Dr. Patty Gabow, the retired CEO of Denver Health has recently been making a presentation that begins with a rhetorical question, “Can the American Healthcare System Deliver Health?” Any rhetorical question is designed more to get the audience thinking than to deliver an answer. She succeeded with me.
She begins with the fundamental question, “What is health?” I have heard it said that patients define health as the ability to take care of those they love and have the energy to have a little fun after our work day. The World Health Organization agrees:
Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.
Howard Koh has said, “Some people need health care some of the time, but all people need health and wellness all of the time.” Audits of our healthcare system comparing the health of Americans to the other developed nations reveals that we are consistently near the bottom of the rankings. This fact would surprise most Americans who have been led to see us as the medical mecca of the world.
Healthcare is important to health especially when we become ill. “Repair care” is what we do best. That is what you saw glorified on “E.R.” and on “Grey’s Anatomy.” I am yet to see a dramatization of preventative healthcare or effective chronic disease management. Perhaps Hollywood could spread the message that the delivery system is a minor determinant of the nation’s health. Greater determinants of health are behavior, income, education, the environment, quality of the community, and our genetics.
Dr. Gabow asked then answered some serious questions about our health system’s performance on cost, coverage and access, quality, and equity and disparities. She used data to compare our ability to produce health to the performance of other advanced countries. We spend relatively more by a large margin than any other nation even as we provide access to healthcare to a lower percentage of our citizens than other developed economies. Any objective analysis of our outcomes and quality metrics put us below the middle of the pack when we are compared to the other advanced economies. What should embarrass us the most is that the data demonstrates a variation of experience within our population that suggests a lack of equity compared to the rest of the world.
We rank 50th out of 55 countries in the efficiency of our health system and waste over 700 billion dollars a year. We spend much more, 18% of our GDP, on health than any other country. Switzerland is second spending less than 12%. 30% of the care we provide either adds no value or is harmful. Medicare spent over 6 billion dollars in 2014 on low value care.
The ACA helped us gain some ground against the coverage gap between us and the 99.9% average coverage levels in Western Europe, Japan, Australia, and Canada, but we still have over 30 million Americans without insurance access. Who knows what percentage of the population will have access to medical care following either eventual repeal of the ACA or the continuing administrative attacks on its vulnerabilities? Coverage is not equal to access. Many patients, especially Medicaid patients, have a challenge finding a doctor.
It should not be a surprise to any of us that the accumulated effect of the deficiencies that Dr. Gabow’s data document is that we have the lowest life expectancy compared with our peer nations. If you lived in Japan your life expectancy would be 83.4 years rather than the 78.8 years that is our expectation. It’s hard to believe, but we are running neck and neck with Cuba and that is not fake news.
Dr. Gabow revealed the dirty little truth that across this country your life expectancy is more a function of your zip code than your genetic code. The life expectancy in the Roxbury section of Boston is in the late fifties while the life expectancy in nearby Back Bay is over 90! Similar discrepancies exist across the country and are evidence that income, education, and environment are potent determinants of health.
The issues of income and locality have a life time impact on health and are experienced from conception to death. We have an embarrassing infant mortality rate of 6.7 deaths per thousand live births. Sweden gets the gold with 2.5. France and Denmark are tied for tenth place at 3.8. North of our border in Canada it’s 5.2. You may say that things aren’t so bad if you measure life expectancy at your current age. That would be nice, but before age 75 we never rank higher than 15th out of the 17 countries in our comparison group.
We are the number one spender on the healthcare of those over 55. In 2009 we were spending an average of almost $45,000 a year on the care of ninety year olds. Number 2 was Germany at a little over $10,000. A recent analysis of deaths in America from all causes revealed that medical errors caused 251,000 deaths, 688 deaths per day. Is that upsetting? Medical errors are the third leading cause of death behind heart disease (611K) and cancer (585K).
Compared to whites, most outcome measurements for African American and Hispanic patients are worse. Compared to whites, African Americans have twice as many low birth weight babies. Mortality is twice as high in the first year of life for black children, and asthma is twice as prevalent. Stroke and heart disease rates are 1.5 to 2 times higher for African Americans. Life expectancy is five years less for black men, and 3 years less for black women.
There are eerie similarities between the red state/ blue state election results in the last presidential election and the map of the states that did not expand Medicaid. A map placing states into four quartiles of health system performance shows all of the fourth quartile states to be “red” and most of the other red states are in the third quartile. Iowa, Wisconsin, and Pennsylvania were the exceptions. As in real estate, healthcare seems to be about location, location, location. Dr Gabow summed it up nicely, “Where you live determines if you live.”
