Fund is a private foundation started in 1918 by one of America’s first female philanthropists Anna Harkness. Its mission is to research, study and promote high performing health care systems to achieve better access, improved quality, and greater efficiency, particularly for society’s most vulnerable citizens.
 
Paying More for Less
In its most recent report, Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care, the authors note that despite having the most expensive health care, the United States ranks last overall among the 11 countries on measures of health system equity, access, administrative efficiency, care delivery, and health care outcomes.

While there is room for improvement in every country, the U.S. has the highest costs and lowest overall performance of the nations in the study, which included Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, and the United Kingdom. The U.S. spent $10,739 per person on health care in 2017, compared to $4,094 in the U.K., which ranked first on performance overall.

Among the 11 high-income countries surveyed, the U.S. is the only one without universal health insurance coverage. The U.S. offers its citizens the least financial protection among these wealthy countries.

Since 2004, the U.S. has ranked last in every one of six similar reports.

In a recent issue of the New England Journal of Medicine, lead author and Commonwealth Fund senior vice president for policy and research Eric Schneider, M.D. reflected on lessons from top performing countries and actions the U.S. could take to move from last to first among wealthy countries. They include:

  • Expand health insurance coverage. The highest-performing countries have universal coverage that allows people to get the health care they need at little or no cost.
  • Invest more in primary care. Spending up front to make primary care accessible, available on nights and weekends, and affordable keeps people healthier and reduces costs in the long run.
  • Cut down on paperwork. The U.S. leads the world when it comes to time spent dealing with the requirements of our cumbersome health insurance system. Reducing the administrative burden would give countless hours back to patients, caregivers, and physicians while also making the system easier for people to navigate.
  • Invest more in social services to reduce disparities. Factors beyond traditional health care, such as housing, education, nutrition, and transportation, have a substantial effect on people’s health. Investing in services that provide support in these areas can make our population healthier as a whole and reduce health care costs.

Additional report findings related to improving the U.S. health system include:

  • Access to Care: Other studies show that access to care and ability to afford care have improved markedly in the U.S. following the Affordable Care Act. Nevertheless, compared to other countries, Americans of all incomes have the hardest time affording the health care they need. The U.S. ranks last on most measures of financial barriers to care, with one-third (33%) of adults reporting they did not take a prescription drug, visit a doctor when sick, or receive recommended care in the past year because of the expense. This is four times the rates for patients in Germany (7%), the U.K. (7%), Sweden (8%), and the Netherlands (8%).
  • Health Care Outcomes: The U.S. ranks last overall on health care outcomes. Compared to other countries, the U.S. comes in last on infant mortality, life expectancy at age 60, and deaths that were potentially preventable with timely access to effective health care. However, there are some bright spots: the U.S. performs relatively well on certain clinical outcomes, such as lower in-hospital mortality rates for a heart attack or stroke and is a top performer in breast cancer survival.
  • Care Process: The U.S. ranks in the middle for care process, which is a combination of four separate measures: delivery of preventive services, safety of care, coordinated care, and patient engagement. On three of the four measures, the U.S. ranks near the top, coming in third on safety and fourth on prevention and engagement. The U.S. tends to excel on measures that involve the doctor–patient relationship, wellness counseling, and preventive care, such as mammograms and adult flu shot rates.
  • Administrative Efficiency: The U.S ranks near the bottom on this measure because of the amount of time providers and patients must spend dealing with administrative issues, duplicative medical testing, and insurance disputes. More than half (54%) of U.S. doctors reported problems trying to get their patients needed treatment because of insurance coverage restrictions. In Norway and Sweden, which rank first on this measure, only 6 percent of doctors reported this problem.

Special thanks to the Commonwealth Fund for their research as well as the outstanding materials they provide.  


For Consideration:

  • What do you see as the key reasons for the U.S. to have such low performance ratings compared to the investments made in the health system?
  • What might we learn from other countries that invest less but have health measures that are significantly better than the U.S.?
  • Do you believe this data provides a valid comparison of the performance of health systems and also reflect the “performance measures” that are important in assessing value?

Resources:

Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care:

Additional resources my be found by clicking on the “Resources” in the Navigation bar

 

2019: The Ten Greatest Threats to Health Worldwide

How should the planet’s ten biggest health threats affect our approach to health reform in the United States?

The world we live in is facing multiple health challenges. The World Health Organization (WHO) recently released a report detailing the top ten major threats to global health.  From outbreaks of vaccine-preventable diseases like measles, growing rates of obesity, to the health impacts of environmental pollution and climate change, these issues are relevant in our approach to health reform and health policy in the United States.

Here are the planet’s ten biggest health threats according to WHO:

1.    Air pollution and climate change

According to WHO, nine out of ten people breathe polluted air every day. In 2019, air pollution is considered by WHO as the greatest environmental risk to health. Microscopic pollutants in the air can penetrate respiratory and circulatory systems, damaging the lungs, heart and brain, killing 7 million people prematurely every year from diseases such as cancer, stroke, heart and lung disease.

2. Noncommunicable diseases

Seventy percent of deaths worldwide are due to noncommunicable diseases, such as diabetes, cancer, and heart disease.

According to WHO, the five risk factors driving increases in noncommunicable diseases are tobacco use, alcohol use, physical inactivity, unhealthy diets, and air pollution. 

3. Influenza

The world will face another influenza pandemic – the only thing not known is when it will hit and how severe it will be. Global defenses are only as effective as the weakest link in any country’s health emergency preparedness and response system WHO says. 

4. Fragile and vulnerable settings

Over 22% of the world’s population lives in fragile settings, which are defined as places where access to basic health care is minimal, often due to being in a state of crisis and having poor health services.

Fragile settings exist in almost all regions of the world, and these are where half of the key targets in the sustainable development goals, including on child and maternal health, remain unmet. 

5. Antimicrobial resistance

The development of antibiotics, antivirals and antimalarials are some of modern medicine’s greatest successes. Now, time with these drugs is running out. Antimicrobial resistance – the ability of bacteria, parasites, viruses and fungi to resist these medicines – threatens to send us back to a time when we were unable to easily treat infections such as pneumonia, tuberculosis, gonorrhea, and salmonellosis. The inability to prevent infections could seriously compromise surgery and procedures such as chemotherapy. 

Drug resistance is driven by the overuse of antimicrobials in people, but also in animals, especially those used for food production, as well as in the environment, according to WHO.

6. Ebola and high-threat pathogens

When it comes to responding to a high-threat pathogen such as Ebola, context is “critical,” according to WHO. The way a high-threat pathogen spreads and impacts a rural area might look very different from the way it would look in urban areas or active conflict zones—making it difficult for health systems and governments to prepare an effective emergency response.

WHO’s current watchlist of high-treat pathogens includes Ebola, Zika, SARS, and disease X—a placeholder for any unknown pathogen that could cause an epidemic.

7. Weak primary care

Primary care is supposed to be the most consistent and accessible form of health care a patient has over their lifetime, WHO explains. But when a country lacks adequate primary care facilities, patients lack affordable and comprehensive care for their needs, which can cause everyday health problems to evolve into health emergencies.

