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).

Film Review: Mike Moore's "Sicko"

"Who are we, and what has happened to our soul?"
—Mike Moore, narrating Sicko

A couple days ago I saw Sicko, and left with a glimmer of hope that the debate about our scandalous and brutal system of health care might move to another level. How? By looking beyond the limited "solutions" proposed in places like D.C. and here in Oregon, where an increased cigarette tax—blocked by legislative Republicans (1)—would've provided coverage for all uninsured children in the state.

Meanwhile, the health-care crisis becomes more pronounced every year: only 60% of employees have health insurance through their jobs, compared to 69% in 2000 (2). And the coverage is less comprehensive as it grows more expensive. As Moore's interviewees appallingly reveal, insurance companies are relentless about applying policy exclusions to limit or deny coverage altogether.

The film also takes a close look at the myths about the purported failures of "socialized medicine" in places like Canada, Great Britain and France, then concludes with a foray into the Cuban health-care system. Moore's interviewees suggest that national health insurance in those countries is widely viewed as successful, and they look upon the U.S. system with horror. And those systems are not only less expensive: they produce better health outcomes, including such things as lower infant-mortality rates and longer life expectancies.

Moore argues that it's time to broaden the discussion to see what could be borrowed from these foreign models to create a system of universal care that's appropriate for the U.S. and our boundless (and often justified) suspicion of government programs. ("Appropriate for the U.S." would probably mean, of course, a "mixed" system of private and public payers rather than the simple "single payer" system that gets surprising support in polls.)

But Moore's film isn't about the uninsured, nor is it just about those who think they're adequately insured until the hospital and doctor bills start to fill their mailboxes. And it's not ultimately about alternative health-care systems in other countries, either. Its real focus is the same issue that's presented by the torture "debate:" "who are we," as Moore asks, and what do all these policy choices reveal about our national values? (3)

I've always defined politics as public morality, since policy choices always reflect personal and social values and, ultimately, moral decisions. Moore's films, including Fahrenheit 9/11, demonstrate how policy debates and decisions are distorted by a dysfunctional political process that is front-loaded in favor of narrow economic interests. And by a national media that is too lazy or ideologically conditioned to inform or redefine the debate.

The inevitable result, in health-care policy and everything else, comes at the expense of the democratic and utilitarian notion of the "greatest good for the greatest number."

Moore contrasts the contentious model of French politics, in which the "government fears the people," with the contemporary American model in which "people fear the government." If Americans make limited demands on their government and its corporate masters, Moore argues, then it's because of economic insecurity—the fear of losing their jobs and their health insurance, fear of being unable to pay the massive debts that they've incurred (often for health care). That gnawing anxiety has been amplified in the atmosphere of generalized fear that is one of the legacies of 9/11—a legacy that politicians from Bush to Cheney to Giuliani have been quick to exploit.

The result is a political climate in which the large majority of citizens seems demoralized, anxious, cynical and abstracted—and too jaded to even vote. This vacuum has reinforced the tendency of politicians of both parties to respond to those who finance their campaigns and, quite often, employ them after they leave office. In the absence of populist pressure from the disaffected majority, national and state governments are dominated by those who have a deep economic interest in the status quo (4). This dynamic results in policies that are patently absurd, producing the cruel, mechanistic and inhuman health-care system that Moore describes.

One other thing that shouldn't be overlooked in any review of Sicko, or any other Moore film: it's hilarious. Moore heaps well deserved, and unanswerable, ridicule on those who have created and perpetuated this absurdity. When I wasn't on the verge of tears or rage, I was often laughing uncontrollably.

Margaret Thatcher famously said: "There is no such thing as society: there are individual men and women, and there are families." In that kind of world, there can only be individual, rather than collective, solutions. Even in this great American bastion of individualism, though, Moore points out that we've found collective solutions to individual problems by creating police and fire departments, schools, libraries, social security, Medicare and a postal system.

Everyone faces the risk of illness and death, so why not find a common solution to the need for health care? If John has to pay for Mary's medical procedures now, whether through taxes or health-insurance premiums, then Mary and the rest of us will pay for his later. If you spread the risks and share the costs, everyone ultimately benefits. The private system now in place simply excludes too many people and costs too much (due in part to the constant administrative pressure to exclude people). And it produces bad outcomes far too often.

Illness may be an individual problem, but we have a common interest in seeing that we all get the best available treatments for it. And it's the only approach that's morally defensible.

Sicko is an important film, as most critics seem to realize. See it, then come back and add your comments.

NOTES

(1) Oregon law, as a result of the conservative "tax revolt" that has decimated the state's public sector, requires a 3/5 majority to approve any additional taxes. The Democrats enjoy a majority in both house of the legislature, for the first time in years, but they lack the necessary 60% to pass any tax. So the conservative program of "starving the beast" of government has resulted in denying basic health care coverage to thousands of uninsured Oregon children. Legislative Republicans, yielding to pressure from the beer and wine lobby, refused to raise a tax on alcoholic beverages that hasn't been adjusted for 30 years. And the pathetic corporate minimum tax of $10, which is actually paid by thousands of Oregon corporations, also remains unchanged after decades. "Who are we," indeed?

(2) And their premiums increased by 9.2% in just one year (2005).

(3) This is a familiar subject on this blog (as seen here and here) And also here, where I wrote (not long before Mitt Romney proposed "doubling" the size of Guantanamo rather than closing it):

Unfortunately, and to our national shame, it's an exaggeration to say that there's a "debate" at all: there's little evidence of any controversy outside the Beltway, raising profound questions about the state of U.S. political culture these days. If I had to guess, I'd say that the general attitude on the subject may be summarized by a phrase from an altogether different controversy: "don't ask, don't tell." The Administration, it would seem, is tacitly authorized to take whatever action George Bush deems suitable to protect the country...

(4) This analysis isn't new, of course, as Greens and the few remaining Naderites would hasten to add. The system of "legalized extortion and bribery," otherwise known as campaign finance, has been around for decades and has never been more entrenched than it is in 2007.

PHOTO: A demonstration in support of public services in Paris, 2005. The banner reads: "Privatizations: Stop! All together for public services."