According to a comprehensive new report by the Commonwealth Fund, the healthcare system in the U.S. is, in general, declining. This year, the U.S. received a score of 64 out of a possible 100. In 2006, the U.S. got a 67 out of a possible 100, and in 2008 it earned a 65.
The report, entitled “Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011,” covers key health indicators from the years 2008-2009, and is the third installment of the series that began in 2006.
This year, the U.S. received a score of 64 out of a possible 100. In 2006, the U.S. got a 67 out of a possible 100, and in 2008 it earned a 65.
The researchers, gathered from various hospitals and research institutions across the country, considered 42 key measures of healthcare in five different areas reflecting financial, medical and human considerations:
- Healthy Lives included variables having to do with life expectancy, mortality, and the prevalence of certain factors like smoking, and childhood overweight or obesity.
- Quality measured how well medical care delivered its goals and whether it is “well coordinated, safe, timely, and patient-centered.”
- Access determined whether health care and health insurance were available to patients.
- Efficiency looked at how smoothly operations run in the health business, including how often preventable readmissions to hospitals occur and whether facilities are using information systems.
- Equity assessed how different groups of patients are treated in the healthcare system.
Cost and Care, Two Related Problems
The main message of the report is that healthcare costs are rising but they are simply not matched by improvements in the care people receive. In other words, breaking it down to the most fundamental issues, there are two problems: Cost and care.
The cost of healthcare is rising faster than the average American income, which leaves many people without access to insurance and health care at all.
The total cost of healthcare – which includes everything from primary care and preventative medicine to the treatment of chronic diseases to hospitalization and long term care – is rising faster than we can keep up, according to the report.
The U.S. spends twice per capita what other countries spend. The authors of the report comment that “U.S. health system performance continues to fall far short of what is attainable, especially given the enormity of public and private resources devoted nationally to health.” The cost of healthcare is rising faster than the average American income, which leaves many people without access to insurance and health care at all.
Beyond the issue of cost, the quality of the care in the U.S. seems to be suffering. Measures like infant mortality and the number of unnecessary rehospitalizations indicate that the U.S. still has a long road ahead. That said, there were some bright spots, signs that we may be on the right track, at least in some ways. For example, the U.S. is gaining ground in the management of certain chronic diseases and in the quality of long term care, both of which are important markers for healthcare quality.
The authors argue that the Affordable Care Act will, and has already begun in some ways, to change the state of the heath care system in the U.S. How far-reaching its effects will be remains to be seen.
Where the U.S. Succeeds
The U.S.'s overall score of 64 reflects a variety of strengths and weaknesses. The areas of improvement were not insignificant. In general, the U.S. showed promise in the control of chronic conditions, smoking rates, the use of electronic files for record keeping, and in certain aspects of hospital and long term care. Breaking it down, we find the following trends.
- Blood pressure control rose from 31% to 50%, which means that half the people with high blood pressure were managing it effectively, vs. less than a third at the previous measure, eight years earlier. Another chronic care marker reported nationally is long term diabetes care (control of blood sugar), which did not improve, but remained fairly stable in 2007-2008, compared to four years earlier.
- Cigarette smoking declined from 21% to 17% from 2004 to 2009.
- The percentage of primary care doctors using electronic medical records (EMR) and information systems, increased from 17% to 46% from 2000 to 2009. However, the report also indicates that the use of EMR in the U.S. still lags far behind that of other countries.
Since preventable hospitalizations and rehospitalizations are a major cause of economic stress to the health care system, reducing those is a major goal.
- Preventable mortality – deaths that could have been avoided with earlier or more effective treatment measures – improved by 21%, but because other countries, on average, improved by 32% on this measure, the U.S. fell last in preventable deaths.
- Preventable hospitalizations such as admission rates for heart failure and pediatric asthma each dropped by 13% from 2004 to 2007, which may be a reflection of better disease management. Since preventable hospitalizations and rehospitalizations are a major cause of economic stress to the health care system, reducing those is a major goal.
- Some aspects of hospital care also improved. Hospitals reduced surgery complications 96% of the time in 2009, vs. only 71% in 2004.
- Long term care, which includes factors like the frequency of pressure ulcers in people living in nursing homes and the mobility of people with home health care aids, improved as well.
The Areas in Decline
Despite progress in the areas above, there are three areas that show no improvement or have actually declined in recent years: healthcare, insurance accessibility, and cost of care. The issues, of course, are not completely separate from one another.
The U.S. scored 53 out of a possible 100, about the same as in previous reports, in a measure known as efficiency – how well the healthcare system functions overall. Efficiency is a broad area, encompassing the “level of inappropriate, wasteful, or fragmented care; avoidable hospitalizations; variation in quality and costs; administrative costs; and use of information technology.” Here are some of the factors contributing to this score:
- Premature deaths were 68% higher in the U.S. than in the best-performing countries. The premature death rate is an important measure of the quality of care, and includes all deaths that could have been avoided with better or earlier medical care.
- Only 44% of Americans have a primary care doctor.
