5 Myths About USA Ailing Health-Care System

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5 Myths About Our Ailing Health-Care System

By Brownlee and Ezekiel Emanuel

Sunday, November 23, 2008; B03

With Congress ready to spend $700 billion to prop up the U.S. economy,

enacting health-care reform may seem about as likely as the Dow

hitting 10,000 again before the end of the year. But it may be more

doable than you think, provided we dispel a few myths about how health

care works and how much reform Americans are willing to stomach.

1. America has the best health care in the world.

Let's bury this one once and for all. The United States is No. 1 in

only one sense: the amount we shell out for health care. We have the

most expensive system in the world per capita, but we lag behind many

developed countries on virtually every health statistic you can name.

Life expectancy at birth? We rank near the bottom of countries in the

Organization for Economic ation and Development, just ahead of

Cuba and way behind Japan, France, Italy, Sweden and Canada, countries

whose governments (gasp!) pay for the lion's share of health care.

Infant mortality in the United States is 6.8 per 1,000 births, more

than twice as high as in Japan, Norway and Sweden and worse than in

Poland and Hungary. We're doing a better job than most on reducing

smoking rates, but our obesity epidemic is out of control, our death

rate from prostate cancer is only slightly lower than the United

Kingdom's, and in at least one study, American heart attack patients

did no better than Swedish patients, even though the Americans got

twice as many high-tech treatments.

Moreover, the quality of health care is different in different parts

of the country. The Centers for Medicare and Medicaid Services have

issued a list of 26 measures of quality, such as making sure that

heart-attack patients being discharged from the hospital get a

prescription for a beta blocker or aspirin to help reduce the risk of

a second attack. It turns out that quality is all over the map, and it

isn't necessarily better in the places we might expect, such as

academic medical centers. Worse still, according to the Congressional

Budget Office (CBO), there appears to be no connection between how

much Medicare and other payers spend on patients in different parts of

the country and the quality of the care the patients receive. You are

no more likely to get that beta blocker or aspirin in Los Angeles than

in Portland, even though Medicare spends twice as much per beneficiary

in Los Angeles.

2. Somebody else is paying for your health insurance.

Nope. Even when your employer offers coverage, he isn't reaching into

his own pocket to cover you and your fellow employees; he's reaching

into your pocket, paying you lower wages than he would if he didn't

have to pay for your health insurance.

Rising health-care costs are partly to blame for stagnant wages. Over

the past five years, health insurance premiums have risen 5.5 times

faster on average than inflation, 2.3 times faster than business

income and four times faster than workers' earnings. Four times.

That's why wages have been nearly flat since the 1980s, even as U.S.

productivity has been going up. In effect, about half the money you

should be earning for being more productive is being sucked up by ever

more expensive health-insurance premiums.

If you pay taxes, you're also paying for the health care provided

through state and federal programs such as Medicare, Medicaid, the

Veterans Administration and the military. All told, the average family

of four is coughing up $29,000 a year for health care through taxes,

lower wages and out-of-pocket medical expenses.

3. We would save a lot if we could cut the administrative waste of

private insurance.

The idea that we could wring billions of dollars in savings this way

is seductive, but it wouldn't really accomplish that much. For one

thing, some administrative costs are not only necessary but

beneficial. Following heart-attack or cancer patients to see which

interventions work best is an administrative cost, but it's also

invaluable if you want to improve care. Tracking the rate of heart

attacks from drugs such as Avandia is key to ensuring safe

pharmaceuticals.

Let's just say that we could wave a magic wand and cut private

insurers' overhead by half, to what the Canadian government spends on

administering its health-care system -- 15 percent. How much would we

save? Not as much as you may think. Private insurers pay a little more

than a third of what we spend on health care, which means that we'd

cut a little more than 5 percent from our total budget, or about $124

billion. That's not peanuts, but it's not even enough to cover

everybody who's currently uninsured.

More to the point, we only get to save it once. That's because

administrative waste isn't what's driving health-care costs up faster

than inflation. Most of the relentless rise can be attributed to the

expansion of hospitals and other health-care sectors and the rapid

adoption of expensive new technologies -- new drugs, devices, tests

and procedures. Unfortunately, only a fraction of all that new stuff

offers dramatically better outcomes. If we're worried about costs, we

have to ask whether a $55,000 drug that prolongs the lives of lung

cancer patients for an average of a few weeks is really worth it.

Unless we find a cure for our addiction to the new but not necessarily

improved, our national medical bill will continue to skyrocket,

regardless of how efficient insurance companies become.

4. Health-care reform is going to cost a bundle.

Only if you think that covering the uninsured is our only priority.

Yes, making health care available to all citizens is the right thing

to do. But it isn't the only thing to do. We also have to fix the

spectacularly wasteful and expensive way doctors and hospitals deliver

care.

Our physicians are working within a truly dysfunctional, often chaotic

system that prevents them from caring for us properly. Between 50,000

and 100,000 patients die each year from preventable medical errors.

According to the Centers for Disease Control, 1.7 million Americans

acquire an infection while in the hospital and nearly 100,000 of them

die from it. Laboratory imaging tests are routinely repeated because

the originals can't be found. Patients with such chronic illnesses as

heart failure and diabetes land in the hospital because their

physicians fail to monitor their condition. When patients have

multiple doctors, there's often nobody keeping track of the different

medications, tests and treatments each one prescribes.

Our doctors and hospitals are failing to provide us with care we need

while delivering a staggering amount that we don't need. Current

estimates suggest that as much as 20 to 30 percent of what we spend,

or about $500 billion, goes toward useless, potentially harmful care.

There are two bright spots. One: We can improve the quality of care

and cut costs without rationing. There are models out there for how to

do it right -- the Mayo Clinic, the Geisinger Clinic in Pennsylvania,

the Cleveland Clinic and California's Kaiser Permanente are just a few

of the organized group practices that are doing a better job for less.

Their doctors are better than average at using the best medical

evidence available. They're more likely to be using electronic medical

records, which can help keep track of patients who have multiple

physicians and need complex care. And they're less likely to provide

unnecessary care.

Two: Even moderate reform of the delivery system would improve care

and save money. The Lewin Group's analysis shows that a bill proposed

by Sen. Ron Wyden, an Oregon Democrat, calling for a more

comprehensive overhaul of the health-care system than either McCain's

plan or Obama's could actually insure everyone and save $1.4 trillion

over 10 years. More reform is cheaper.

5. Americans aren't ready for a major overhaul of the health-care system.

We may be readier than you think. A recent study published in the New

England Journal of Medicine found that only 7 percent of Americans

rate our health-care system excellent. Nearly 40 percent consider it

poor. A whopping 70 percent believe it needs major changes, if not a

complete overhaul.

Now is not the time to think small, to cover a few million Americans

and leave the bigger job of controlling costs and improving quality

for another day. We can't afford not to reform the delivery system as

soon as possible. At 17 percent of gross domestic product, health care

is the biggest single sector of the economy, and it's consuming a

larger and larger proportion every year. According to CBO projections,

health care will account for 25 percent of GDP by 2025 and 49 percent

by 2082. That's simply unsustainable. Any plan that reforms health

care has to do more than simply cover the uninsured. The nation's

health and wealth depend on it.

Brownlee, a visiting scholar at the National Institutes of

Health Clinical Center, is the author of " Overtreated. " Ezekiel

Emanuel, an oncologist and author of " Healthcare, Guaranteed, " is

chairman of the center's Department of Bioethics. The views expressed

here are the authors' own.

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