Louise Brown was an accountant with a 25-year history of diabetes. Her physician taught her to monitor her glucose at home, and her dietician helped her follow a diabetic diet. Her diabetes was brought under good control. Diabetic retinopathy was discovered at yearly eye examinations, and periodic laser treatments of her retina prevented loss of vision. Ms. Brown lived to the age of 88, a success story of the US health care system.
Angela Martini grew up in an inner-city housing project, never had a chance for a good education, became pregnant as a teenager, and has been on public assistance while caring for her four children. Her Medicaid coverage allows her to see her family physician for yearly physical examinations. A breast examination located a suspicious lesion, which was found to be cancer on biopsy. She was referred to a surgical breast specialist, underwent a mastectomy, was treated with a hormonal medication, and has been healthy for the past 15 years.
For people with private or public insurance who have access to health care services, the melding of high-quality primary and preventive care with appropriate specialty treatment can produce the best medical care in the world. The United States is blessed with thousands of well-trained physicians, nurses, pharmacists, and other health caregivers who compassionately provide up-to-date medical attention to patients who seek their assistance. This is the face of the health care system in which we can take pride. Success stories, however, are only part of the reality of health care in the United States.
The health care system in the United States has been called “a paradox of excess and deprivation” (Enthoven and Kronick, 1989). Some persons receive too little care because they are uninsured, inadequately insured, or have Medicaid coverage that many physicians will not accept.
James Jackson’s Medicaid benefits were terminated because of state cutbacks. At age 34, he developed abdominal pain but did not seek care for 10 days because he had no insurance and feared the cost of treatment. He began to vomit, became weak, and was finally taken to an emergency room by his cousin. The physician diagnosed a perforated ulcer with peritonitis and septic shock. The illness had gone on too long; Mr. Jackson died on the operating table. Had he received prompt medical attention, his illness would likely have been cured.
Betty Yee was a 68-year-old woman with angina, high blood pressure, and diabetes. Her total bill for medications, which were only partly covered under her Medicare plan, came to $200 per month. She was unable to afford the medications, her blood pressure went out of control, and she suffered a stroke. Ms. Yee’s final lonely years were spent in a nursing home; she was paralyzed on her right side and unable to speak.
Mary McCarthy became pregnant but could not find an obstetrician who would accept her Medicaid card. After 7 months, she began to experience severe headaches, went to the emergency room, and was found to have hypertension and preeclampsia. She delivered a stillborn baby.
While some people cannot access the care they need, others receive too much care that is costly and may be harmful.
At age 66, Daniel Taylor noticed that he was getting up to urinate twice each night. It did not bother him much. His family physician sent him to a urologist, who found that his prostate was enlarged (though with no signs of cancer) and recommended surgery. Mr. Taylor did not want surgery. He had a friend with the same symptoms whose urologist had said that surgery was not needed. Since Mr. Taylor never questioned doctors, he went ahead with the procedure anyway. After the surgery he became incontinent of urine.
Consuelo Gonzalez had a minor pain in her back, which was completely relieved by over-the-counter acetaminophen. She went to the doctor just to make sure the pain was nothing serious, and it was not. The physician gave Ms. Gonzalez a stronger medicine, indomethacin, to take three times a day. The indomethacin caused a bleeding ulcer requiring a 9-day hospital stay at a cost of $27,000 to her health insurer.
In 2009, over 50 million people in the United States had no health insurance. Many are victims of the changing economy, which has shifted from a manufacturing economy based on highly paid full-time jobs with good fringe benefits, toward a service economy with lower-paying jobs that are often part-time and have poor or no benefits (Renner and Navarro, 1989). Three-fourths of uninsured adults are employed. Lack of insurance is not simply a problem of the poor but has also become a middle-class phenomenon, particularly for families of people who are self-employed or work in small establishments. Many people with health insurance have inadequate coverage. In 2007, 45% of adults could not get needed care because they could not afford to pay the bills (Collins et al, 2008).
According to health services expert Robert Brook (1989):
…almost every study that has seriously looked for overuse has discovered it, and virtually every time at least double-digit overuse has been found. If one could extrapolate from the available literature, then perhaps one-fourth of hospital days, one-fourth of procedures, and two-fifths of medications could be done without. (Brook, 1989)
A 1998 report estimated that 20%–30% of patients continue to receive care that is not appropriate (Schuster et al, 1998). A 2003 study found that elderly patients in some areas of the country receive 60% more services—hospital days, specialty consultations, and medical procedures—than similar patients in other areas; the patients receiving fewer services had the same mortality rates, quality of care, access to care, and patient satisfaction as those receiving more services (Fisher et al, 2003a and 2003b). In 2009, health care quality expert Brent James estimated that half of all health care dollars are wasted (James, 2009).
Health care in the United States encompasses a wide spectrum, ranging from the highest-quality, most compassionate treatment of those with complex illnesses, to the turning away of the very ill because of lack of an ability to pay; from well-designed protocols for prevention of illness to inappropriate high-risk surgical procedures performed on uninformed patients. While the past three decades have been witness to major upheavals in health care, one fundamental truth remains: the United States has the least universal, most costly health care system in the industrialized world (Davis et al, 2010).
Many people view the high costs of care and the lack of universal access as indicators of serious failings in the health care system. In 2009, only 15% of people in the United States believed that the system was working well (Blendon et al, 2009). In 2010, 33% of Americans reported not seeing a doctor or not filling a prescription due to costs, a prevalence of access problems considerably higher than that in other developed nations (Schoen et al, 2010).
In order to correct the weaknesses of the health care system while maintaining its strengths, it is necessary to understand how the system works. How is health care financed? What are the causes and consequences of incomplete access to care? How are physicians paid, and what is the effect of their mode of reimbursement on health care costs? How are health care services organized and quality of care enhanced? Is sufficient attention paid to the prevention of illness, and what are different strategies for preventing illness?
How can the problems of health care be solved? Does the health reform law enacted by Congress in 2010 provide the answer? Can costs be controlled in a manner that does not reduce access? Can access be expanded in a manner that does not increase costs? How have other nations done it—or attempted to do it? How might the health care system in the United States change in the future?
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Collins SR et al. Losing Ground: How the Loss of Adequate Health Insurance Is Burdening Working Families. New York: Commonwealth Fund; 2008.
Davis K et al. Mirror, Mirror on the Wall. New York: Commonwealth Fund; 2010.
Enthoven A, Kronick R. A consumer-choice health plan for the 1990s. N Engl J Med. 1989;320:29.
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Fisher ES et al. The implications of regional variations in Medicare spending. Part 2: Health outcomes and satisfaction with care. Ann Intern Med. 2003b;138:288.
Renner C, Navarro V. Why is our population of uninsured and underinsured persons growing? The consequences of the “deindustrialization” of the United States. Int J Health Serv. 1989;19:433.
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