8. Vaccine hesitancy

Vaccine hesitancy – the reluctance or refusal to vaccinate despite the availability of vaccines – threatens to reverse progress made in tackling vaccine-preventable diseases. Vaccination is one of the most cost-effective ways of avoiding disease – it currently prevents 2-3 million deaths a year, and a further 1.5 million could be avoided if global coverage of vaccinations improved. 

Measles, for example, has seen a 30% increase in cases globally. The reasons for this rise are complex, and not all of these cases are due to vaccine hesitancy. However, some countries that were close to eliminating the disease have seen a resurgence (including the United States). 

9. Dengue

About 40% of the world is at risk of becoming infected with dengue, a mosquito-borne illness that infects 390 million people each year and kills up to 20% of people with a severe form of the disease, according to WHO.

10. HIV

The progress made against HIV has been enormous in terms of getting people tested, providing them with antiretrovirals (22 million are on treatment), and providing access to preventive measures such as a pre-exposure prophylaxis (PrEP, which is when people at risk of HIV take antiretrovirals to prevent infection). 

However, the epidemic continues to rage with nearly a million people every year dying of HIV/AIDS. Since the beginning of the epidemic, more than 70 million people have acquired the infection, and about 35 million people have died.

The list provides an overview of the top 10 health threats WHO and the organization’s partners will target under a five-year strategic plan that kicks off this year. According to WHO, the goal is to ensure one billion more people benefit from access to universal health coverage, one billion more people are protected from health emergencies, and one billion more people enjoy better health and well-being.


For Consideration:

  • Does the WHO list of the top Global Health Risks fit with what you consider to be the top health risks facing the United States?
  • Which risks as noted by WHO should be included in the top health risks faced by Americans?  
  • What other issues do you consider to be the Top Health Risks facing the United States?
  • Many of the top risks defined by WHO are “Social and Environmental Determinants of Health.” What is your view on whether these should be considered part of health reform?

Additional Resources:

Visit the World Health Organization’s web page to learn more about the Top Global Health Threats of 2019.

Review this primer on Social Determinants of Health from NEJM Catalyst.

Go deeper on Social Determinants of Health by visiting the Centers for Disease Control and Prevention’s website: Social Determinants of Health: Know What Affects Health

$3.5 Trillion: Where it Comes From and Where it Goes

In the time it takes to read this $4 million will be spent on healthcare. Here’s where it went.

You don’t need to be an economist to understand that in the time it takes to finish this sentence $4 million will be spent on healthcare.  On average, this is the amount of money that will trade hands as you read each and every sentence.

Where does this money come from? Well, mainly from you and people like you.

Today the annual price tag for the American healthcare system is $3.5 trillion.[i]  This is what $3.5 trillion looks like:

$3,500,000,000,000

That’s an average of $10,739 per citizen per year to provide some, but not all, Americans with access to health services.

To put this number in perspective, about eight trillion dollars a year is spent on healthcare worldwide.[ii] This is roughly ten percent of the world’s Gross Domestic Product (GDP). By comparison, healthcare in America currently consumes 17.9% of its GDP and climbing.

No other industrialized country has similar healthcare costs. We spend two-and-a-half times more than other developed nations.

By any standard these are big numbers. Perhaps if the United States had the healthiest citizens with the best longevity our investment in healthcare would represent a bargain.  But, as noted in other posts, we put more in but get less out compared to other nations.

Imagine putting more money into your 401k retirement plan than your neighbors only to learn they were much better off with a larger nest egg because they invested in things that provided a higher return. The challenge for reforming healthcare is not much different.

While the dialogue around healthcare is complex, the goal of reform is simple: Where should we make investments in keeping with a set of goals that provide the best returns we seek to achieve with the health system?  As you consider this question, let’s start by looking at where all money for the health system comes from and where it goes. 

Where money comes from

To start, it’s important to understand that the majority of resources for health come directly from government-run health and medical programs funded through taxes paid by employers, employees and retirees.

The government also influences how private funds from employers and citizens are collected and spent through a complex series of laws, regulations and tax incentives. These include things like coverage mandates, payroll taxes and medical savings accounts.

Explaining the intricacies of how the healthcare finance system works would fill volumes of books. For now, we’ll keep things simple by using a view from government accounting known as “Type of Sponsor”.  Type of Sponsor is the entity that is ultimately responsible for financing the health care bill, such as private businesses, households, and governments.  These sponsors pay health insurance premiums and out-of-pocket costs, or finance health care through dedicated taxes and/or general revenues.[iii]

In using this approach, we see that the federal government accounts for the largest share of health spending at 29%, followed by households at 28%, private businesses at 20 % and finally state and local governments at 17%.

Today, almost half of all funds used in healthcare (45%)  come from government sources including the federal government which funds programs such as Medicare (healthcare for seniors) as well as state and local governments which contribute funds to support programs such as Medicaid (healthcare for low income).

The second largest category is “households” which is really all of the “out-of-pocket” expenses consumers like you spend on everything from healthcare co-pays to the costs of over-the-counter and other items purchased to manage health and medical conditions.

Where the money goes

Now that we have a sense of where money comes from to fuel today’s the health system, let’s shed some light on where we all this money goes. Here is how $3.5 trillion is spent:

A quick glance at where the money goes shows that more than half of all funds go to support hospitals and physicians. Almost a quarter of all funds are used to support the cost of administering health systems and programs.  This leaves roughly one quarter of all funds for everything else such as home health, school and workplace health, dental and other clinical disciplines such as chiropractic and physical therapy.

Within these numbers are other issues to be understood and addressed. As an example, the Institute of Medicine reports that up to one third of all expenditures, about $750 billion, is spent on unnecessary administrative services, inefficiencies and care that doesn’t actually improve health.[iv]

For most of us, it’s easy to get lost in these numbers. To better understand what’s going on, and formulate our own views on how we spend on healthcare, let’s look at four trends driving how money is spent which start to shed light on why we have some of the performance issues we’ve already noted. 

It’s Sickcare not Healthcare

While we euphemistically talk about the reform of “healthcare”, the numbers above show that that the majority of the systems and expenditures today are heavily weighted towards treating people once they become ill or injured. While this may seem like stating the obvious, it’s a fundamental issue when it comes to the debate around spending more than any other country only to have our comparative measures be lower than other countries spending less.  

When you “follow-the-money” you see that today’s health care system is mainly a disease-management system. It’s rooted in financial incentives for treating medical problems once they occur as opposed to helping people maintain or regain their health.

This brings us to a fundamental question critical to the health reform debate: What is the purpose and goal of our health system?

Should it focus on treating illness and injury once these occur or should it be geared towards prevention and health maintenance?

To put this into perspective, in 2015, thirty two percent of all funds spent went to hospitals while two tenths of one percent of all funds went towards things like maternal/child health services and school health programs.[v]

The simple answer is that the system should do both. The deeper question to ponder is what the balance should look like in terms of priorities, expenditures and desired outcomes.


For Consideration:

  • What is you view on the balance of where funds come from and how they are allocated or spent?
  • If you could change things, how would you balance investments in treating people who are ill or injured versus investing in prevention and wellness measures?

