This blog post is an excerpt from “How We Do Harm: A Doctor Breaks Ranks About Being Sick in America,” By Otis Webb Brawley, M.D. with Paul Goldberg. Reprinted with permission.©2011 with Otis Webb Brawley, M.D., with Paul Goldberg.
This book is a guided tour of the back rooms of American medicine. When I was fresh out of the University of Chicago medical school and newly admitted behind the curtains of these back rooms, I could dismiss medical horror stories as isolated episodes of the malfunctioning of the system: another person overlooked, another judgment error, another example of bum luck, another case of the
frustratingly slow march of progress.
More than a quarter century later, I have seen enough to conclude that no incident of failure in American medicine should be dismissed as an aberration. Failure is the system, and those of us who are not yet its victims are at high risk of being sucked into its turbines.
My friend and colleague Peter Bach is fond of saying, “America does not have a health-care system. We have a sick-care system.” Peter, a health-systems researcher and a pulmonologist at Memorial
Sloan-Kettering Cancer Center, goes on to say it’s a stretch to use the word system to describe our health care because this word denotes organization.
Too often, helping the patient isn’t the point. Economic incentives can dictate that the patient be ground up as expensively as possible with the goal of maximizing the cut of every practitioner who gets involved. When we, doctors, are at our best, we set aside our self-interest and put the patient’s interest first. When we aren’t at our best, the public pays more in fees, insurance premiums, taxes – and poor outcomes.
America’s System is Not ‘Best in the World’
I get furious every time I hear politicians and pundits assert that the American health-care system is the best in the world. I hear this far too often from opponents of the 2010 health-care reform bill. I can think of several explanations for repeating this falsehood. Ignorance is the first and most elegant. Being out of touch with reality would explain it, as would lying, either to ourselves or to others.
America is the greatest place in the world to get care for a complicated but treatable disease if you have the ability to get the care and pay for it. It’s not a great place to be sick if you are poor and uninsured and want consistent, basic care.
When you look at outcomes, our health-care system – technology notwithstanding – is closer to Communist states, both former and current, than to other technologically advanced nations.
The CIA publishes a lot of information that is publically available. The agency’s data notes that life expectancy for Americans is 78.37 years. This makes us No. 50 among nations. Taiwan is No. 51. Monaco is on top, with the life expectancy of 89.73 years. Canada is No. 12, with 81.3 years, the United Kingdom is No. 28, with 80.05 years.
Some argue that this comparison is inappropriate since the United States has high homicide and accident rates compared to other first-world countries. I argue that this is the very point. Homicide, accident prevention, and other preventive health measures are a part of the health-care system and are recognized as such by most outside this country.
Life expectancy is heavily driven by infant mortality rates. This is not an area where we have much to be proud of. Forty-four countries have better infant mortality rates than the United States, including Cuba and Slovenia. This means that compared to a lot of other countries – many of them vastly poorer than us – we have a problem getting good care to pregnant women and babies.
Paying for Mediocre Results
And we pay a lot for mediocre results. Per capita, our health-care spending is the highest in the world. Here we are, indeed, No. 1. The No. 2 slot belongs to Switzerland, but our spending exceeds theirs by 50 percent. Americans spend two and a half times more on health care than on food.
Health care’s share of America’s gross domestic product is expanding. It jumped to 17.3 percent in 2009 from 16.2 percent in 2008 – the largest single-year increase since 1960. At the current rate of growth, health-care costs are predicted to jump to $4.5 trillion in 2019.
At that point, health care will account for 19.3 percent – almost a fifth – of our gross domestic product. Some estimate that these increases are on course to make health care account for 25 percent of our economy by 2025.
Conservative pundits and politicans are fond of maligning the Canadian health-care system. Yet, Canadians spend half of what we do per capita. Switzerland is ranked tenth in life expectancy, and
Canada is seventh. As No. 50 and the biggest spender by far, we aren’t getting what we pay for.
It’s Time to Try A ‘Painfully Obvious Approach’
Efforts to slow the expansion of our health-care system predate my career in medicine. Twenty-five years after I earned my white coat, from all my vantage points – as a doctor on the ward, as an
epidemiologist, and as a policy-maker – I see the same picture: our medical system fails to provide care when care is needed and fails to stop expensive, often unnecessary, and frequently harmful
interventions even in situations when science proves these interventions are wrongheaded.
From my vantage points, I see that one painfully obvious approach to health-care reform has never been tried: No one has tried to make the entire system function rationally, based on science.
Dr. Brawley will be the keynote speaker at The Alliance Annual Seminar on May 19, 2015.
- A Guided Tour of the Back Rooms of American Medicine - April 22, 2015