Global Health Blogs with Professor Swahn

Everyone knows that the United States is a first world country, but does a first world country forget to prioritize healthcare? The United States is a democracy with a commercial economy, laws set in place, and a high standard of living. Other countries with lower incomes and less stable democracies often look at us, the United States, to aid them and assist them with their issues and problems. The reality of this is that while the United States is a first world country with money and resources to help others, we often fail to help our own people. We have tremendous health disparities in our country and even those who are well off can sometimes not get the care or medicines they need.

The United States suffers in more ways than one when it comes to treating our people equally. Systemic racism has become embedded in our culture, which leaves this to trickle into other systems, including schools, workplaces, and even healthcare. The largest problem that sets the United States apart from other well-established, first world countries is our culturally implemented view on racism.  Until this is handled on a cultural level, meaning that we eliminate racism from an everyday standpoint, we will never eradicate racism in the healthcare system.

Whether you are a newborn who cries to convey your feeling of unease, or a twenty-eight-year-old woman screaming from giving birth to her first child, we know what it feels like to be sick, in pain, and in need of help from a medical professional. Unfortunately, the access and quality of care provided to these individuals varies greatly by where they live. Hawaii, Minnesota, and Connecticut have life expectancies equivalent to high income countries, like Germany and Great Britain. The life expectancy in these states and countries is around 80 years old. Mississippi has the lowest life expectancy, at roughly 75 years old. From the map you can see that the average life expectancy greatly varies by state. Even though we are considered the United States, we do not always seem to be so united.

The United States spends more per capita on health care than any other country yet has worse outcomes than other comparable developed countries. An estimated three trillion (that is after million and billion — a total of twelve zeros) dollars is spend per year on healthcare in the united states. As of 2019, roughly 29 million Americans are without insurance; or approximately 8.8% of the total population. This number includes individuals and families who are completely uninsured but fails to mention the amount of people without access to healthcare. Being insured and having full access to healthcare are two completely different phenomenon’s that should go hand in hand, but in this country they do not. 

Dr. Ashish K. Jha is a medical doctor at the Harvard T.H. Chan School of Public Health. He also received his Master’s in Public Health and is the senior author of ‘Health Care Spending in the United States and Other High-Income Countries.’  In this video, he discusses the differences in United States healthcare versus other comparable countries. In terms of structural capacity (hospital beds, number of physicians and nurses, special scanning machines), access and quality of care (immunizations, wait times, preventative screenings), and healthcare utilization (medical imaging, surgery) the United States does not differ that much from other leading countries.

Dr. Jha is confident in the fact that utilization of services is not the main problem, but more so the cost of services and where the prices vary. Drug cost is 10-15% of healthcare spending, and administrative costs account for roughly 8% of overall spending. Other countries spend approximately only 1-5% of healthcare spending on administrative services, which includes insurance claims, billing, coding, and government reporting. The problem is that these numbers do not add up when you look at the map of life expectancy ages for the United States. With this much spending going out, our life expectancy should be higher, and our health insurance prices should be lower.

Looking at this graph, you can see just how steep the spending in the United States healthcare system is:

Taking a closer look at the second highest spending country, Germany, there are many notable differences compared to the United States. First, health insurance is mandatory in Germany. That means everyone has to have it; and Emergency Rooms of public hospitals are not flooded with uninsured patients they are required to treat. In fact, over 86% of the country is enrolled in a government health insurance plan that covers inpatient and outpatient care, as well as mental health services and prescription drug coverage. Sickness funds are even financed through wage contributions, so a portion (~1%) of paychecks are supplemented for healthcare purposes. Click here to watch a detailed video explaining how healthcare works in Germany.

Canada has a program called Canadian Medicare that is a universal publicly funded system. Each providence in Canada, similar to each state in the United States, has its own insurance plan and options, but they all receive assistance directly from the federal government. “All citizens AND permanent residents receive medically necessary hospital and physician services free at the point of use.” As an American, it is extremely difficult to imagine walking into a hospital without having to pay a dime. The government fully pays for their medical care and emergency expenses; yet the country as a whole spends less than half of what the United States does on healthcare costs.