Resources:

Americans Remain Dissatisfied With Healthcare Costs is a report by Gallup on the results of a recent poll showing that most Americans consider healthcare costs and access to be a major issue. Provides a breakdown of the issues along with useful charts to explain details surrounding the issues.

The National Health Expenditure Accounts (NHEA) are the official estimates of total health care spending in the United States. Dating back to 1960, the NHEA measures annual U.S. expenditures for health care goods and services, public health activities, government administration, the net cost of health insurance, and investment related to health care. This is one of the best starting point sites for researching or understanding health expenditures in the United States.

Download this brief from CMS which highlights National Health Expenditures for the most recent year data is available. A concise resource that serves as a great handout or reference guide to understanding health expenditures.

Explore and compare Global Health Expenditures through this site sponsored and managed by the World Health Organization. Includes data updated to 2018 and reflects health financing reforms taking place in Member States, between 2000-2016.


References:

[i]https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/NationalHealthAccountsHistorical.html

[ii] World Health Organization. Global Health Expenditure Database (GHED) [

[iv] http://www.nationalacademies.org/hmd/Reports/2012/Best-Care-at-Lower-Cost-The-Path-to-Continuously-Learning-Health-Care-in-America/Infographic.aspx

[v] National Health Expenditures by type of service and source of funds, CY 1960-2015. CMS.   https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2015.zip

The High Cost of Self-Inflicted Disease

The role of citizens vs. government in managing health goes beyond the current health reform debate in Washington.

An issue as big as healthcare is the environment. And so, what if there was a way to dramatically improve the health of all Americans while decreasing our consumption of fossil fuels by a billion gallons a year?

Transformational new technology? Innovative legislation from Washington?  The answer is simple. We would achieve these goals by reducing the weight of the average American to what it was in 1962. [1]

Sheldon Jacobson is a computer science professor who has studied the effects of obesity and fuel consumption.  His work points to a simple matter of physics. Heavier drivers increase fuel consumption. Car engines use more energy to move more weight. The added weight Americans have packed on since the sixties costs motorists an estimated $4 billion a year.[2]

Supersizing America

Americans are being “supersized” at an alarming rate as part of a global obesity pandemic that is driven by a variety of lifestyle and environmental factors. Around the world today more people now die from obesity than malnutrition. It has overtaken tobacco as the largest cause of preventable disease.

Obesity is a real disease recognized by the American Medical Association, World Health Organization and others. Like smoking, overreliance on alcohol and drugs, it is a non-communicable disease.

Communicable diseases, like flu, malaria and measles are caused by forces in nature. Most non-communicable diseases may be influenced by things like genetics or exposure to hazardous materials in the environment, but in some manner, are self-inflicted by choices we as consumers and as a society make.[3]

Let’s use obesity to illustrate how self-inflicted diseases impact both our health and our wallet.

Today, more than two-thirds (68 percent) of American adults are either overweight or obese.[4]  Since 1980 adult obesity rates have more than doubled.[5] [6] If nothing changes 42 percent of U.S. adults will be obese by 2030 with more than ten percent of Americans being severely obese. [7] 

And while obesity is an “equal opportunity” disease affecting all walks of society, it is more pervasive and impactful among low income Americans and minorities. [8]

Beyond its direct impact, obesity is also a “gateway disease”. It dramatically increases the prevalence of diabetes, cardiovascular disease, cancer, osteoarthritis, infertility, sleep apnea and other health conditions.[9]   For example, as the prevalence of obesity grows, new cases of type 2 diabetes, coronary heart disease and stroke, hypertension and arthritis are on track to increase 10 times between 2010 and 2020 — and then double again by 2030.[10]

Over the next twenty years it is estimated that obesity will be a causal factor in 8 million cases of diabetes, seven million cases of coronary heart disease and stroke and a half million cases of cancer.[11]

A heavy price paid by all

Obesity is not only bad for our health, it’s also very expensive. Worldwide, obesity has the same economic impact as smoking or armed conflict.[12]

Within the United States, obesity-related illness treatments cost Americans an estimated $190.2 billion annually and will add another $550 billion in additional costs between now and 2030. [13] [14]

On average Americans who are obese spend more on medical services and medications than smokers and heavy drinkers. [15]  They incur 40% higher inpatient hospital costs, 27% more physician visits and outpatient costs and consume 80% more prescription drugs.[16]

Beyond direct medical, obesity impacts the productivity and competitiveness of America’s employers and workforce. A study by the Society of Actuaries estimates that U.S. employers are losing $164 billion in productivity each year due to obesity-related issues with employees.[17] The Robert Wood Johnson Foundation predicts that annual economic productivity loss due to obesity is likely to reach $550 billion by 2030.[18]

Without significant change, obesity-related costs will rise dramatically with increases being absorbed by employers and goods and services they provide. Consumers will be increasingly impacted by larger out of pocket expenses as well as higher taxes to support programs such as Medicare and Medicaid which are already teetering on the brink of disaster because of their national price tag. Obesity-related medical expenditures already cost these programs an extra $62 billion annually.[19]

Solving for Obesity is simple and complex

When it comes to understanding what is driving obesity and what can be done to slow or stop this epidemic, the answer is both simple and complex.

At a simple level the obesity epidemic is caused by Americans consuming more calories through food and beverages than they expend.

But the deeper answer to why this is occurring is rooted in a myriad of issues that have unfolded over the past four decades.

Today we live in a world where inactive lifestyles are the norm and inexpensive, high calorie foods and drinks are readily available 24 hours a day.

There are fewer safe places to walk or play. Parts of our communities (especially low-income neighborhoods) lack food outlets offering affordable, healthy foods. We are constantly bombarded by advertisements for unhealthy foods and beverages.

While we are all affected by these trends, our children are at greatest risk. Today, one in three American children is overweight or obese. The prevalence of obesity in children more than tripled since 1971 and is now the Number One health concern among parents in the United States, topping drug abuse and smoking.[20]

If you are a parent and want your child to be healthy, it would seem reasonable that there are simple things to do to ensure that they are not overweight or obese. For example, a study from the American Journal of Preventive Medicine found that eliminating just 41 calories a day could halt rising body weight trends in children and teens.[21]

Unfortunately, a variety of forces make it difficult to achieve such a simple goal.

Today the majority of children in the United States are high in added sugar and fat and too low in fruits and vegetables, whole grains, and low-fat and nonfat dairy products.[22]

Children are less active today than at any point in our history. On average, kids consume 7.5 hours of screen or media time a day.  In 1969, half of all children walked or biked to school. Today about 13 percent walk or bike to school.[23]

Fast food companies are specifically marketing to children and adolescents. In one study by the Robert Wood Johnson Foundation, McDonald’s was found to have the strongest emphasis on the children’s market, with 40 percent of 44,062 ads studied aimed at kids.[24]

Beyond the blitz of airtime focused on children, the fast-food companies use free toys and popular movies to appeal to kids by focusing on promotions, brands, and logos—not on food.[25]  

As a result, on any given day, more than one third of U.S. children eat fast food.[26]  French fries are now the most common “vegetable” that kids eat, making up 25% of American children’s total vegetable intake.[27]

And so, can something like regulating fast food advertising to children (like advertising bans and warning labels for tobacco products) impact the obesity epidemic in children, which in turn, may improve health and lower medical costs?

