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| Journal of the New Zealand Medical Association,
05-September-2008, Vol 121 No 1281
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How to spend a sixth of your entire economy on
healthcare
Pauline Norris
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 ill-healthCreate 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.
Turn real and imagined health problems into market opportunitiesThe 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.
Have no brake on pricesIn 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.
What can be done if you find that all this money isn’t making people healthy?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: pauline.norris@stonebow.otago.ac.nz
References:
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