In The U.S., A Health Care System Rich In Resources, Poor In Outcomes
The United States spends twice as much on medical care per person than other wealthy countries. In the U.S., it costs an average of about $12,600 a year for every man, woman and child.
That has led to a health care system that’s rich in resources, but with health outcomes that are remarkably poor. We’re a lot sicker. We die younger, and we’re more likely to have chronic diseases like diabetes and heart disease.
Over the next 11 weeks, WFAE will examine the medical, business and cultural factors that contribute to this dichotomy.
WFAE’s Dana Miller Ervin kicks off the series with a look at how the U.S. delivers care compared with other wealthy countries.
Stockholm native Dr. Lars Lund did his medical training at Duke and Columbia universities. Now he’s a cardiologist and researcher at Sweden’s prestigious Karolinska Institute. Swedes live longer than Americans, have less chronic disease and less maternal mortality. But when you ask Lund why that is, he’ll tell you it’s not because of the quality of U.S. medical care.
“Health care, when it is provided in the United States, is not at all worse than in Sweden,” Lund said. “If anything, it’s better because there are more resources.”
There are a lot more resources. The U.S. spends an average of $12,641 per person on medical care annually when you factor in health insurance premiums, deductibles, medical bills and what we pay in taxes for Medicaid, Medicare and government subsidies for health insurance. That allotment also goes toward resources such as facilities, technology and doctors.
We spend more than twice the average of 10 other wealthy countries, such as Switzerland, Norway, Germany and Sweden, according to the Organization for Economic Cooperation and Development (OECD), a free-market group of 37 countries. But we’re also a lot sicker than people in those countries. Some of that is because of America’s large socioeconomic differences, but some of our problems stem from the way health care is delivered in the United States.
“Access to care is poor and inconsistent,” Lund said. “So is continuity of care. And there are huge inequalities in access, so large segments of the population have terrible health outcomes.”
Americans die younger than residents of every other wealthy country. The U.S. life expectancy of 78.9 years in 2019 was lower than Germany (81.4), Canada (82.1) and Italy (83.6), to name a few. And we’re more likely to die from illnesses that could have been treated, according to OECD data.
American women are more than twice as likely to die because of a pregnancy or birth than women in other wealthy countries. And almost 30% of Americans have multiple chronic medical problems, compared with an average of 17% in 10 comparable countries, according to the health research and advocacy group The Commonwealth Fund.
But 30 million people in the U.S. had no coverage in 2020, according to the U.S. Department of Health and Human Services — including an estimated 1.2 million in North Carolina. And, that doesn’t include the large number of people who are underinsured.
Reginald Williams heads the Commonwealth Fund's international health program. He agrees that Americans’ unequal access to care is a big part of the problem.
“We have a health care system that focuses on delivering the best interventions, mastering a kind of complicated, intensive care,” Williams said. “But if you kind of peel back the onion and look at things that kind of drive everyday health, that’s where you see our struggles.”
We may be larger and more diverse, but we’re also the only rich, free-trade country without universal health insurance, according to OECD data. Some, such as Sweden, rely on the government to provide health care services. Others, such as Germany and the Netherlands, require residents to purchase insurance.
Over 50% of Americans with lower incomes skipped care because of the cost, and you just don’t have that in other countries.
“Over 50% of Americans with lower incomes skipped care because of the cost,” Williams said, “and you just don’t have that in other countries.”
But even those with insurance can suffer because of the fragmentation of our system. That can hamper communication and the sharing of records, says Chris Kerns, of the health research group Advisory Board.
“You might have different providers that are reimbursed in different ways that may not necessarily have any relationship to one another, so doctors and hospitals may or may not be coordinated,” Kerns said. “That also contributes to worse patient outcomes.”
Another problem in the U.S.? We have a weaker primary care system, Kerns said.
“When you look at a lot of other countries, especially in the OECD, what you see is a greater emphasis on primary care,” Kerns said. “And one of the main reasons for that is reimbursement is just much more generous for specialist care in the U.S.”
But there’s an upside to our fee-for-service system. All that money pays for a lot of technology, so Americans who have coverage are more likely to get mammograms, for example. We’re also more likely to survive some cancers, such as breast cancer, than those in other wealthy countries.
Another upside? There’s a lot of unused capacity in our system. So Americans who have good coverage can usually get in to see a doctor when they need one. Lund said waiting is a problem at his cardiology center in Sweden.
“As a specialized center, we have a duty to the population to see the most serious and the most urgent cases first, and our resources allow only so many visits per month,” he said.
But some waiting isn’t necessarily a bad thing, said Kerns.
“Not all care needs to be done on an extraordinarily timely basis,” Kerns said. “So for example, orthopedic implants, those can usually be just fine. Whereas when we’re talking about oncology, a wait time of two months versus two weeks can make a huge difference.”
Ultimately, improving outcomes may involve trade-offs, including how much we’re willing to spend and how much we value equitable access. But those are questions the U.S. has struggled to address, said Jonathan Oberlander, a health policy professor who is chair of the Department of Social Medicine at UNC-Chapel Hill. In part that's because “fear of government is in our political DNA,” Oberlander said.
The U.S. also places a lower value on community well-being, Oberlander said.
“Our commitment to solidarity, to community, is less than other countries because what we have now would be unimaginable,” Oberlander said. “They just wouldn’t allow it.”
But the biggest obstacle to improving overall health may be the huge amount we spend on health care.
“There are a lot of people who do well in the status quo,” Oberlander said. “And that includes the health care industry, the insurance industry, pharma. But it also includes a lot of Americans who like their insurance coverage as it is right now.”
In other words, there are just too many people who think they’d lose out.
Next week, we explore how where and how you live can affect the quality of your life and your access to health care.