When I think of the cost of healthcare in the US, I think of cost in dollars and in human suffering. Since we have both the most expensive system and the worst outcomes of other developed countries, we need to ask some serious questions. I guess that if people were asked why that was, we would either hear that we were getting ripped off, or it costs a lot to be the best. Let’s review the data.
First, if we look for answers on the web, we can easily fall down the rabbit hole.
Anyone can make a case, recollect an anecdote, or outright lie, and be followed by thousands of people. Physicians get information from multiple sources, most of whom have demonstrated that their information is reproducible and can be proven in a standard manner. Before being published, it is reviewed by multiple experts. When something new or startling comes along, we usually take a beat, and wait for results to be replicated by others. Only then do we start to accept it, and even then, we watch closely to see if it holds up over time.
According to several sources with long histories of unbiased academic reviews of these data (such as the Commonwealth Fund, and the Kaiser Family Fund), we are not getting our money’s worth. When we look at outcomes that are generally recognized as standards for evaluating health systems, such as life expectancy, maternal and infant mortality, and quality treatment of common chronic disease such as diabetes and heart disease, we are the worst. There are dramatic differences in quality care based on income, with the poor doing much worse than the well to do, but even our wealthier citizens have worse outcomes. Why is this?
In the US healthcare is a profit-driven industry, run largely by private industry.
Even though the federal government pays much of the cost of care (through Medicaid, Medicare and the VA system), it takes little control over what is charged. For example, despite Medicare being in place since 1965, it was just in the last couple of years that there was a discussion of using the government’s reach to gain some control of drug costs. Some efforts have been made to decrease costs, especially of hospital care, such as by reduction of hospital acquired infections by handwashing regularly. This is important, but I would say, “really?”
We have to teach doctors and nurses to wash their hands? (Parenthetically, one of the agencies the Trump administration has cut is the agency responsible for tracking hospital-acquired infections.) To reduce cost, we must know where the money goes, then be willing to make the changes needed to reduce costs.
Health insurance was first developed in the late 1800s, primarily to support workers and pay doctors and hospitals. It developed further after the Great Depression, again as a method to ensure payments to hospitals, then federal programs were developed to support the poor and elderly, with Medicaid and Medicare. The latest factor is the significant increase in private investment spending in care, through venture capital and private equity, whose interest is primarily maximizing profit, often through compromises in quality of or access to care.
The US spends about twice as much per person as similar countries. This excess is due to administrative costs of insurance, administrative costs for providers, higher cost of prescription drugs, more physician and nurse earnings, and more in medical equipment and machinery. There is no real oversight of these costs, and no significant pressure reduce costs, as long as profits continue to be made. Other countries which provide better outcomes at a lower cost, pay for a major portion of their healthcare, insuring universal care, through government programs.
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