Editorial
Worlds Best Medical Care?
Published: August 12, 2007
Many Americans are under the delusion that we have the best health care system
in the world, as President Bush sees it, or provide the best medical care in
the world, as Rudolph Giuliani declared last week. That may be true at many
top medical centers. But the disturbing truth is that this country lags well
behind other advanced nations in delivering timely and effective care.
Michael Moore struck a nerve in his new documentary, Sicko, when he extolled
the virtues of the government-run health care systems in France, England,
Canada and even Cuba while deploring the failures of the largely private
insurance system in this country. There is no question that Mr. Moore
overstated his case by making foreign systems look almost flawless. But there
is a growing body of evidence that, by an array of pertinent yardsticks, the
United States is a laggard not a leader in providing good medical care.
Seven years ago, the World Health Organization made the first major effort to
rank the health systems of 191 nations. France and Italy took the top two
spots; the United States was a dismal 37th. More recently, the highly regarded
Commonwealth Fund has pioneered in comparing the United States with other
advanced nations through surveys of patients and doctors and analysis of other
data. Its latest report, issued in May, ranked the United States last or
next-to-last compared with five other nations Australia, Canada, Germany, New
Zealand and the United Kingdom on most measures of performance, including
quality of care and access to it. Other comparative studies also put the United
States in a relatively bad light.
Insurance coverage. All other major industrialized nations provide universal
health coverage, and most of them have comprehensive benefit packages with no
cost-sharing by the patients. The United States, to its shame, has some 45
million people without health insurance and many more millions who have poor
coverage. Although the president has blithely said that these people can always
get treatment in an emergency room, many studies have shown that people without
insurance postpone treatment until a minor illness becomes worse, harming their
own health and imposing greater costs.
Access. Citizens abroad often face long waits before they can get to see a
specialist or undergo elective surgery. Americans typically get prompter
attention, although Germany does better. The real barriers here are the costs
facing low-income people without insurance or with skimpy coverage. But even
Americans with above-average incomes find it more difficult than their
counterparts abroad to get care on nights or weekends without going to an
emergency room, and many report having to wait six days or more for an
appointment with their own doctors.
Fairness. The United States ranks dead last on almost all measures of equity
because we have the greatest disparity in the quality of care given to richer
and poorer citizens. Americans with below-average incomes are much less likely
than their counterparts in other industrialized nations to see a doctor when
sick, to fill prescriptions or to get needed tests and follow-up care.
Healthy lives. We have known for years that America has a high infant mortality
rate, so it is no surprise that we rank last among 23 nations by that
yardstick. But the problem is much broader. We rank near the bottom in healthy
life expectancy at age 60, and 15th among 19 countries in deaths from a wide
range of illnesses that would not have been fatal if treated with timely and
effective care. The good news is that we have done a better job than other
industrialized nations in reducing smoking. The bad news is that our obesity
epidemic is the worst in the world.
Quality. In a comparison with five other countries, the Commonwealth Fund
ranked the United States first in providing the right care for a given
condition as defined by standard clinical guidelines and gave it especially
high marks for preventive care, like Pap smears and mammograms to detect
early-stage cancers, and blood tests and cholesterol checks for hypertensive
patients. But we scored poorly in coordinating the care of chronically ill
patients, in protecting the safety of patients, and in meeting their needs and
preferences, which drove our overall quality rating down to last place.
American doctors and hospitals kill patients through surgical and medical
mistakes more often than their counterparts in other industrialized nations.
Life and death. In a comparison of five countries, the United States had the
best survival rate for breast cancer, second best for cervical cancer and
childhood leukemia, worst for kidney transplants, and almost-worst for liver
transplants and colorectal cancer. In an eight-country comparison, the United
States ranked last in years of potential life lost to circulatory diseases,
respiratory diseases and diabetes and had the second highest death rate from
bronchitis, asthma and emphysema. Although several factors can affect these
results, it seems likely that the quality of care delivered was a significant
contributor.
Patient satisfaction. Despite the declarations of their political leaders, many
Americans hold surprisingly negative views of their health care system. Polls
in Europe and North America seven to nine years ago found that only 40 percent
of Americans were satisfied with the nations health care system, placing us
14th out of 17 countries. In recent Commonwealth Fund surveys of five
countries, American attitudes stand out as the most negative, with a third of
the adults surveyed calling for rebuilding the entire system, compared with
only 13 percent who feel that way in Britain and 14 percent in Canada.
That may be because Americans face higher out-of-pocket costs than citizens
elsewhere, are less apt to have a long-term doctor, less able to see a doctor
on the same day when sick, and less apt to get their questions answered or
receive clear instructions from a doctor. On the other hand, Gallup polls in
recent years have shown that three-quarters of the respondents in the United
States, in Canada and in Britain rate their personal care as excellent or good,
so it could be hard to motivate these people for the wholesale change sought by
the disaffected.
Use of information technology. Shockingly, despite our vaunted prowess in
computers, software and the Internet, much of our health care system is still
operating in the dark ages of paper records and handwritten scrawls. American
primary care doctors lag years behind doctors in other advanced nations in
adopting electronic medical records or prescribing medications electronically.
This makes it harder to coordinate care, spot errors and adhere to standard
clinical guidelines.
Top-of-the-line care. Despite our poor showing in many international
comparisons, it is doubtful that many Americans, faced with a life-threatening
illness, would rather be treated elsewhere. We tend to think that our very best
medical centers are the best in the world. But whether this is a realistic
assessment or merely a cultural preference for the home team is difficult to
say. Only when better measures of clinical excellence are developed will
discerning medical shoppers know for sure who is the best of the best.
With health care emerging as a major issue in the presidential campaign and in
Congress, it will be important to get beyond empty boasts that this country has
the best health care system in the world and turn instead to fixing its very
real defects. The main goal should be to reduce the huge number of uninsured,
who are a major reason for our poor standing globally. But there is also plenty
of room to improve our coordination of care, our use of computerized records,
communications between doctors and patients, and dozens of other factors that
impair the quality of care. The worlds most powerful economy should be able to
provide a health care system that really is the best.