Data suggests that much of our spending has been misdirected. A National Academy of Sciences report from 2016 prepared by a committee of luminaries including Atul Gawande and Don Berwick tried to explain why our health system delivered such poor results despite spending so much money:
A major reason lies in the fact that the foci of our attention, our resources and our incentives are too narrow…our investments are primarily directed to a biomedical focus…
Countries that have better outcomes than we do spend a larger percent of their GDP on social services than we do, and often spend more on the combination. We are thirteenth in the combination of spending as a percent of GDP on healthcare plus social programs. All European countries spend a larger percentage of their GDPs on social programs than we do. In terms of producing health, the focus on social spending over healthcare seems to “potentiate” the benefit of the lesser amounts they spend on healthcare. “Waste” in healthcare may create jobs or provide economic benefit for providers, institutions, big pharma, and medical device manufacturers, but wasting resources on low value care and not investing in the improvement of the social determinates of health does not improve the nation’s health.
Income inequality is a much discussed domestic issue as the rich get richer and the middle class pays taxes. We have tax legislation in Congress now that is largely crafted from a debatable economic concept that giving more money to the wealthy will stimulate business development and job creation with the resultant growth producing enough new revenue at the new lower tax rate to fund and justify the proposed tax reductions. Such tax policy has never worked and threatens our investments in health. Kansas has come close to bankrupting itself and neglected social investment while vigorously testing the theory that lower taxes create growth.
The analysis of the association between income and life expectancy from 2000-2014 yields some important insights. The wealthiest 1% have a life expectancy at age 40 that’s 10-15 years greater than the poorest 1%. The life expectancy of the poorest 1% of men in America is that of men in Sudan. Life expectancy at age 40 differs by location. People in the lowest quartile of income are healthiest in New York and California. People in the top quartile of income do best in Utah and Maine. Most of the difference in life expectancy between the wealthiest and poorest seems attributable to health behaviors.
The data that correlates health and longevity with education and income should not be a surprise. It should upset you to know that Americans carry a much higher risk to their health from the environment than the citizens of European countries, Canada, and Japan. Behaviors determine much of our health.
We are now in the midst of an epidemic of opioid overdoses and trying to decide just who should be blamed. Opioid deaths now exceed gun deaths. It is a fact that we have improved deaths rates from automobile accidents so that guns now kill as many people as cars. A lower percentage of Americans smoke than thirty years ago, but it is still estimated that 40% of deaths can be attributed to tobacco use, unhealthy diets, drinking problems, and a lack of exercise. The realities of low income exacerbate all of these problems.
If health in America is to improve something different needs to happen. Public policies should begin with scientific facts and take advantage of the information that can be gleaned from the social sciences and the experience of prior programs. Things won’t improve unless we we have the courage to do a collective “self analysis.” We must use data to measure where we are. We must question our “current state” to enable an analysis of how and why we have failed, and how we might do better. It’s one huge problem begging for leadership, Lean analysis, and a vision for a better future that can unite a divided country.
Dr. Gabow finished her presentation talking about short term and long term efforts that begin at home. She asked the rhetorical question, “Can the healthcare system be the entity that broadens our national focus from its current narrow biomedical focus to the broader determinants of health.” She thinks that it will require changes outside the healthcare system but the healthcare system can continue improvement efforts on access, cost, and quality. Those efforts are necessary but insufficient. We must do more to reduce waste to free up resources. We need to make the public aware of the social determinants of health and the healthcare disparities that exist and advocate for addressing the problems. We must address income inequality by ensuring that all work produces a “living wage.” We must be sure that all of our healthcare programs and institutions are adequately funded.
We can make the choice to improve our delivery efficiencies, avoid non value producing care, practice more effective preventative and chronic care, and invest in programs that improve the social determinants of health. The work will require a willingness to participate in a real transformation of our healthcare system. Our operating systems will need to be reengineered to reduce the fragmentation of care. We will need to practice patient centered care and care redesign that allows us to bring the wisdom of patients and families into the process. We will need to embrace the advantages of technology and augmented intelligence, but apply them to reduce waste, lower the cost of care and improve outcomes by more effective clinical management and not use them as mechanisms to generate revenue. We must learn how to effectively align these improvements with the larger social goals of improving the health of everyone.