The bottom line is that for the United States, the health care system and its prices are for profits. This makes the underlying problem within the United States healthcare system vividly open and obvious — the system is designed to generate profits. This is a major barrier to making progress and to take better care of our many unmet health issues and health disparities.

Most of us studying public health, agree with other countries and the WHO who clearly state that we should not put a price tag on health. Health is a human right.

Many Americans immediately assume the worst when they hear the words “Socialized Medicine”. Americans are fed horror stories about how individuals in countries that have socialized medicine have to wait months or even years to see a doctor or how the treatments they are seeking aren’t even available in those countries. With little knowledge of how healthcare systems work, Americans are forced to believe the outrageous stories they hear about socialized medicine. However, when taking a closer look, is socialized medicine as bad as it sounds?

Canada, America’s neighbor to the north, is a country with a strong socialized medical system. Canada has a decentralized, publicly funded health system called Canadian Medicare. Canadian Medicare is available to all citizens and permanent residents of Canada and is funded through taxes. The system covers basic medical services, and some of the services not included are prescription medications, dental care, and ambulance service. A majority of Canadians use supplemental private insurance that they purchase on top of their Canadian Medicare to cover the costs of services not covered.

The American health care system is vastly different to the Canadian health care system. America’s health care system is America’s largest industry, and Americans are mostly covered through employer sponsored private health insurance plans. Americans who are not employed or live at or below the poverty line qualify for American Medicaid which covers basic medical services. Since the Affordable Care Act (ACA) was passed in 2010, private insurance has become available to everyone, but often times it is still not affordable. As of 2019, approximately 10 percent of Americans are still uninsured.

There are several pros of the Canadian Medicare system. One major positive result of the system is that all Canadian citizens and permanent residents have access to basic health care. Individuals don’t have to worry about losing coverage if they change or lose their job, and because the system offers the same basic care to everyone, Canadians are able to choose their providers. Most Americans are limited to providers than are in network with their insurance plans. Prescription medications on average are a lot more affordable under the Canadian Medicare system. Overall, the Canadian Medicare systems provides more equitable care to its citizens when compared to the American system.

While there are several pros to the Canadian Medicare system there are also some cons. There are often wait times for non-emergency or elective surgeries and/or procedures, and wait times vary depending on the surgery or procedure. Canada has fewer physicians and inpatient beds per 1000 people than most other OECD (Organization for Economic Cooperation and Development) countries. The comparison to the OECD is particularly relevant because OECD members are among the most developed nations in the world. Because the Canadian Medicare system is funded through taxes, Canadian citizens and residents pay higher taxes than Americans. Another drawback is that Canadian Medicare only covers basic medical services, some care is not covered, and obtaining supplemental coverage to cover services not considered basic can be costly.

              The American health care system, like the Canadian health care system, has many benefits. Americans accessing the health care system have access to an array of procedures and surgeries, often without having to wait. The American health care system is mostly funded through private insurance, and when it comes to choosing a private insurance plan there are many different plans with different options. Americans who have the money to pay for insurance premiums have access to some of the greatest care in the world. Another pro of the American health care system is it has the ability to provide advanced surgical procedures and state of the art treatments not available in other countries.

              There are many cons of the American health care system that require the system to make a change. One major drawback of the system is that health care services are very expensive, and if one is uninsured or underinsured, they might not get the care they need. Many Americans who are uninsured or underinsured forego medical treatment until their illness or condition becomes extreme. Treating an extreme illness is much more costly than preventative care. The US health care system is very wasteful; every year doctors order thousands of unnecessary tests and procedures, wasting money and resources. The American health care system spends more money than any other health care system in the world, and yet has worse health outcomes than other comparable countries that spend less. A final con of the American health care system is that Americans who live in rural areas have less access to healthcare and services than Americans who live in urban and metropolitan areas.