The province of Quebec banned fast-food advertising to kids in electronic and print ads 34 years ago. And while Canada is seeing as similar explosion in childhood obesity like the United States, Quebec has the lowest childhood obesity rate in Canada.

Researchers from the University of British Columbia who studied the impact of the advertising ban in Quebec concluded two things. First, the ban resulted in a 13 percent reduction in fast food expenditures.  At the same time, they estimate that 4 billion fewer calories were consumed by children in the province.[28]

In the end, childhood obesity has many consequences for our kids and our country. The most dire is that obesity may lead to a shorter life span for our children than that of their parents.[29] Children who are obese are more than twice as likely to die before the age of 55 compared to non-obese children.[30]

Solving for the Obesity epidemic brings us face-to-face with the need to better understand and make decisions as part of the health reform debate. Like other self-inflicted diseases (think smoking/vaping, alcohol/drugs), highlighting the consequences of Obesity illustrates the need to broaden the health reform discussion to include a view towards creating new paradigms and models to prevent or mitigate many of the health issues we now face.   Failure to do this means such medical and health conditions will continue to fill hospitals beds, cost more in dollars and deaths that would otherwise be prevented.


For Consideration:

  • What is your view in how to balance the responsibility of a citizen to manage their own health with the role government plays in legislating or regulating products and services in an attempt to create healthier environments and citizens?
  • Should drinks containing high amounts of sugar be regulated or taxed in an effort to reduce obesity (similar treatment to how alcohol and tobacco are taxed and regulated)?
  • What other actions might be taken by state and local governments to put forward legislation or regulations to create healthier environments which encourage a high level of health status or mitigate the effects of personal choices leading to a growing number of Americans who are destined to have costly health and medical conditions that could be avoided?

Additional Resources:

“Sugar: Consumption at A Crossroads” by the Credit Suisse Research Institute

Get the Facts: Sugar-Sweetened Beverages and Consumption from Centers for Disease Control and Prevention (CDC)

Learn more about Noncommunicable Diseases with news and information from the World Health Organization.


References:

[1] Sheldon Jackson (2006,2008), The Engineering Economist. “The Economic Impact of Obesity on Automobile Fuel Consumption,” published in The Engineering Economist (Volume 51, Number 4, 307-323, October –December 2006)

[2] Ibid

[3] Noncommunicable diseases fact sheet, (2013), World Health Organization, http://www.who.int/mediacentre/factsheets/fs355/en/

[4] Flegal KM, Carroll MD, Ogden CL, et al.  Prevalence and Trends in Obesity among U.S. Adults, 19992008. Journal of the American Medical Association, 303(3): 235-41, 2010.

[5] National Center for Health Statistics.  “Prevalence of Overweight, Obesity and Extreme Obesity among Adults.”

[6] Ogden CL, Carroll MD, Kit BK, Flegal KM.  Prevalence of Obesity in the United States, 2009-2010.  NCHS data brief, no 82.  Hyattsville, MD: National Center for Health Statistics, 2012.

[7] Ibid

[8] Trust for America’s Health and Robert Wood Johnson Foundation.  F as in Fat: How Obesity Threatens America’s Future — 2011.  http://www.tfah.org/report/88/ (accessed July 2012).  Based on data using the previous BRFSS methodology in use from 2008-2010.

[9] Y Claire Wang, Klim McPerhson, Tim Marsh, Steven L. Gortmaker, Martin Brown. Health and economic burden of othe projected obesity trends in the USA and the UK. The Lancet. 2011. 815-827

[10] F as in Fat: How Obesity Threatens America’s Future. Trust for America’s Health (TFAH) and the Robert Wood Johnson Foundation. 2012.

[11] Y Claire Wang, Klim McPerhson, Tim Marsh, Steven L. Gortmaker, Martin Brown. Health and economic burden of other projected obesity trends in the USA and the UK. The Lancet. 2011. 815-827

[12] Overcoming Obesity: An Initial Economic Analysis, McKinsey Global Institute, November 2014 http://www.mckinsey.com/Insights/Economic_Studies/How_the_world_could_better_fight_obesity

[13] John Cawley, Chad Meyerhoefer. The medical care costs of obesity: An instrumental variables approach. Journal of Health Economics, 2012; 31 (1): 219 DOI: 10.1016/j.jhealeco.2011.10.003

[14] [14] Ogden CL, Carroll MD, Kit BK, Flegal KM.  Prevalence of Obesity in the United States, 2009-2010.  NCHS data brief, no 82.  Hyattsville, MD: National Center for Health Statistics, 2012.

[15] Sturm R.The Effects of Obesity, Smoking,and Problem Drinking on Chronic Medical Problems and Health Care Costs.Health Affairs.2002;21(2):245–253.

[16] Ibid

[17]  Overweight and obesity study. Society of Actuaries. 2009. https://www.soa.org/Research/Research-At-A-Glance.aspx

[18] Trust for America’s Health and Robert Wood Johnson Foundation.  F as in Fat: How Obesity Threatens America’s Future — 2011. 

[19] Finkelstein, Trogdon, Cohen, et al.  “Annual Medical Spending Attributable to Obesity”.

[20] Overweight in Children, American Heart Association. http://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/ChildhoodObesity/Overweight-in-Children_UCM_304054_Article.jsp#.WGavuWwzWbg

[21] Wang YC, Orleans CT and Gortmaker SL.  Reaching the Healthy People Goals for Reducing Childhood Obesity: Closing the Energy Gap.  Am J Prev Med, doi: 10.1016/j.amepre.2012.01.018, 2012.

[22] Ibid

[23] The National Center for Safe Routes to School, 2011.   http://guide.saferoutesinfo.org/introduction/the_decline_of_walking_and_bicycling.cfm

[24] Fast-Food Television Ads Use Toys, Movies to Target Kids. Robert Wood Johnson Foundation. April 2013. http://www.rwjf.org/en/library/articles-and-news/2013/08/fast-food-television-ads-use-toys–movies-to-target-kids.html

[25] Ibid

[26] Caloric Intake From Fast Food Among Children and Adolescents in the United States, 2011–2012. Centers for Disease Control. September 2015. https://www.cdc.gov/nchs/data/databriefs/db213.htm

[27] Obesity in Infants to Preschoolers. American Heart Association. http://www.heart.org/HEARTORG/HealthyLiving/HealthyKids/ChildhoodObesity/Obesity-in-Infants-and-Preschoolers-Infographic_UCM_467593_SubHomePage.jsp

[28] Fast Food Consumption and the Ban on Advertising Targeting Children: The Quebec Experience. Tirtha Dhar Assistant Professor, Division of Marketing, Sauder School of Business, University of British Columbia. April 2011. http://www.marketingpower.com/aboutama/documents/jmr_forthcoming/fast_food_consumption.pdf

[29] American Heart Association, 2010; Olshansky et al., 2005

[30] Franks PR, Hanson W, Knowler M, et al.  “Childhood Obesity, Other Cardiovascular Risk Factors, and Premature Death.”  New England Journal of Medicine, 362(6):485-93, 2010.

