While the United States continues to argue about whether and how to provide all of its citizens with health insurance and how to contain the high costs of health care, it has lost sight of the purpose of it all. The purpose of the vast $2.8 trillion health care industry, the most expensive by far of all countries in the world, is to produce better health for all Americans. It is failing and it is getting worse.
Health Care’s Veiled Purpose
Why has the United States taken its eyes off the prize of better health? Part of the reason is that many Americans believe the slogans from some political pundits who say that the American health care system is the best in the world and should not be touched with reforms like the Affordable Care Act (ACA). “When Italian Prime Minister Silvio Berlusconi needed heart surgery, he didn’t go to an Italian hospital...He had his surgery at the Cleveland Clinic in Ohio... because the U.S. health care system still provides the highest quality care in the world,” proclaimed Michael Tanner of the CATO Institute.1 Of course, a few anecdotes about the special treatment provided to world leaders does not square with the body of evidence that paints a different picture about how well the American health care system fares for all its citizens. Cathy Schoen, senior vice president at the Commonwealth Fund, which studies the performance of the U.S. health care system as compared with other developed nations, says “We (the United States) spend a lot more, our access is often worse, we face more medical debt, and our health outcomes are often worse.”2
Another reason why we do not have a laser focus on health outcomes may be the mistaken belief that outcomes are not measureable. As we will see shortly, the measures are credible, the data are compelling and convergent, and the interpretations are reasonably clear.
The harder part about outcomes is not so much in the measurement, but in the doing. The doing involves deciding who to hold accountable and collaborating across health, medical, and social systems—and with the people served—to set a vision and goals and actually make improvements happen. Outcomes are shaped by many factors, including social, behavioral, genetic, environmental, and health care delivery, with multiple systems making specific contributions based on their unique missions. However, the defining feature of the U.S. health care “system” is its fragmentation and lack of coordination among its stakeholders within health care and (even worse) across systems with other co-producers of health, including the public health system, social services, civic communities, and people themselves. Integration is hard and messy and has been perennially elusive. Who dares to step to the plate? In the meantime, we concentrate on other things besides outcomes, such as costs, driven by other purposes.
The nation spends much more time worrying about saving dollars than about saving lives. Dollars are easier to measure. Even the value of a life is measured in dollars. According to economists, it is valued at about $71,000 per year of life.3 In the United States, the policy and business calculus is often focused on how to save money while not damaging the quality of care. At its best, it is about getting more value for money spent. However, all too often, the achievement of better quality and outcomes through known approaches is not attempted because it costs too much, is not rewarded financially, or is hard to accomplish successfully because of an ingrained status quo culture and other implementation challenges.
Economists fixate on expenditures and are very influential in framing the major debates about health care. Prominent economists have projected that the tab for health care services will be almost double and reach $5 trillion in 2022 (just seven years away) if historical growth trends continue.4 They warn that health care would pose a “crushing burden” on society and that “health care profligacy, and the strains that such a situation imposes on society, could fundamentally undermine the economic and social well-being of the United States over the long term.”5 Got your attention? This is not a new Armageddon theme from the “dismal profession.”
However, the future may not be so bleak. It is not at all clear that the historical growth trends will reemerge following the recent period of several years when health care spending growth has been at historical lows and lower than the growth of the gross domestic product (GDP). Federal estimates for the long-term growth in Medicare and Medicaid have been ratcheted down significantly. And, growth in health care expenditures may not be bad if it actually produced good health and better productivity and thereby increased GDP! However, at the present time, too much, perhaps a third, of the health care tab is pure waste. And, unfortunately, the health outcomes produced are getting worse.
Measuring Health Outcomes
The most recent study on the health of the U.S. population was published in JAMA in July 2013 and authored by over 125 research collaborators around the world. The purpose of the study was to measure the burden of diseases, injuries, and leading risk factors in the United States from 1990 to 2010 and to compare these measurements with those of the 34 countries in the Organisation for Economic Cooperation and Development (OECD) countries.6 The good news is that between 1990 and 2010, the United States made progress in improving health. The bad news is that its improvements were not as great as other countries and the United States is losing ground to most other countries in securing the best health for its citizens.
The headline from the study is that the United States ranks twenty-seventh in the age-standardized death rate behind countries having a significantly lower GDP and health expenditures per capita, including Chile, Portugal, Slovenia, and South Korea. This puts the United States at the lowest quartile among the 35 countries. Further, the rank is getting worse. It changed from eighteenth to twenty-seventh in these 20 years.
