Friday, August 17, 2007

42nd and counting

The latest comparative study on world life expectancy received a lot of attention this week:

"The U.S. has been slipping for decades in international rankings of life expectancies as other countries are improving health care, nutrition and lifestyles, according to the AP/Daily Star. Countries that rank above the U.S. include Japan, most of Europe, Jordan and the Cayman Islands. A U.S. resident born in 2004 has a life expectancy of 77.9 years, placing the U.S. in 42nd place, down from 11th place two decades ago.

"Researchers say the lower U.S. ranking is attributed to the high uninsured rate among the population, in addition to rising obesity rates and racial disparities in life expectancy. Black U.S. residents have a shorter life span, at 73.3 years, than whites. The U.S. also has a high infant mortality rate compared with other industrialized nations, with 40 countries [including Cuba] having lower infant mortality rates than the U.S. in 2004."

In a long editorial on the subject, the New York Times surveyed the life expectancy study and various findings from other recent comparative analyses:

  • "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."
  • "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."
  • "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."
  • "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."
  • The U.S. performs "poorly in coordinating the care of chronically ill patients, in protecting the safety of patients and in meeting their needs and preferences";
  • The U.S. "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."
  • "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."
  • "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."
  • The widespread negative views "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."
  • "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."
The Times concluded:
"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."
Another recent study by the Partnership for Prevention reinforces the notion that lack of access to preventive care for the uninsured is a major factor in life expectancy:
Utilization rates remain low for preventive services that are very cost effective and have been recommended for years. Increasing the use of just 5 preventive services would save more than 100,000 lives each year in the United States.
  • 45,000 additional lives would be saved each year if we increased to 90 percent the portion of adults who take aspirin daily to prevent heart disease... [Note: Consultation with a doctor is strongly recommended before anyone starts taking maintenance doses of aspirin.]
  • 42,000 additional lives would be saved each year if we increased to 90 percent the portion of smokers who are advised by a health professional to quit and are offered medication or other assistance. Today, only 28 percent of smokers receive such services.
  • 14,000 additional lives would be saved each year if we increased to 90 percent the portion of adults age 50 and older who are up to date with any recommended screening for colorectal cancer. Today, fewer than 50 percent of adults are up to date with screening.
  • 12,000 additional lives would be saved each year if we increased to 90 percent the portion of adults age 50 and older immunized against flu annually. Today, 37 percent of adults have had an annual flu vaccination.
  • 3,700 additional lives would be saved each year if we increased to 90 percent the portion of women age 40 and older who have been screened for breast cancer in the past 2 years. Today, 67 percent of women have been screened in the past 2 years.
  • Breast and cervical cancer screening rates were lower in 2005 compared to five years earlier for every major racial and ethnic group: White, Hispanic, African American and Asian women all experienced declines.
  • 30,000 cases of pelvic inflammatory disease would be prevented annually if we increased to 90 percent the portion of sexually active young women who have been screened in the past year for chlamydial infection. Today, 40 percent of young women are being screened annually.
The Partnership for Prevention study found that race and ethnicity are critical variables in access to health care:
In several important areas, use of preventive care among racial and ethnic groups lags behind that of non-Hispanic whites.

Hispanic Americans have lower utilization compared to non-Hispanic whites and African Americans for 10 preventive services.

Hispanic smokers are 55 percent less likely to get assistance to quit smoking from a health professional than white smokers.

Hispanic adults age 50 and older are 39 percent less likely to be up to date on colorectal cancer screening than white adults.

Hispanic adults age 65 and older are 55 percent less likely to have been vaccinated against pneumococcal disease than white adults.

Asian Americans have the lowest utilization of any group for aspirin use as well as breast, cervical and colorectal cancer screening...

Despite higher screening rates among African Americans for colorectal and breast cancer compared to Hispanic and Asian Americans, increasing screening in African Americans would have a bigger impact on their health because they have higher mortality for those conditions.

If the 42 percent of African Americans age 50 and older up-to-date with any recommended screening for colorectal cancer increased to 90 percent, 1,100 additional lives would be saved annually...

The Partnership for Prevention study concludes:

"Low utilization rates for cost-effective preventive services reflect the emphasis that our health care system currently gives to providing acute care. Among the 12 preventive services examined in this report, 7 are being used by about half or less of the people who should be using them. Racial and ethnic minorities are getting even less preventive care than the general U.S. population.

"Expanding the delivery of preventive services of proven value would enable millions of Americans to live longer, healthier, and more fulfilling lives. There is the potential to save 100,000 lives annually by increasing use of just 5 preventive services. It would also lead to more effective use of the nation's resources because the United States would get more value--in terms of premature death and illness avoided--for the dollars it spends on health care services."
Patients often receive "acute care" in hospital emergency rooms because they have no access to preventive care, which is vastly less expensive. A system of effective preventive care would, more importantly, also be more humane.

The Chair of the commission that conducted the Partnership for Prevention study notes that:
"A lot of Americans are not getting live-saving preventive services, particularly racial and ethnic minorities. As a result, too many people are dying prematurely or living with diseases that could have been prevented," said Eduardo Sanchez, MD, MPH, Chair of the National Commission on Prevention Priorities, a blue-ribbon panel convened by Partnership for Prevention to guide the study. "We could get much better value for our health care dollar by focusing upstream on prevention."
Dr. Julie Gerberding, director of the Centers for Disease Control and Prevention, added:
"This report illustrates that the health benefits would be great if more people took preventive actions... More illnesses would be avoided, fewer lives would be lost, and there would be more efficient use of our limited health care resources. It's important that all of us make a concerted attempt to focus our energies and efforts on preventing disease, not just treating it."
One of the most common objections to proposals for a national health system is that the U.S. "can't afford" it. Yet quite the opposite is true: the U.S. can no longer afford to support a massive insurance bureaucracy whose primary function is to find reasons for denying coverage to patients for medical treatment.

But access to health care is fundamentally a moral issue (as previously discussed here). Failure to address it results in thousands of avoidable deaths each year and suffering on a scale that would be difficult to document.

Maybe the news isn't all bad: the latest findings on life expectancy actually place the U.S. in a slightly higher position than the CIA's earlier estimate for 2007. On their list, the U.S. had dropped to 47th out of 222 countries.

PHOTO: "Health Care Voter" Dave Peter talks to candidate Dennis Kucinich in Nevada (Flickr).

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