Two Important Numbers in Health Reform are 5 & 50

5 & 50 are two numbers that explain where half of all healthcare expenditures go in America today and represent a key area health reform must address.

We often here about the $3.5 trillion we invest annually for Healthcare in the United States. Breaking this down further, this means we spend an average of  $10,739 per citizen.

This last number demonstrates how statistics can sometimes be misleading. As noted, we spend an average of $10,739 per citizen.  But, understanding where the money is actually going provides a key insight as to why our investments are high but results are often lower than other countries spending less.

Look closely at where the money goes you see that five percent of people account for 50 percent of total health spending.

Think about these stats for a moment.

Health-care spending represents almost one-fifth of the United States’ economy.

In digging further into these numbers, the data from the National Institute for Health Care Management suggests that the health problems of about 15 million Americans consume almost one-tenth of the Gross Domestic Product (GDP) of the United States — around $1.7 trillion.

Those citizens in the “five percent” group are known as “super users” of the health system.  They include the “sickest-of-the-sick” or have multiple chronic conditions requiring intense and continuous care regimens.

We are bombarded with stats that show, on average, the United States spends more on health per citizen than any other country on the planet. The reality is that most of these expenditures are concentrated on fewer people entering the health system once they are very ill (including being admitted to expensive, technology rich environments when nearing end-of-life).

Ethicists often ponder the issue of distributive justice…How do we use a finite amount of resources to do the most good for the most people?

To raise the question above is not to suggest we turn our backs on those women and men who are members of the medical “super-users” group whose lives (including quality of life) are dependent on utilizing the system in place today.  

If we are serious about true reform, the deeper issue to consider is how we change the systems super-users are dependent on to better serve their needs while becoming more effective stewards of the resources required to meet the needs of this vulnerable population.

As we look ahead, these questions are worth considering by anyone in, or touched by, the current healthcare system.


For Consideration:

  • What is your view on whether half of all resource expenditures should go towards supporting the needs of a small group of people?
  • The rapid growth of the elderly population (a baby-boomer now turns 65 every 15 seconds and will for the next decade) will expand the size of the “super-user” group requiring intensive & costly services. What alternative or innovative ideas would support the needs of this population while making better use of our resources?
  • Do you know someone who is a “super user” of the health system? What services are they dependent on? What might you change to better serve his or her needs while make better use of resources?

Resources:

If you want to go deeper in exploring this topic:

There is a great article in the Atlantic by writers Karen Weintraub and Rachel Zimmerman. Fixing the 5 Percent is a thoughtfully-written piece that explores both the problem as well as solutions others are pioneering to improve the effectiveness of services and costs.

If you want to delve deeper in the actual data and trends download this PDF from the Agengy for Healthcare Quality and Research


References:

National Health Expenditures by type of service and source of funds, CY 1960-2015. CMS.   https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/NHE2015.zi

“UNDERSTANDING U.S. HEALTH CARE SPENDING”. National Institute of Healthcare Management, July, 2011. http://www.bcnys.org/inside/health/2011/HealthCarePremiumsNIHCM0711.pdf

“The High Concentration of U.S. Health Care Expenditures”. Agency for Healthcare Research and Quality. https://archive.ahrq.gov/research/findings/factsheets/costs/expriach/

http://www.washingtonpost.com/blogs/wonkblog/wp/2013/09/19/the-two-most-important-numbers-in-american-health-care

Health Reform: What a Long Strange Trip it’s Been – Part 1

Implementation of health reform poses formidable challenges for Democrats, Republicans, and the political process itself. What can the past teach us about what to do now?


“What is old is new again”


Today’s health reform debate is deeply rooted in the ideologies and legislative efforts of the past 75 years.

Should Social and Environmental Determinants of Health be part of reform efforts? In 1945, President Harry Truman proposed solutions to these issues as part of comprehensive health reform. Can we legislate “healthcare for all” while maintaining a private system that allows consumers to choose their own physicians? In 1962, President John F. Kennedy championed such an approach.

Sound like familiar issues relevant to today?

Understanding past struggles helps to shape our current efforts for positive change by providing useful perspectives on the similarities of issues as well as the politics of reform that have persisted for decades.

And so, here’s a short history on the “roots” of today’s issues and efforts to improve health systems in America.

This installment (Part 1) begins in the 1940’s and culminates in 1969 with the landmark passage of both Medicare and Medicaid.

In Part 2, we’ll look at reform efforts from the 1970’s leading up to the passage of the Affordable Care Act and what’s happening today.


1933-1945: Franklin D. Roosevelt Administration

While health reform as a movement in the United States goes back to the early 1900’s, a national effort supported by a significant political party emerged in the 1940’s. President Franklin Delano Roosevelt believed in the concept of “healthcare for all” as part of his broader view on the role of government to create and manage “social programs” to benefit all Americans.

His key push to provide Healthcare for All was part of what would become known as “America’s Second Bill of Rights.”

President Roosevelt taking his case for Universal Health Coverage to the people as part of his initiative known as America’s Second Bill of Rights.

As World War II was coming to a close, it had been rumored that Universal Health Care was to be President Roosevelt’s next big political crusade. Unfortunately, he died just before the end of the war and so the world would never really know what might of come from President Roosevelt’s resolve to make healthcare accessible to all.


1945-1953: The Truman Administration

In November of 1945 President Harry Truman called on Congress with a special message recommending passage of a Comprehensive Health Program.

President Harry S. Truman

You can access the full speech here which enumerates the vision, issues and opportunities to deliver universal coverage to all Americans.

While the full speech is worth reading, there are two areas that are especially relevant to the challenges of today.

The first area of importance is where the Truman administration puts forward the tenent of healthcare as a “right”:

“In my message to the Congress of September 6, 1945, there were enumerated in a proposed Economic Bill of Rights certain rights which ought to be assured to every American citizen. One of them was: “The right to adequate medical care and the opportunity to achieve and enjoy good health.” Another was the “right to adequate protection from the economic fears of sickness.”

Millions of our citizens do not now have a full measure of opportunity to achieve and enjoy good health. Millions do not now have protection or security against the economic effects of sickness. The time has arrived for action to help them attain that opportunity and that protection.”

Harry S. Truman in a speech to Congress advocating healthcare as a right.

The second area that is especially noteworthy to today’s challenges and struggle for comprehensive reform is this: Long before contemporary experts began championing the notion of Social and Environmental Determinants of Health, Harry Truman nailed the correlation of these factors to the health of a nation. His proposal tied social and environmental issues to the macro view of what “systems of health” should include:

” If we agree that the national health must be improved, our cities, towns and farming communities must be made healthful places in which to live through provision of safe water systems, sewage disposal plants and sanitary facilities. Our streams and rivers must be safeguarded against pollution. In addition to building a sanitary environment for ourselves and for our children, we must provide those services which prevent disease and promote health.”

Harry S. Truman advocating that Social and Environmental Determinants of health be part of a national health plan.

The issue that ultimately became the lightning rod for Turman’s proposal was a provision that called for universal health insurance coverage to be administered and paid for by a National Health Insurance Board. The American Medical Association, quickly decried this to be “socialized medicine,” with a Congressional subcommittee labeling the approach “communistic.” The bill died, but Truman continued pushing for expanded access to health services right up to the outbreak of the Korean War which then took priority.


