Mini-Med on U.S. Health Care System

Pnina and I have been going to a series of lectures at the University of Washington called Mini-Med. Each Tuesday, a few med-school faculty members are invited to do a short presentation to the general public on their area of focus.

Until now, most of the topics were about the science of medicine. For example, last week we heard an interesting lecture about a kind of super-bacteria (MRSA) that has developed resistance to all known kinds of antibiotics. But yesterday the lectures were about the US health care system; they were much more focused on statistics and on the social and political issues surrounding medicine.

There were three speakers: Stephen A. Bezruchka, Benjamin Danielson, and Jeffrey Huebner. They were all great, and they all had a similar message. It’s hard to summarize it all here, but I’ll try to pull out the points that made a big impression on me…

First off, a lot of money is spent on health care in the US. In 2005, it was about $2 trillion, enough to make the US health care system the 6th largest economy in the world (by GDP), ahead of countries like Italy, Canada, and Spain. With so much money spent on health care, you’d expect that we have the best health. We don’t.

There are various measures of health that you can take. Two popular ones are life expectancy and infant mortality rates. In both, the US is far behind other developed countries. Although health care has been getting better in the US over the years (e.g. life expectancy is growing), other countries have far outpaced us. In particular, in countries like Japan, England, Norway, and Sweden, the average person lives 1-3 years longer than in the US. The US is now ranked about 30′th in the world in overall health, or worse, depending on which study you look at.

So, the big question is — why?

One aspect that comes to mind: how well do we take care of ourselves? If Americans have unhealthy habits, it makes sense for us to live shorter lives. This is true when it comes to obesity — Americans are some of the fattest people in the world. It’s also interesting that immigrants quickly pick up this bad habit; the longer they live in the US, the more likely they are to be obese.

However, this is not true when it comes to many other habits. For example, Japan has the highest rate of adult male smokers in the world, and yet Japan has the healthiest population.

The speakers argued that habits only go so far to explain the health differential between the US and other developed countries. For the rest, you need to look at socio-economic issues. The quote that summed it best: “more egalitarian societies (e.g., those with a less steep differential between the richest and the poorest) have better average health”. This came from an Institute of Health publication called The Future of The Public’s Health. There have been lots of studies that prove this point over and over, and we saw various graphs from those studies. We also saw a graph that compared each of the US’ 50 states to one another, as if they were independent countries, and the same point applied again — states that have a smaller gap between the rich and the poor have better overall health. Incidentally, the states that did worst are in the southeast: Louisiana, Alabama, Mississippi. The states that did best are: Utah, the Dakotas, Minnesota, Idaho, Iowa, and others (they tended to cluster in the midwest).

At the same time, the gap between the rich and the poor in the US has broadened since the late 1970’s, largely as a result of lowered taxes on the super-rich. In 1980 the top 0.01% of the US citizens owned 1.3% of all assets. In 2005 they owned 5.1%. At the same time, the bottom 90% of the country went from owning 65% of all assets to owning 51%. Dr. Bezruchka called this “Hood-Robinosis” — taking from the poor and giving to the rich. And the decline in health in the US correlates very closely.

Another problem is that there isn’t enough focus on primary care, and in particular on early-life. Lots of studies have shown that it’s much more cost effective to spend money on preventative care than to try to cure an advanced-stage illness. Studies also show that investments in early life (e.g. pre-birth to age 3 or 5) pay the biggest dividends. There are four countries in the world that do not give guaranteed paid maternity leave: Papua New Guinea, Lesotho, Swaziland, and the United States of America. That means that mothers-to-be are more likely to put their bodies under stress, and less likely to get the care they need, especially in lower-income brackets.

In addition, there are fewer primary care (e.g. family-practice) doctors to be seen. In 1997, about 2300 medical students said they were interested in pursuing a career in family medicine. That number has dropped gradually over the last 10 years, such that in 2007 it was only 1100 students. There’s a stigma against this branch of medicine. Dr. Huebner said that he was told many times “you’re too smart to go into family practice”. Of course, family practice also offers the lowest salaries. “It’s still plenty of money”, said Huebner, “but it’s the lowest-paying kind of medicine.” Incidentally, Dr. Bezruchka said that in Sweden a doctor and a teacher get paid the same amount. He drew a mixed reaction for this comment from an audience that was otherwise very supportive

Dr. Danielson also pointed out that health care in the US is very divided along race lines, that there are differences that can’t be explained simply by economic level. He showed one particularly convincing graph that illustrated infant mortality rate as a function of the mother’s race and education level. The good news is that infant mortality goes down as mothers become more educated, across all races. However, the most educated black mothers (college+) still see a higher rate of infant mortality than even the least educated mothers of all other races (< high school). Native Americans also see much higher rates of illness than most other races.

So, what all these speakers were pointing at is that we need some kind of social health care system.

Next question — how will we afford it? The first assumption people make when you talk about socialized mecidine is that we’ll need to pay a lot more in taxes, and how are we going to convince the public to put up with that? Well, the speakers argued that this is a false assumption, that the cost for most people may end up being the same, or perhaps slightly more. They didn’t get into a lot of specifics, which was disappointing. But they did illustrate ways in which money is not being spent very wisely today. For example, the pharmaceutical industry spends $7 billion a year on drug marketing to MD’s ($13,000 per doctor). This includes salaries for 90,000 sales representatives (about 1 for every 5 doctors).

The speakers all mentioned the upcoming elections and the various solutions that will be talked about, but they didn’t get into details, which again was disappointing — I was hoping to hear them dissect the Obama plan and the Clinton plan and to point out the pros and cons of each. They did indicate that our current health care “non-system” is so broken that any of those solutions would bring us a big step forward.

They also talked about previous attempts to legislate socialized medicine and how they failed, including the famous album: Ronald Reagan speaks out against socialized medicine, which you may have seen mentioned in Michael Moore’s Sicko.

One person from the audience asked: “if we had the political will to create a socialized health care system today, how long would it take us to catch up to other countries?”. Dr. Bezruchka guessed that it would take about 30 years. Why? Because it took Japan about that long to go from being one of the less healthy countries after WWII to being the most healthy country. He argued that Japan can thank the US for taking many steps towards making health care in Japan better, including some non-obvious things like making war constitutionally illegal and breaking up the largest monopolies.

For more info, Dr. Bezruchka recommended a TV series that will air on PBS in late March called Unnatural Causes.

Dr. Huebner recommended looking through the Washington State report on health care and costs from 2006: Blue Ribbon Commission. He also asked for support for HB 2536, which would give money to analyze several health care solutions and make a proposal. Finally, he mentioned that drug companies today have the right to look through records that specify which drugs were prescribed by each doctor, which allows them to do more targeted marketing at the doctors. He argued that this is a conflict of interest that should be disallowed, and in fact there’s a bill that would disallow it, though it’s unclear whether it’ll pass: HB 2664 “The Prescription Privacy Act”.

Update: One counter-argument is found on Free Market Cure.

Update: A comparison of the different candidates’ health care reform plans: http://www.washingtonpost.com/wp-dyn/content/article/2008/02/08/AR2008020803443.html