- Only 50% of U.S. citizens received basic preventative care services in 2008, including immunization, screenings for cancer, and cholesterol and blood pressure tests. There was no significant change from 2002.
Premature deaths were 68% higher in the U.S. than in the best-performing countries.
Unsurprisingly, the Commonwealth Fund report found that In 2010, 44% of adults (81 million people) were either uninsured or underinsured, which means that “they were insured all year but had medical bills or deductibles that were high relative to their incomes.” This represents a one-third increase from 2003. The high cost of health insurance is the main reason for this.
- Only 43% of adults with a health problem in 2008 were able to get a doctor’s appointment quickly when their condition required it.
- Minorities, low-income and uninsured adults, and children were less likely to have access to health care and seek it in a timely way. These groups were also more likely to “experience poorly coordinated care, and to have untreated dental [problems], uncontrolled chronic disease, avoidable hospitalizations, and worse outcome” than their white, insured peers.
- “Safe care” in hospitals was also weak: up to a quarter of seniors on Medicare were prescribed drugs that were “potentially inappropriate for older people.” The researchers suggest that increasingly widespread use of electronic records systems could help improve safety in hospitals.
- Infant mortality was twice as high as in other countries though it was down slightly, from 7 to 6.8 deaths per1,000 live births.
- Childhood obesity rates continue to grow, with almost one-third of kids 10-17 overweight or obese. In some states, the number rises to 40%. The authors say that if it keeps going this way, the trend will negate the positive changes in other areas, like the decline in smoking.
In 2003, the percentage of adults spending less than 15% of their household income on health insurance was 57%. In 2009, the number spending 15% dropped to 4%. At the same time, the number of people in medical debt rose to 40% in 2010, up from 34% five years earlier.
As the numbers above suggest, the final area where we differ considerably from other nations is in the amount of money we spend on healthcare in the country. According to the report, the U.S. spends twice as much per capita than other countries. And the rate at which our spending is increasing is steeper than in other countries. In fact, we are close to spending one out of every five dollars of income on healthcare. As the authors say, given all the shortcomings in the healthcare system, “[w]e should expect a better return on this investment.”
What Is at Stake if We Don’t Change?
The report's conclusions are not big news, but the depth of detail in the picture it paints makes it a major contribution to the healthcare debate. The report concludes that there are risks – both “human and economic” – if we don’t make changes to the system sooner than later.
Yet to be accomplished, but hand in hand with access to care, improving primary care is the second critical step. Better primary care could theoretically affect everything from the management of chronic conditions to the prevention of unnecessary rehospitalizations to the avoidance of emergency room visits.
The authors of the report predict that healthcare costs will increase further, more and more people will be uninsured, and the quality of care will continue to suffer. The three areas chase each other in a vicious cycle. Pushing it further, we could argue that as a result of a worsening situation, chronic disease would also continue to rise, mortality would increase, and, not unimportantly, our quality of life would decline.
But there is a silver lining: the situation has begun to improve. In the same way that shortcomings in the system perpetuate one another, improving just one area of health care can set in motion a positive chain of events, with multiple areas showing improvement as the result of a single change.
The report's authors argue that the Affordable Care Act (ACA) Act has already facilitated access to care, which is an important step. For example, adults up to 26 years of age can now be insured under their parents’ policies. This has allowed an additional one million people health coverage. When the Act is in full effect the authors calculate the country’s average insurance coverage rate should match the level of the best-insured states.
Other nations have stronger health care systems in part because they are smaller and have been utilizing other methods for years or decades.
Yet to be accomplished, but hand in hand with access to care, improving primary care is the second critical step. Better primary care could theoretically affect everything from the management of chronic conditions to the prevention of unnecessary rehospitalizations to the avoidance of emergency room visits. Beginning with these couple of changes (which are admittedly not small ones) we should start moving things in the right direction.
If the United States were able to meet the same benchmarks for healthcare as other developed countries, the authors project we would see:
- 91,000 fewer people dying prematurely each year.
- 38 million more adults with access to a primary care provider.
- 66 million more adults receiving recommended preventive care.
- A savings of $1.6 billion to $3.1 billion per year in medical costs as a result of improved control of diabetes and blood pressure and its related prevention of additional diseases and complications.
- A savings of $144 billion per year if health insurance administrative costs were lowered; simply reducing the costs to the level of countries with mixed private–public insurance systems (like the U.S.) would free up $55 billion.
These projections are both inspiring and daunting. Clearly, a massive change in a massive country won’t happen over night. Other nations have stronger health care systems in part because they are smaller and have been utilizing other methods for years or decades. It’s clear that the American public is ready for change, and we are slowly making steps in that direction. Things have already started to improve, if slowly.
Time will tell how the Affordable Care Act will continue to improve the situation, and over what timeframe. It may need to be amended considerably as its effects become visible over the coming years, or additional measures may be necessary. But as the authors of the new report point out: "Although the task of moving to a system that is truly high performing is enormous, the stakes are even higher if we fail.”
The Commonwealth Fund Commission on a High Performance Health System, Why Not the Best? Results from the National Scorecard on U.S. Health System Performance, 2011 can be viewed here.