1953-1961: The Eisenhower Administration

President Dwight Eisenhower was known from his military career as a brillant strategist who then became an effective and savy politician.

In reviewing the impact of Truman’s push for health reform, Eisenhower came forward with a more modest approach and a very clear message for Congress, voters and special interest groups to hear:

“I am flatly opposed to the socialization of medicine. The great need for hospital and medical services can best be met by the initiative of private plans. But it is unfortunately a fact that medical costs are rising and already impose severe hardships on many families. The Federal Government can do many helpful things and still carefully avoid the socialization of medicine.”

President Dwight Eisenhower
National television broadcast to promote Eisenhower proposal for national health reform.

President Eisenhower proposed a four-part plan to increase access to affordable care for more Americans that included:

  • Federal funding to increase number of hospitals in the United States.
  • Legislation and funding increase services to those with “disabilities.”
  • Greater flexibility in allowing states to utilize federal funds for public health services.
  • Private health insurance reform to encourage new types of plans to cover more Americans.

To pitch this plan to the American public, and make very clear the differences compared to the proposals made by the Truman Administration, President Eisenhower made use of the new political tool of television (social media of the 1950’s) to make his case for health reform.

Sidenote: While the clip above is worth watching for the sake of understanding what was being proposed, it is most noteworthy in that the majority of the broadcast features one of America’s first female cabinet members Oveta Culp Hobby.

Like so many woman leaders whose contributions are lost in history, Hobby was first female secretary, of the new Department of Health, Education, and Welfare. In this role, she made the (then controversial) decision to approve Jonas Salk‘s polio vaccine. She was also the first women to receive the Army’s Distinguished Service Medal for her leadership efforts during WWII, including serving as the head of the Women’s Army Corps which was created to fill the gaps left by a shortage of men. The brilliance and contributions of Oveta Culp Hobby comes through in this short clip.


1961-1963: The Kennedy Administration

Under President John F. Kennedy, a proposal for expanding access to health services included health insurance coverage for those 65 years and older as part of a Social Security benefits package.

While this work began laying a foundation for what would ultimately become Medicare, it was met with strong opposition by special interest groups. Frustrated by the efforts of special interests to kill a bill making its way through Congress, President Kennedy went on the road to make the case for his proposal directly to the public in a series of public rallies. This effort culminated in the spring of 1962 with a rally in New York City.

Madison Square Garden: President Kennedy making the case for expanding access to health care.

Eighteen thousand citizens packed Madison Square Garden with Kennedy’s speech being televised nationally. Despite public opinion being in favor of Kennedy’s proposal the bill was defeated in Committee. President Kennedy vowed to press forward but did not live to see his plan come to fruition.


1963-1969: The Johnson Administration

Following the death of President Kennedy, Lyndon B. Johnson (LBJ) was sworn in as the President of the United States. He then won a landslide victory to be elected to a full term as President in November, 1964.

President Johnson was purposeful in visibly picking up the social programs that President Kennedy had proposed in order to “keep a promise made to the American Public.” With a Democratic majority in both houses of Congress, President Johnson had a receptive body for extensive social reforms that came to be known as the Great Society.

Even with control of Congress, there was strong opposition from the American Medical Association, conservative Republicans and congressional leaders within his own party.

With President Johnson working behind the scenes to build a coalition to support both Medicare and Medicaid programs, the Social Security Amendment was introduced in the House Ways and Means Committee in March of 1965, gained final approval by the Senate on July 28, 1965 and was signed into law by President Johnson on July 30, 1965.  It is noteworthy that such landmark legislation was passed within the first six months of President Johnson taking office.

“No longer will older Americans be denied the healing miracle of modern medicine. No longer will illness crush and destroy the savings that they have so carefully put away over a lifetime.

President Johnson on the signing of Medicare into law

As originally enacted, healthcare coverage would now be provided to those 65 years of age and older, and to the poor, blind and disabled. It covered healthcare services provided by hospitals, physicians, nursing facilities and home care providers. 

A behind-the-scenes look at what it took to make Medicare a reality.

Medicare was milestone legislation that guaranteed healthcare as a right for seniors. It showed that major reform is possible with the support of the public, and the alignment of the powers in Washington.

It should also be noted that such progress was made because elected leaders made healthcare access a legislative and executive priority. Even then, reform was a hard-fought battle.

The clip above from CBS’ Washington Unplugged is an exceptionally candid behind-the-scenes look at what President Johnson went through to make Medicare a reality. It demonstrates the kind of resolve and types of action needed today to enact meaningful reform going forward.

In Part 2, we will look at health reform events in the 1970’s leading up to the passage of the Affordable Care Act in 2010.

All videos used in this story provided via links to original content on YouTube. Full attribution and copyrights property of the original content owner who post to YouTube.

Has Healthcare Value Improved in the Last 25 Years?

Measuring the value we receive from the U.S. Health system is a tricky but important part of the health reform conversation.

Measuring the value we receive from the U.S. Health system is a tricky but important part of the health reform conversation. If we strip down the complexities there are two questions worth considering:

  • Is the U.S. health system generating better value than in the past?
  • How do factors other than the healthcare system affect health outcomes (compared to other countries)?


As noted in other articles on this site, the United States spends more per citizen than any other country but ranks lower than most on almost all comparative value measures including quality, costs and outcomes.

To examine the issue of “value” the Kaiser Family Foundation developed an approach to measure the level of improvement in health outcomes over time, and the incremental costs incurred by the health system.

This work is part of the Peterson-Kaiser Health System Tracker which includes a “Dashboard” of indicators that can be used to describe, evaluate and compare changes in the value of U.S. healthcare over time. With many measures spanning 25 years, or approximately a generation, the Dashboard paints a picture of how the value of the system has changed over time.

The assessment looks at whether the value of the U.S. health system has improved or worsened from 1991 – 2016 by measuring the level of improvement in health outcomes, and the incremental costs the healthcare system incurred at the same time.

Here is a summary of results:

  • Between 1991 and 2016, life expectancy increased by 3.1 years to 78.6, representing a 4% improvement. In the same time, disease burden (as measured by  something known as the total number of disability adjusted life years, or DALYs) improved by 12%.
  • At the same time, there was a worsening of years living in disability which is largely due to  an increase in substance use disorders. Substance use is actually one of the primary contributors to the decline in life expectancy in 2015 and 2016, the first time life expectancy has dropped two years in a row in several decades. This trend clearly points to the importance of social and environmental determinants being included in the broader debate of health reform.
  • In looking at this data there is a very troubling trend in Women’s Health where outcomes have actually gotten worse.  In the United States maternal mortality has gone up significantly from 14 deaths per 100,000 live births in 1991 to nearly 31 in 2016.  