Overall, mortality rates are a useful, but gross, measure. More refined and meaningful measures provided in the report include (1) years of life lost due to premature mortality (YLL)*, (2) years lived with disability (YLD), and (3) healthy life expectancy (HALE). On two of these measures, YLL and HALE, the United States dropped significantly in the rankings to twenty-eighth (see Figure 1.1) and twenty-sixth, respectively. The YLD also dropped, but not as much (from fifth to sixth).
Figure 1.1 The United States ranks 28 among 34 OECD countries on years of life lost due to premature mortality.
Adapted from U.S. Burden of Disease Collaborators, 2013.
The authors also compared the ranks of YLLs for 25 medical conditions across the 34 countries. Overall, the United States scores worse than the mean rank of the countries for a majority (15) of the conditions, at the mean for 9 conditions, and better than the mean for only one condition (stroke). For example, the United States scores in the lowest decile of ranks, that is, a rank of 31 or worse out of 34, for the following conditions: interpersonal violence, road injuries, chronic obstructive pulmonary disease, diabetes, drug use disorders, Alzheimer’s disease, poisonings, cardiomyopathy, and chronic kidney disease.
Similarly, a report from the National Academy of Sciences and The Institute of Medicine, “U.S. Health in International Perspective: Shorter Lives, Poorer Health,”7 demonstrates that the United States fares the worst among 17 wealthy OECD nations on nine health domains, most of which align with those in the JAMA report. They state that deaths that occur before age 50 are responsible for about two thirds of the difference in life expectancy between males in the United States and peer countries, and about one third of the difference for females. This has been a long-standing finding. Since 1980, the people of the United States have had the first or second lowest probability of surviving to age 50 among the 17 peer countries. The conditions that account for this difference include chronic disease and perinatal conditions, but over 50% are not defined as a usual medical disorder and include violence and accidents. The authors refer to a health-wealth paradox that is a “pervasive disadvantage that affects everyone (in the US), and it has not been improving.”8
Convergent data on the low rank of the United States on health and wellness measures comes from the Social Progress Index.9 The index addresses three overarching domains that cover basic human needs, well-being, and opportunity. One of the indicators included in the well-being domain is health and wellness. The indicator is composed of measures of life expectancy, premature death from chronic diseases, obesity, deaths attributable to outdoor pollution, and suicide. The health and wellness score for the United States is 73.61, which places it at a rank of 70 among the 132 countries included in the analysis. The usual suspects have the highest ranks, including Japan, European countries, Australia, Iceland, and (not so usual) Peru. Countries that scored in the low 70 rankings alongside the United States included the Dominican Republic, Togo, Kenya, Ghana, Cuba, Nepal, Slovakia, and Mali. Russia, Ukraine, and Kazakhstan had the worst ranks. Further, of the 12 components of the Social Progress Index, covering diverse areas, including personal safety, ecosystem sustainability, tolerance, and inclusion and access to education, the lowest rank for the United States was for health and wellness.
There are multiple causes for the worsening of health outcomes in the United States. One that requires close examination is the performance of the delivery system. One good indicator is a measure called premature mortality amenable to health care. Included in this mortality rate are diseases with a well-known clinical understanding of its prevention and treatment, including ischemic heart disease, diabetes, stroke, and bacterial infections. In other words, the science is very clear on what needs to be done for these diseases and the premature mortality rate is an important indicator of the success of the health care system in executing on the science. Figure 1.2, adapted from the Commonwealth Fund’s National Scorecard on U.S. Health System Performance 2011,10 compares the mortality amenable to health care rate across 17 wealthy countries. The U.S. rate of 96 deaths per 100,000 lives is almost 40% higher than that of the best performing five countries, including France, Australia, Italy, Japan, and Sweden at 59 deaths per 100,000. The United States is almost twice as high as the country with the lowest rate, France, at 55 deaths.
Figure 1.2 Mortality amenable to health care: premature death rate per 100,000
Adapted from the Commonwealth Fund, 2011.
This “voltage drop” from what is known to what is actually practiced was first documented in a now-classic study authored by Elizabeth McGlynn and her colleagues at the RAND Corporation, The Quality of Health Care Delivered to Adults in the U.S.,11 over ten years ago. Their research addressed the clinical adherence to recommended processes of care for 30 acute and chronic illnesses, as well as preventive care, with 439 indicators. Overall, the results showed that patients received recommended care about 55% of the time. They concluded that these deficits in the provision of recommended care “pose serious threats to the health of the American people.”12
In summary, it is important to underscore the severity of these findings. The health of the American population, as measured by living a long and healthy life, is worse than most other developed countries and getting worse. The data has been clear for years. Yet, the statistic of ranking twenty-eighth seems to elicit a collective shrug expressing “that’s the way it is” and nothing can be done about it. It has a similar ring to climate change—the problem is undeniable, it has to be fixed, and we (mostly) know how to do it.