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

 

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.

Does Sugar Addiction Impact $1 Trillion in U.S. Healthcare Spending?

This article looks at the explosion of added sugars in our food and drink supply and reports on the health and cost consequences to all.

It is clear that the obesity epidemic is a key issue in the health reform debate as research conclusively shows that it drives significant increases in chronic diseases like coronary heart disease and diabetes.

What is less clear from a science and public policy perspective is the role sugar plays in both obesity and chronic diseases and what, if anything, should be done to regulate or manage its presence in our food and drink supply as part of the health reform debate in the United States.

“Sugar: Consumption at A Crossroads” is a groundbreaking report from the Credit Suisse Research Institute that explores the medical, economic, consumer and public policy implications of global sugar consumption.

Amongst the many data points and in-depth content in the report is this estimate of the economic impact of sugar in the United States:

“30% – 40% of healthcare expenditures in the USA go to help address issues that are closely tied to the excess consumption of sugar.”

The consumption of added sugar (sugar not contained in natural products like fruit or milk) or high-fructose corn syrup (HFCS) has increased dramatically over the last few decades. According to this report:

  • The world daily average consumption of sugar and HFCS per person now averages 17 teaspoons per day, up 46% from 30 years ago. This is the equivalent of 280 calories per day.
  • In comparison, Americans now consume an average of 40 teaspoons per day. As a benchmark, the American Heart Association recommendation for daily sugar intake is six teaspoons for women and nine for men.
  • Added sugars now represent 17% of a normal US diet with 43% of added sugars coming from sweetened beverages.

The report also includes a survey of physicians in the US, Europe and Asia. Key points from the physician view include:

  • 90 percent of the doctors surveyed believe that the sharp growth in type II diabetes and the current obesity epidemic are strongly linked to excess sugar consumption.
  • 82% of the doctors surveyed in the U.S. and Europe believe that sugar calories are handled differently by the body. 
  • On the question “is sugar addictive,” 65% think this is the case.

While medical research has yet to prove conclusively that sugar is the leading cause of obesity, diabetes type II and metabolic syndrome, the balance of recent medical research studies are coalescing around this conclusion. Advances in understanding the negative effects of refined carbohydrates on blood sugar regulation and cholesterol, and the metabolic impacts of fructose, are changing the traditional view that all calories are the same.

From a public policy perspective, governments and regulators have done little to address the impact of sugar consumption. Typical options often discussed, but rarely acted upon, include higher taxation as an attempt to reduce sugar intake while helping to fund healthcare costs related to obesity and diabetes, as well as increased spending on educating and explicit product labeling and warnings.

Worldwide, obesity now kills more people than starvation and malnutrition. The rapid growth of obesity, diabetes and related nutritional issues is arguably America’s top social health concern for which solutions can be devised to slow the growth and improve both health outcomes and costs.

And so, there is an opportunity to bring this social determinant of health into the mainstream of the health reform discussion. It’s a great example of the choices we can make to either continue to spend more money caring for the those medical maladies that come from the over-consumption of added sugars, or investing in a thoughtful response to increasing public awareness to deal with the root causes to slow the trend and improve the health of citizens.


For Consideration:

  • As part of health reform, what role, if any, should government play to address the growing implications in how the rapid rise of sugar impacts health status and eventually health costs?
  • Should sugar be regulated in ways similar to the treatment of other items that impact consumer health such as tobacco products?
  • Do you look at, or monitor, the level of added sugars found in the items you and your family consume? How does personal responsibility come into play when it comes to reducing the impact of sugar becoming a significantly higher portion of the average Americans caloric intake?

Additional Resources:

To go deeper on this topic:

“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)