The good news is that the study shows that health outcomes have generally improved in the U.S. over the past 25 years as measured by life expectancy and disease burden. However, since value is a function of outcomes and costs, one must also take into account the increase in health spending

In 1991, the Gross Domestic Product (GDP) attributable to healthcare was 12.8% or $788 billion. By 2016, healthcare consumed 17.9% of GDP or $3.3 Trillion. This brings us to a key question in how we evaluate value:

  • Is the 4% improvement in life expectancy and 12% reduction in disease burden enough to warrant a 40% increase in GDP consumption over the past 25 years?
  • What does this portend for future access and affordability? This is an especially important issue to address as part of health reform in the United States as we consider a shift in demographics such as increase in elderly population, as well as the impact of other key health challenges such as the Opioid epidemic.

As a comparison to America’s performance as noted above, similar nations during the same period generated an average increase in life expectancy of 5.2 years, or 7%, compared to the U.S.’s 3.1 years, or 4% improvement. In these countries, disease burden improved by 22%, compared to the U.S.’s 12%.

By these indicators, comparable countries spent under two thirds (60%) of what the U.S. spent on healthcare relative to GDP.

Relative to the health reform debate, another interesting finding is that the United States spends less on social services and more on healthcare,  but has worse health outcomes than similar countries.

And so, to summarize the question of whether value from the healthcare system has improved:

  • The outcomes generated by U.S. healthcare as measured by life expectancy, mortality amenable to healthcare, and years lost to premature death have improved over the past quarter century.
  • Total years living in disability have increased with mental health and substance use issues being the leading contributors to the increase.
  • If total spending for health had remained constant at 12.8% of GDP, one could easily conclude that the value proposition had improved dramatically. Unfortunately, healthcare spending in 2016 consumed 17.9% of the nation’s wealth, which is a 40% increase from 1991.  

This assessment points to a significant opportunity to be more efficient and effective in improving life expectancy and reducing the burden of disease while shedding light on socioeconomic factors and the potential impact lower investment in social services is having on outcomes.


For Consideration:

  • Did improvements seen over the past quarter century need to cost this much as they did?
  • Had the level of investment in the U.S. health system been at a similar level (percentage of GDP) from 1991, or mirrored other countries, what else might we have invested in to improve the health and wellbeing of citizens?
  • Do you believe that higher levels of investment in public and social services (as happens in other countries) correlates to higher levels of health outcomes?

Additional Resources:


Americans Remain Dissatisfied With Healthcare Costs

This report from Gallup summarizes results of a recent poll showing that most Americans consider healthcare costs and access to be a major issue. Provides a breakdown of the issues along with useful charts to explain details surrounding the issues.

Peterson-Kaiser Health System Dashboard

This site includes a rich set of data from credible sources that allow users to explore a variety of indicators of health spending, quality of care, access, and health outcomes. Provides great visuals and infographics that can be downloaded and used (with attribution). While easy to use, the site also includes a brief tutorial.

The Kaiser Family Foundation (KFF)

The Kaiser Family Foundation (KFF) is a non-profit, private operating foundation focusing on the major health care issues facing the U.S., as well as the U.S. role in global health policy. KFF’s website focuses on policy research, basic health care facts and numbers, and health reform implementation information. The Kaiser Family Foundation is not associated with Kaiser Permanente or Kaiser Industries.

The Single Most Important Question in the Reform Debate

Regardless of your political leanings your approach to any reform proposal will be anchored to this single question.

Regardless of your political views or social priorities, your approach to any health reform proposal or debate should be anchored to a single question. Directly or indirectly, how you answer this question is central to evaluating any proposal for creating sustainable reform.

The question that is foundational to all others in the health reform debate comes down to this:

Is healthcare a right or a privilege?

For the record, while most other developed countries have constitutionally declared or legislated healthcare as a right for all citizens, America has not. This is not an editorial comment but a statement of fact.

When the framers of the Constitution and Bill of Rights were defining fundamental human rights, average life expectancy was 35 years of age. [i]  The concept of “healthcare” as we know it today simply did not exist.

Healthcare as a right means that all citizens are guaranteed access to some level of care or services. While the type or level of service might change, the commitment of equal access to “something” does not.

For example, Canada decreed healthcare as a right in 1984.  Their system is known for guaranteeing all citizens access to certain services but often then keep patients waiting in line to access services based on budgetary targets. The United Kingdom guarantees all citizens the right to care with a founding principle of “free at the point of service” but often have some people waiting in line for service while others buy supplemental insurance policies that allow them to “jump the que” and gain better access to services.

Regardless of how the system is organized, or how well it actually works, healthcare as a right means that there is a safety net that catches all citizens.

The debate about healthcare as a right in America began with the advent of two events in history.

The first was the beginning of the Industrial Revolution. A massive shift of people going from working on farms to factories gave rise to a new set of health issues and began the debate on the role of private companies and the government in providing for the health of workers and citizens.

Around the same time medicine moved out of the shadows of quackery and into the realm of being a repeatable, scientific discipline.

Ever since, America has wrestled with whether healthcare is a right or privilege.

In the 1940’s President Roosevelt attempted to address the issue of whether healthcare is a right as part of a broader social initiative known as America’s “Second Bill of Rights.”

As WWII was coming to a close, FDR put forward a sweeping social program known as America’s Second Bill of Rights that included healthcare.

In 1945 President Truman proposed a national health program to include all Americans declaring in a speech to Congress “We should resolve now that the health of this Nation is a national concern; that financial barriers in the way of attaining health shall be removed; that the health of all its citizens deserves the help of all the Nation.”  It was denounced by the American Medical Association and called a communist plot by a House subcommittee.[ii]

The Clinton administration made healthcare their top platform priority but failed to get a plan through Congress.

Finally, the Affordable Care Act was passed during the Obama administration (aka Obamacare) in 2010 that created vehicles for citizens to have access to health plans while mandating coverage and fines for those choosing not to participate. The Trump administration from the outset worked to disassemble the Affordable Care Act.

The brief history of Affordable Care Act noted above is a cautionary tale that shows us that until healthcare is deemed a right, the fate of lasting reform will rise and fall based on the whims and views of those who control Congress and the White House (This situation continues to play out as I write this article).

An interesting corollary to the right to healthcare is our view and laws pertaining to the “right” to education. While the U.S. Constitution does not explicitly enumerate a positive fundamental right to education, a series of court decisions and legislation provide any citizen a right to a certain level of education.

As daunting as it may seem, American voters, business and political leaders have shown that they can commit to healthcare as a right in certain circumstances.

Healthcare has been decreed as a right in certain situations and for certain people. As part of the Great Society, congress enacted legislation in 1965 to guarantee seniors the right to healthcare via the Medicare program and to assist states in the provision of health services to the indigent via Medcaid.

And, since 1986, all citizens have a right to assistance in an emergency room…Unfortunately, the law only requires that a patient be stabilized. [iii]  After that you are subject to the whims of the situation.

If you believe that healthcare is a right, then any proposal for reform must call out and explicitly address this issue.


For Consideration:

  • Do you believe healthcare to be a right or a privilege?
  • If you believe healthcare to be a right, the question that follows is “a right to what?”  Is there a set of services to which everyone has access?
  • How should any proposal for reform address these fundamental questions?

Additional Resources

To better understand the history of this issue in the United States, see the article , Health Reform – What a Long Strange Trip It’s Been.

Learn which countries have Universal Health Access and explore how each has achieved this status (single payer, private system mandates, other models) from Wikipedia.

