Journal of the New Zealand Medical Association, 05-September-2008, Vol 121 No 1281
How to spend a sixth of your entire economy on healthcare
Healthcare now eats up 16% of the entire United States (US) economy1 yet US health outcomes are not particularly good. Some of the factors leading to this are undoubtedly due to the specific history of the US,2 while others are general trends that provide lessons to those in other countries like New Zealand.
This editorial shares impressions from my recent visit to the US, about how a country of (in the large part) kind, intelligent, and reasonable people can end up in this predicament.
Create and sustain large economic and social inequalities
American society is characterised by large inequalities in access to material resources, opportunity for advancement, and social inclusion. The US’s Gini index (a measure of income inequality) is 45, substantially higher than New Zealand’s 36.2, or the Nordic countries (24–28).3
Widespread poverty, homelessness, and lack of basic medical care lead to significant physical and mental health problems. An estimated 3.5 million people in the US experience homelessness each year, and the fastest growing segment is families with children. At any one time, homeless adults suffer from an average of 8–9 illnesses.4
Make food cheap, taste good, and super-size it
In Chicago airport, even I baulked at the size of the individual fresh-baked warm buns, dripping with icing, that were about 6 inches square. So I asked for a smaller one, but unfortunately they were only available in a row of 6!
Destroy opportunities for incidental or deliberate exercise (except in a gym)
A combination of urban design, lack of public transport, and the availability of cheap fuel can be used to minimise walking, cycling or running, and ensure that everyone drives everywhere, all of the time. If you locate shops and services out of town, such as by the side of highways, or in large malls, that can only be accessed by car, only the most determined person will visit on foot. Wide highways without footpaths or pedestrian crossings can make it impossible to cross from one side to another without getting in a car.
The American public are bombarded with advertisements for medicines, for medical procedures, for medical insurance, and for particular medical services. See Figure 1.
Figure 1. Boston advertisement
An increasing range of symptoms of everyday life are seen as medical problems. In one issue of the newspaper—USA Today (29/10/2007)—I found the following: advertisements for the Boston Medical Group (for erectile dysfunction); health insurance (as part of an advertisement for life insurance); electric scooters for mobility; ‘Resperate’ a system of structured breathing exercises to lower blood pressure; Viamedic—a company which delivers prescription medicines; overnight shipping of three ED medications; a full-page advertisement from Sanofi-Aventis recommending taking insulin earlier in diabetes treatment; and a full-page advertisement advising that children should have an hour’s play/exercise per day.
During 2 hours of television (Turner Network Television, 9–11pm, 29/10/2007) I was informed that Quaker Oats could reduce my cholesterol, Lasix Plus could allow me a good deal on laser eye surgery, Walgrens pharmacy could offer “special services” for caregivers, Asmanex would help my asthma (advertised twice), Ducolax could relieve my constipation, and that I should take Centrum Silver vitamin supplement, and Emergen-C vitamins (advertised twice). The actress Betty White even advertises discount medications for pets on US television.
Pharmaceutical solutions to these real and imagined health problems are not only widely advertised by also widely accessible. Tylenol (paracetamol) can be found in food vending machines, and all non-prescription medicines can be bought off the shelf in liquor stores, supermarkets, or elsewhere.
In New Zealand the government’s monopsony position as the biggest payer for health services gives it considerable ability to put the brakes on price growth, on total expenditure, and to balance healthcare with other goals.
In US, the huge diversity of payers means that no one can do this. If they restrict what they pay for, customers can go elsewhere. The American healthcare system is not really a system at all; it is a whole range of competing providers and payers.
For example, Medicare, as the US government’s health insurer for the elderly and disabled, pays for a vast quantity of medication. But instead of using this position to gain price advantages (as PHARMAC does in New Zealand), Medicare offers patients a choice of about 2000 different prescription medicines plans. Medicare patients have to choose the plan they think will be most advantageous for them. This requires complex judgements about the medicines they currently take, and impossible judgements about what they are likely to need in the future.
In spite of the huge level of expenditure on health care, life expectancy for both males and females is lower in the USA than in New Zealand3 and the number of Americans without health insurance increased from 44.8 million in 2005 to 47.0 million in 2006.5
Both candidates in the presidential election agree on the problems: the number of uninsured people and the cost of healthcare. (www.barackobama.com and www.johnmccain.com). Barack Obama is promising to extend healthcare coverage to every American, with lower premiums whereas John McCain is promising a tax credit to offset the cost of insurance. However the chances of either candidate being able to make significant changes should not be overestimated—as (in the past) the lobbying power of insurers and providers has stymied any attempts at significant reform.
Competing interests: None known.
Author information: Pauline Norris, School of Pharmacy, University of Otago, Dunedin
Correspondence: Pauline Norris, School of Pharmacy, University of Otago, PO Box 913, Dunedin, New Zealand. Fax: +64 (0)3 479 7034; email: email@example.com
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