              As you can see, no health care system is perfect. Each system has its pros and cons and each system needs changes. Unfortunately, some of the cons weigh more heavily than others: like the fact that the American system is very expensive and people who cannot afford care often times go without. America should look to its neighbor to the north to help improve its health care system.

For more information on Canadian Medicare visit the following websites:

https://www.canada.ca/en/immigration-refugees-citizenship/services/new-immigrants/new-life-canada/health-care-card.html

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5400751/

https://vittana.org/21-canadian-medicare-pros-and-cons

The most important sector of public health is the prevention of diseases, and a large part of prevention is receiving the necessary care to see the signs. However, systems vary vastly from country to country. Let’s compare the difference between the United States Healthcare system and a country on the other side of the world, Australia.

Australia’s public health system began back in 1973, with the establishment of a strict free health care service limited to retired persons. The Medicare system was changed in 1984, making it the current healthcare system that Australia has now. All of its citizens are automatically enrolled in this system. The government has three levels in charge of health insurance. The federal government provides the money and indirect support of in and outpatient care. They are also in charge of regulating private health insurance, pharmaceuticals, and therapeutic goods. The state-level manages and owns the public hospitals, ambulances, general dental care, community health, and mental health care. The state is in charge of regulating private hospitals, the location of pharmacies, and the healthcare workforce. Local governments deliver preventative health programs and community health, including immunizations and the regulation of food standards.

The United States system of healthcare has much different coverage. The United States, at the moment, does not have universal health coverage. The first public health insurance was introduced in 1965, known as Medicare and Medicaid, enacted through the Social Security Act. Medicare is the universal right to health care for anyone age 65 or over and was expanded to long-term disabilities or those with renal end-stage disease. The Medicaid program gave states the option to receive federal matching funding to provide health care services to low-income families, the blind, and individuals with disabilities. The program was later progressed to low-income women and infants and eventually to children up to 18. The eligibility to be enrolled in Medicaid varies from state to state, and they need to re-enroll every year. The United States has an extension of Medicaid or a separate program to include children, known as the Children’s Health Insurance Program.

This process of having so many different programs to provide for so many diverse populations is a weakness. The typical person may not have the ability to go through each plan to realize which one works for them. Unlike Australia, which automatically enrolls all its citizens due to the universal healthcare portion, the United States has many programs with varying requirements. If we focus specifically on child healthcare, the CHIP program is an extension of the Medicaid program or a separate program.

Both countries are trying to reduce disparities in the population in different ways. A majority of disparities are mainly related to income and race but have reduced between 2000 and 2016. In the United States, federal offices are in charge of ensuring that these groups receive quality care. The Health Resources and Services Administration provides funding to organizations and state/local governments who are low-income, uninsured, or vulnerable. The Indian Health Services gives 2.6 million American Indians that help with their health insurance. In Australia, the most prominent disparity between the aboriginal and Torres Strait Islander and life expectancy differs vastly from the rest of the Australian population. This is not on track, and the country has issues with reaching the rural and urban centers. The federal government provides financial incentives to practitioners to reach these underprivileged communities.

Currently, both countries have a set system of providing electronic health records. For example, in the US, 96% of hospitals and 86% of office physicians have adopted an electronic health record. Some of the programs can track patient demographics, list medications, store medical notes, and track medications, tests, and imaging results. The US has also passed an act in 2016 that required all health care providers to make electronic copies of patient records and be available to the patient, per request, in machine-readable forms. The electronic system of health records is known as the Australian Digital Health Agency, with its citizens being allowed to opt-out of the service. This service supports prescriptions, medical notes, any referrals, and also imaging results. The system also allows patients to view and control who sees their medical record with also allowing the ability to add allergy information, adverse reactions, and health care wishes should the patient not be able to communicate.

