Archive for August, 2007
A must-read editorial from today’s Times…
August 12, 2007
New York Times
World’s Best Medical Care?
Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.
Michael Moore struck a nerve in his new documentary, “Sicko,” when he extolled the virtues of the government-run health care systems in France, England, Canada and even Cuba while deploring the failures of the largely private insurance system in this country. There is no question that Mr. Moore overstated his case by making foreign systems look almost flawless. But there is a growing body of evidence that, by an array of pertinent yardsticks, the United States is a laggard not a leader in providing good medical care.
Seven years ago, the World Health Organization made the first major effort to rank the health systems of 191 nations. France and Italy took the top two spots; the United States was a dismal 37th. More recently, the highly regarded Commonwealth Fund has pioneered in comparing the United States with other advanced nations through surveys of patients and doctors and analysis of other data. Its latest report, issued in May, ranked the United States last or next-to-last compared with five other nations — Australia, Canada, Germany, New Zealand and the United Kingdom — on most measures of performance, including quality of care and access to it. Other comparative studies also put the United States in a relatively bad light.
Insurance coverage. All other major industrialized nations provide universal health coverage, and most of them have comprehensive benefit packages with no cost-sharing by the patients. The United States, to its shame, has some 45 million people without health insurance and many more millions who have poor coverage. Although the president has blithely said that these people can always get treatment in an emergency room, many studies have shown that people without insurance postpone treatment until a minor illness becomes worse, harming their own health and imposing greater costs.
Access. Citizens abroad often face long waits before they can get to see a specialist or undergo elective surgery. Americans typically get prompter attention, although Germany does better. The real barriers here are the costs facing low-income people without insurance or with skimpy coverage. But even Americans with above-average incomes find it more difficult than their counterparts abroad to get care on nights or weekends without going to an emergency room, and many report having to wait six days or more for an appointment with their own doctors.
Fairness. The United States ranks dead last on almost all measures of equity because we have the greatest disparity in the quality of care given to richer and poorer citizens. Americans with below-average incomes are much less likely than their counterparts in other industrialized nations to see a doctor when sick, to fill prescriptions or to get needed tests and follow-up care.
Healthy lives. We have known for years that America has a high infant mortality rate, so it is no surprise that we rank last among 23 nations by that yardstick. But the problem is much broader. We rank near the bottom in healthy life expectancy at age 60, and 15th among 19 countries in deaths from a wide range of illnesses that would not have been fatal if treated with timely and effective care. The good news is that we have done a better job than other industrialized nations in reducing smoking. The bad news is that our obesity epidemic is the worst in the world.
Quality. In a comparison with five other countries, the Commonwealth Fund ranked the United States first in providing the “right care” for a given condition as defined by standard clinical guidelines and gave it especially high marks for preventive care, like Pap smears and mammograms to detect early-stage cancers, and blood tests and cholesterol checks for hypertensive patients. But we scored poorly in coordinating the care of chronically ill patients, in protecting the safety of patients, and in meeting their needs and preferences, which drove our overall quality rating down to last place. American doctors and hospitals kill patients through surgical and medical mistakes more often than their counterparts in other industrialized nations.
Life and death. In a comparison of five countries, the United States had the best survival rate for breast cancer, second best for cervical cancer and childhood leukemia, worst for kidney transplants, and almost-worst for liver transplants and colorectal cancer. In an eight-country comparison, the United States ranked last in years of potential life lost to circulatory diseases, respiratory diseases and diabetes and had the second highest death rate from bronchitis, asthma and emphysema. Although several factors can affect these results, it seems likely that the quality of care delivered was a significant contributor.
Patient satisfaction. Despite the declarations of their political leaders, many Americans hold surprisingly negative views of their health care system. Polls in Europe and North America seven to nine years ago found that only 40 percent of Americans were satisfied with the nation’s health care system, placing us 14th out of 17 countries. In recent Commonwealth Fund surveys of five countries, American attitudes stand out as the most negative, with a third of the adults surveyed calling for rebuilding the entire system, compared with only 13 percent who feel that way in Britain and 14 percent in Canada.