References:

[i] http://keywen.com/en/LIFE_EXPECTANCY

[ii] Dr. Howard Markel, “69 years ago, a president pitches his idea for national health care”. November 19, 2014. PBS Newshour. http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/

[iii] Health Care for Some: Rights and Rationing in the United States since 1930. Beatrix Hoffman.  University of Chicago Press. 2012

Health Reform Heroes: What can we learn from Rwanda?

Only twenty percent of citizens have electricity, but everyone has universal access to this life-changing service.

Other countries have proven that health, government and business leaders can work together to decide on what all citizens should have access to and create programs to provide universal access even in the most challenging of circumstances.

Such is the case in Rwanda. Five years ago, the government made a commitment to create a nationwide program to provide universal eye care to all citizens.

Why vision care? More than 2.5 billion people around the world suffer from poor vision without access to even the most basic treatment. Poor vision affects the ability of a child to see a classroom chalkboard or learn to read. It affects an adult’s ability to work.  

Making a singular commitment of providing universal access to vision care for all citizens was just right for a country like Rwanda. This choice addressed a health issue affecting all citizens, did not require an expensive, high tech solution and contributed to health improvement in ways that help break the cycle of poverty, especially for women.

To make universal access to eye care possible, a public-private partnership with Vision for a Nation was created to train nurses, build supply chains for glasses and eye medications, and visit all 15,000 of the country’s villages.

As of last year, the government took over responsibility for the management and financing of the services. To date, more than 2.4 million eye screenings have been carried out with over 1.2 million treatments provided.

And so, what does the good work in Rwanda have to do with health reform in the United States? Let us recognize that the United States and Rwanda are worlds apart geographically, economically and socially. But let us also not lose sight of the fact that in a poor country where less than 20 percent of the population have access to electricity, all citizens have access to a health service that improves health and allows them to lead better lives. This life-changing service is available to all because the leaders of Rwanda made it a priority and built a coalition of like-minded people and organizations to make it a reality.

As we look ahead to the process of defining, debating and developing new approaches to the health delivery system in America, imagine if elected leaders would start by “crossing the aisle” to select one thing to which all citizens would have access. This focus would provide the dual benefit of measurably improving outcomes while empowering citizens to lead more healthy productive lives. At the same time it would demonstrate that those we’ve sent to Washington D.C. could actually work together to accomplish something meaningful.


For Consideration:

  • If the United States could demonstrate change by providing its citizens universal access to one service or area, what would it be (and why)?
  • Do you believe all citizens should have equal access to a set of services? If yes, broadly what should be covered?
  • Consider asking your elected officials what one thing would they be most willing to champion to improve access to health services that benefit everyone.

Additional Resources:

Learn more about the work of Vision for a Nation and its mission to unlock the potential of the world’s poorest communities by making eye care globally accessible.

Health Costs and the Disappearing Paycheck

Annual health deductibles for workers have increased eight times faster than wages in the past decade. How is this impacting families?

Every day in America the discussion of Health Costs goes from the news room to the living room of 152 million Americans whose benefits provided by an employer sponsored plan. They don’t need the news anchor to tell them things are going in the wrong direction.

The latest Health Benefits Survey by the Kaiser Family Foundation tells the story of how healthcare costs are increasingly eating up more of the earnings of workers particpating in plans that are becoming harder for companies to provide as costs escalate.

The  2018 benchmark Kaiser Family Foundation Employer Health Benefits Survey chronicles the impact of rising health costs on both workers and employers of all sizes providing sponsored health plans. Top line things to know from this survey:

  • Annual family premiums for employer-sponsored health insurance rose 5 percent to average $19,616 in the past year, extending a seven-year run of moderate increases. On average, workers are now contributing $5,547 toward the cost of family coverage, with employers paying the rest.
  • Since 2008, annual deductibles have increased eight times faster than workers’ earnings and three times faster than general inflation.
  • A quarter (26%) of all covered workers are now in plans with a deductible of at least $2,000, up from 22 percent last year and 15 percent five years ago.  Among covered workers at small firms (fewer than 200 workers), 42 percent face a deductible of at least $2,000.

While there is a great deal of focus on expanding access to health services for the uninsured, those who are insured by company plans face their own set of challenges in the ever-growing personal costs of being insured.

The burden of deductibles on workers will continue to impact them in two ways: a growing share of covered workers will face a general annual deductible, and the average deductible will continue to increase faster than increases in take-home pay.

When it comes to employers being proactive in finding ways to help employees manage health (rather than merely paying bills when they are not) there are several trends worth noting:

  • Among large firms that offer health benefits, one in five (21%) report they collect some information from workers’ mobile apps or wearable devices such as a FitBit or Apple Watch as part of their wellness or health promotion programs. That’s up from 14 percent last year.
  • Most large offering employers (70%) provide workers with opportunities to complete health risk assessments, which are questionnaires about enrollees’ medical history, health status, and lifestyle, or biometric screenings, which are health examinations conducted by a medical professional, or both. Thirty-eight percent of large offering firms provide incentives for workers to participate in these programs. The maximum financial incentives for these and other wellness programs often total $500 or more.
  • Telemedicine: About three quarters (74%) of large offering firms (at least 200 workers) cover services provided through telemedicine, such as video chat and remote monitoring, which allow a patient to get care from a provider at a remote location. That’s up from 63 percent last year and 27% in 2015.
  • Retail health clinics: Similarly, three quarters (76%) of large offering firms cover services received in retail clinics, such as those located in pharmacies, supermarkets and other retail stores. A small share also provide financial incentives for workers to use these clinics.

“Health costs don’t rise in a vacuum. As long as out-of-pocket costs for deductibles, drugs, surprise bills and more continue to outpace wage growth, people will be frustrated by their medical bills and see health costs as huge pocketbook and political issues,” KFF President and CEO Drew Altman said.


For Consideration:

  • How is the trend of rising deductibles and other “out-of-pocket” expenses impacting you and your family? Is this a minor inconvenience or a major issue impacting other aspects of your life (e.g. daily living expenses, vacations, saving for retirement or college)?
  • How does this issue rank relative to issues you would like to have elected leaders review and address?
  • To lower costs how open are you to trying new activities such as actively particpating in workplace wellness programs or using lower cost care options such as telemedicine?

Additional Resources:

The complete Employer Health Benefits Survey report can be downloaded here which includes over 200 exhibits and in-depth review of key issues impacting both the worker and the employers who also continue to be impacted by rapidly increasing health costs.

Download the Summary of Findings which provides an overview of the 2018 survey results. This serves as a great handout for discussions or email attachment for those interested in learning more about this important issues impacting workers.

This related brief on the Peterson-Kaiser Health System Tracker examines employer claims data to measure the uptake of telemedicine services by employees and their family members.

Financial Burden of Medical Care: A Family Perspective: This downloadable data brief from the National Center for Health Statistics utilizes data from the National Health Interview Survey (NHIS) to provide key findings on the financial burden medical care has on American families. The brief reports that 1 in 5 persons was in a family having problems paying medical bills, and 1 in 10 persons was in a family with medical bills that they were unable to pay at all.