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Along with GDP, education level/literacy rate, and life-expectancy, assessing how well a nation is able to provide its citizens with access to health care can be very informative. Health care systems are made up of patients utilizing the system, health care providers, and resource suppliers whether that be insurance companies or medical equipment manufacturers. Observing how well these key stakeholders interact allows us to assess the health care system’s effectiveness. Health care systems SHOULD evolve over time, as culture/society, our understanding of diseases, and our technological capabilities grow. Health care can be expensive, but should not be a luxury only wealthy people can enjoy. As stated in Mills (2014), improving a nations health care system is a long-term goal. 

The United States’ world rankings in health care have steadily declined across the past few decades. This places the US firmly behind a number of low- and middle-income countries and firmly behind almost all high-income countries, as the US faces many of the issues mitigated by other nations.

[Source: The Commonwealth Fund 2016]

While the US ranks relatively low in health care quality, access efficiency and equity it ranks disproportionately high in health care spending. We are well above the average for comparable countries. And while the United States spends more on health care, health outcomes are not generally better than other nations as we lag behind in life expectancy at birth, infant mortality, and other general metrics assessing health status. Western nations with comparable GDP like Germany, Switzerland, and Scandinavian nations are spending a fraction of what the US does, while maintaining better results.

With out-of-pocket payments making up a significant chunk of health care financing in low- and middle-income countries, identifying creative ways to cover the cost is imperative. According to a 2016 Kaiser Family and New York Times survey, more than 25% of Americans had trouble paying a recent medical bill.

We are one of the last high-income/developed nations to resist universal healthcare.  Universal health care would mean ejecting on our current single-payer model of health insurance coverage and more readily adopting social health insurance. Spreading the risk of health care causes across a large population of people should be a no-brainer for Americans, and yet… there is unyielding resistance from some political groups. 

The current US health system is a mix of both private and public insurers and health care providers. Former President Barack Obama, against gnash republican obstruction, was able to enact the Affordable Care Act in 2010 to expand coverage, slow health care spending, and improve clinical quality. Sadly, the ACA was somewhat neutered by the following administration, which was known throughout its short tenure for many overtly racist communications and policies. The ACA was a small step in the right direction, but still not quite the universal health care goal we should be striving for.

Mill (2014) points out that there is no single way to develop a health care system that will work for all nations and stakeholders, but we do have multiple working blueprints for success. One characteristic highlighted is to “take into account the constraints imposed by history and previous decisions”. This, to me, is a clear opportunity for policy makers to address and rectify historically perpetuated inequities by the US government. Not only has access to equitable care been withheld from many communities, but toxic health practices in studies of Black communities has tarnished the relationship between minority [would be] subjects and researchers. Repairing this relationship is vital to achieving health equity.

The Civil Rights Movements provided incredible advancements for minorities to gain access to quality health care and reducing segregation in American medical institutions. In some instances, communities went from literally nothing to something through clinics set up with volunteer physicians.  but health disparities continue to ravage minority and impoverished American communities. 

As stated in Napier et al (2014), understanding how culture plays into health outcomes is a vital key to reducing health inequity, not only in the United States, but in low- and middle-income countries as well. Napier describes the overlap of cultural competence, health inequities and community of care and how health and wellbeing are fundamentally tied to cultural perceptions. Without pointing blame at past wrongs, interventions that engage community stakeholders with the other layers of health care systems should be prioritized. As we’ve mentioned cultural differences within the country, its important to recognize that the developed nations we’ve compared the US to are also fundamentally culturally different, thus their specific fixes might not fit here.

The road to meaningful health care reform is an uphill one, for both the US and developing nations, but progress is continuously being made. There are some positives to the US health care system, including quality of health care services, minimal waiting lists for major procedures and adequate resources. However, the negatives of expensiveness, limited insurance coverage and minimal to no preventive care presently outweighs to good. Overall, the lack of access to care for all casts a harrowing shadow over America’s health future. We’ve seen how our nation has responded to a global pandemic… If we do not learn some needed lessons, I can’t imagine how things will look after the next inevitable public health crisis.