American Health Care: Best in the World?
One obstacle to health care reform is the widespread perception that the quality of American health care (not necessarily the system, but the quality) is the “best in the world.” If it’s the best in the world, one might reason, then tinkering with the system that produces it might threaten its state-of-the-art capabilities.
Well, an interesting paper was released last month. Authored by two Urban Institute scholars, Elizabeth Docteur and Robert A. Berenson, the paper reviews dozens of studies comparing the quality of U.S. health care to that of other countries. The evidence, they conclude,
| …does not provide support for the oft-repeated claim that the “U.S. health care is the best in the world.” In fact, there is no hard evidence that identifies particular areas in which U.S. health care quality is truly exceptional…. Instead, the picture that emerges from the information available on technical quality and related aspects of health system performance is a mixed bag, with the United States doing relatively well in some areas — such as cancer care — and less well in others — such as mortality from conditions amenable to prevention and treatment… Like other countries, the United States has been found to have both strengths and weaknesses in terms of the quality of care available, and the quality of care the population receives. |
And they observe, rather damningly: “the main ways in which the United States differs from other developed countries are in the very high costs of its health care and the share of its population that is uninsured.”
So American health care, like that of any country, has strengths and weaknesses. Among the strengths are cancer screening and treatment, diabetes care, hip fracture treatment, and senior flu vaccination. Among the relative weaknesses are asthma care, renal disease treatment, overuse of procedures, and patient safety.
Many of these findings, it seems to me, should not be surprising:
- The U.S. leads the world in cancer care, but the type of care cancer requires (technology-intensive, specialist-provided) is what the U.S. does well.
- Overuse of procedures is a problem in the U.S., but the fee-for-service payment structure, widespread in the U.S., encourages overuse of procedures.
- The U.S. has a high “amenable mortality” rate (see below), but this is most likely an “access” problem rather than a “care” problem. And of course 46 million Americans are uninsured, many more are underinsured, and health care in the U.S. is heavily rationed by price.
Some have argued that raw mortality numbers aren’t a decisive metric for head-to-head comparisons of different countries’ health-care systems, since lifestyle factors may play a large role in mortality outcomes. So to more narrowly focus on deaths plausibly attributable to a country’s health-care capabilities, Docteur and Berenson use the concept of “amenable mortality” —that is, deaths before age 75 from conditions considered amenable to treatment by medical care such as treatable cancers, diabetes, and cardiovascular disease. The results, however, are no more encouraging than the raw mortality numbers. And the U.S. ranking in amenable mortality, among 19 countries considered in one well-known study, somehow slipped from 15th to 19th place between the late 1990s and early 2000s:
(Data from Ellen Nolte and C. Martin McKee; diagrams from a Commonwealth Fund summary of the findings.)
What amenable mortality statistics can’t tell us is the extent to which poor health outcomes arise from poor quality of care and the extent to which they arise from poor access to care. The question matters since if access is the main problem, American health could be greatly improved by expanding secure access to more people, e.g., to people under age 65.
One passage in the Docteur-Berenson piece that caught my eye was this one about cancer care:
| The United States
had the highest survival rates for cancer of
the colon, rectum, lung, breast, and prostate. U.S. survival rates were
also among the highest for melanoma (fourth), uterine (second) and
ovarian (fifth) cancer, cervical cancer (sixth), Hodgkins disease
(third) and non-Hodgkins lymphoma (fourth). The United States was ninth
in survival of stomach cancer. Although average survival differences
between the United States and Europe as a whole were in some cases
large, the difference between the United States and the other countries
with relatively high five-year survival rates were generally small
(approximately 3 to 4 percent for many cancers) and (due to small
sample sizes) usually not statistically significant. |
Then there’s this observation about younger patients:
| The study also looked at cross-country differences by population group, finding that survival rates for colon, breast and uterine cancer were similar in the United States and Europe for patients under 45 years, but were much better in the United States for patients age 65 or older at diagnosis. In the case of stomach cancer, the U.S. survival rate for patients under age 45 was below those of many European nations, but similar among the older patients. |
In sum the U.S. appears to be very good at cancer care for older patients, but curiously mediocre for younger ones.
The following diagrams, showing five-year survival rates for various types of cancer for different age groups (and for both sexes unless otherwise indicated), bear this out. (The U.S. is represented by the thick red lines.)
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(Data: U.S.: Surveillance Epidemiology and End Results (SEER); Europe: Eurocare.*)
We find that:
- For all types of cancer but one (pancreatic), the U.S. has the highest five-year survival rates for people 75 and older.
- At younger age levels, U.S. five-year survival rates are above average in all areas but one (stomach), but best in only one area (Leukemia).
What makes for effective cancer care? The biggest factor, say Docteur and Berenson (citing a study by Coleman et al.), is “access to diagnostic and treatment services.” And of course regular screening is something the uninsured and underinsured (a large segment of the under-65 population) generally lack. More broadly, better cancer survival rates “are associated with higher national income levels, higher levels of expenditure on health, and higher investment in health technology, as proxied by indicators such as the rate of CT scanners per person.”
Thus the amenable mortality numbers shown above are neither a fluke nor a product of lifestyle alone, but a reflection of a health-care system that caters well to one class of patient—elderly and suffering from emergency health conditions—but poorly to the bulk of the population. American health would obviously be much improved if all citizens could avail themselves of the care currently available to one select class of people.
*These data are if anything biased in favor of the U.S., since the U.S. data are for 1999-2005 while those for Europe are for 1995-1999 (reflecting data availability).
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Is Low Life Expectancy the Fault of Our Health Care System?
What Americans Believe
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Inside the Asylum
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