That may be because Americans face higher out-of-pocket costs than citizens elsewhere, are less apt to have a long-term doctor, less able to see a doctor on the same day when sick, and less apt to get their questions answered or receive clear instructions from a doctor. On the other hand, Gallup polls in recent years have shown that three-quarters of the respondents in the United States, in Canada and in Britain rate their personal care as excellent or good, so it could be hard to motivate these people for the wholesale change sought by the disaffected.
Use of information technology. Shockingly, despite our vaunted prowess in computers, software and the Internet, much of our health care system is still operating in the dark ages of paper records and handwritten scrawls. American primary care doctors lag years behind doctors in other advanced nations in adopting electronic medical records or prescribing medications electronically. This makes it harder to coordinate care, spot errors and adhere to standard clinical guidelines.
Top-of-the-line care. Despite our poor showing in many international comparisons, it is doubtful that many Americans, faced with a life-threatening illness, would rather be treated elsewhere. We tend to think that our very best medical centers are the best in the world. But whether this is a realistic assessment or merely a cultural preference for the home team is difficult to say. Only when better measures of clinical excellence are developed will discerning medical shoppers know for sure who is the best of the best.
With health care emerging as a major issue in the presidential campaign and in Congress, it will be important to get beyond empty boasts that this country has “the best health care system in the world” and turn instead to fixing its very real defects. The main goal should be to reduce the huge number of uninsured, who are a major reason for our poor standing globally. But there is also plenty of room to improve our coordination of care, our use of computerized records, communications between doctors and patients, and dozens of other factors that impair the quality of care. The world’s most powerful economy should be able to provide a health care system that really is the best.
The last one…
An Unreasonable Man.
Note: I have a crush on Ralph Nader, and unapologetically voted for him in 2000. If anyone wants to accuse Nader/people like me of handing the presidency to the sitting douche bag, I’ll show you the way. If you won’t listen, I’ll fight you.
The film begins with a quote from G. B. Shaw: “The reasonable man adapts himself to the world; the unreasonable one persists in trying to adapt the world to himself. Therefore, all progress depends on the unreasonable man.”
And progress he has brought. What I find most interesting about him is that he does contradict the Shaw quote in one way: he has adapted to the capitalist system and works from the inside–a very reasonable position. Being a consumer advocate is a very reasonable thing in America. He’s not fighting consumerism; he wants to tame the capitalist beast. Some would argue he’s more conservative than progressive because of this; I think he’s the most American thing: pragmatic. And I do think pragmatism still has a place in philosophy and politics.
The big question is why he ran for president. Some think (and I’m on the fence with this one) that he did/would do more good remaining outside of politics (i.e., not holding political office). But as consumers of democracy, as consumers of America (because we aren’t really citizens now, are we?), don’t we deserve choice? Republican or Democrat isn’t really a choice; Democrat is merely the lesser of two evils. Democrats who demonize Nader are afraid of losing their stranglehold on progressive voters.
And let’s not forget that Al Gore did win the presidential election in 2000, Nader or no Nader.
The film is a good look at a career that has spanned over fifty years and a man responsible for seat belts and airbags. And who couldn’t love a man who once called hot dogs “missiles of death?”
Yet another classic that I just saw for the first time, and–in my opinion–the best Jack Nicholson movie. It was nice to see Jack before he became a parody of himself, before his signature grin became a signature, and when he performed with a touch of insecurity–not performed insecurity. And Faye Dunnaway is gorgeous.
The movie is great, and could’ve been made yesterday, with the exception of a line like “L.A.’s a small town.” I had a tough time believing the setting was the 1940s for some reason; the movie looked too much like the 1970s, if that makes any sense. Yet this was not a major distraction, just a personal twinge. And I’m still naive enough to feel unsettled about how ultimately little has changed since…well, the turn of the (20th) century, I guess. How the century of the corporation–and its manipulation of the government for its own profit–continues, perhaps stronger than ever. How the line (also mentioned here) “As little as possible” is the motto for “free-market capitalism” (the “free-market” part is a myth) and for about half of the American population–whether they understand its implications or not.
A down-home, country boy villain that really is purely evil (Sound like anyone? Oh, right.) caps the trio of excellent performances. Loved the scene where he and Jack eat fish–with the heads still on. Loved the movie.