R.H. LeBow and C.R. White
Chambersburg, PA: Alan C. Hood & Co, 2007, 328 pages, $15
This country has the best health care system in the world.
President George W. Bush
That's strange; I thought Mr. Bush and I lived in the same country.
C. Rocky White, MD
Interview excerpt, Montana Public Radio, January 2006
Despite the United States' being the richest country in the world, a 2000 World Health Organization report ranked the U.S. health-care system an abysmal number 37. The United States ranks 27th in life expectancy, 29th in maternal mortality, 35th in infant mortality, 36th in mortality before the age of 5, and 40th in population over the age of 60. Countries viewed unfavorably by America, such as Cuba and Kazakhstan, have better immunization rates for measles. Rank for fairness in the health-care system is even worse, tying with Fiji for 54th place. The United States does rank first place in 2 health-care categories: total amount of money spent per capita and percentage of gross domestic product spent on health care. Despite having the most expensive health-care system in the world, the United States still has 46 million citizens uninsured. Given the national sentiment that the United States is the best in almost everything, most Americans still believe that they have the best health-care system in the world.
Health Care Meltdown: Confronting the Myths and Fixing Our Failing System, a book newly revised and updated for the election year, looks at the myths confounding an American health-care system that leaves 1 of 6 Americans without adequate health care. Both authors are originally Republicans who see the United States at an important crossroads, with the imminent danger of a health-care collapse despite many technologic innovations. They see a system with no planning and no vision for the future. This American health crisis is no longer affecting just the poor, indigent population; each day many more middle-class Americans are seeing their coverage denied or are losing insurance altogether. More than half of all bankruptcies are medically related. The majority involve middle-class people, of whom 75% had health insurance when they got sick. Although the authors admit that no one country has a perfect health-care system, they argue that health care should be a human right rather than an economic commodity.
The book focuses on the high degree of misinformation and the myths that politicians, the pharmaceutical industry, and insurance companies have perpetuated in order to steer Americans from national health-care insurance. The first myth discussed is that private solutions are always better than public solutions and that the free market will eventually solve the U.S. health-care crisis. One important concern mentioned by the authors about privately controlled health care is the exuberant administrative cost carried by private-sector health insurances, varying between 9% and 30% and averaging about 15%. Much of this cost that is diverted from true patient care goes into inflated chief executive officers' salaries, stockholders' money, intermediate agents, and advertisements. In contrast, government-run Medicare has only a 2%–3% overhead. Ironically, discrediting government programs is popular among Americans even though they trust the government with defense, public safety, public education, and now even airport security. The most notorious criminal companies involved in manipulating regulations to maximize profits have been private pharmaceutical and private energy industries, such as Enron. In the last few years, major government legal cases have led to huge fines implicating private health-care giants caught in overcoding schemes or plain fraudulent behavior with regard to Medicaid and Medicare. These include Health Corporation of America/Columbia paying $740 million in fines; Tenet, $300 million; and Blue Cross of Illinois, $140 million. These fines have led to increased Medicare paperwork to detect these fraudulent behaviors, giving Medicare a bad name rather than correctly blaming the culprits cheating the system. Americans, known for being advocates of free choice, should note that there is more health-care freedom in terms of provider choices (physicians) with government-controlled Medicare than with most private health insurance plans.
The authors even tackle the myth of the Canadian health-care system, or “socialized medicine.” Americans are continually told that the Canadian health system is going bankrupt and that Canadian patients have to wait in long lines to obtain simple procedures such as cardiac catheterization. Most Americans do not think of how long it takes them to get an appointment with a specialist such as an orthopedist, pulmonologist, or ophthalmologist. Waiting 3–6 mo is common in the United States, if the specialist or claim is not completely turned down by the insurance company as unnecessary. For the uninsured, the wait for a nonemergent procedure such as a cholecystectomy for chronic cholecystitis or removal of a painful prolapsed uterus may take years until someone is convinced to perform the surgery or until the patient qualifies for Medicare. The authors even cite a statistic showing that more Canadian doctors are actually leaving the United States than entering it to practice.
Health Care Meltdown discusses the overall overutilization and underutilization of health services within the United States. Many major hospitals compete to obtain a market share of patients. Rather than cooperating to meet the needs of the community, hospitals are spending millions of dollars on costly duplication of high-tech facilities to perform expensive and profitable procedures with aggressive marketing campaigns. Meanwhile, smaller community hospitals are left to care for uninsured and low-income patients while the specialty centers draw the high-paying private patients. Other health-care problems discussed include the overutilization of the emergency room for uninsured patients, creating an expensive and inefficient way to deliver primary care services.
One “perversion” that the authors wish to break is the link between health-care insurance and employment. Americans are unique in the developed world since they rely on employers to provide access to health insurance. Every day people get locked into jobs they do not like, fearing that a preexisting condition will prevent them and their family members from getting new insurance if they change employment. The cost to the employer providing health insurance can be enormous. For example, it is estimated that $1,400 of the cost of an automobile goes to the health benefits of the workers, thus giving foreign car makers a competitive advantage in the market.
In the United States, it is becoming rare that charitable hospitals offer charity, and free clinics are becoming extinct. Drs. LeBlow and White make strong arguments in favor of national health-care insurance. In support of their views, they cite a survey of medical school faculty, residents, and students published in the New England Journal of Medicine in 1999 that found that 57% chose a single payer as the best solution to the American health crisis. However, the American Medical Association has spent millions of dollars to discredit this type of system.
The many anecdotes of patients left out of the American health-care system add a human touch to Health Care Meltdown. In one chapter, the authors discuss Ralph, a 37-y-old man who has uncontrolled diabetes and no health insurance. He cannot afford diabetic medication or even the glucose testing strips. He is unable to work because of chronic back problems and shows up at the clinic only when he has an acute illness or injury or is in need of hospitalization:He had suddenly gone blind from diabetes—retinal bleeding. With the catastrophe, he immediately got attention from an ophthalmologist who did laser surgery on his eyes (cost of about $5000). Unfortunately, the surgery helped very little, if at all. A blood test drawn when he came in showed he was in severe kidney failure from his diabetes. His creatinine was 16.9, his creatinine clearance 1 millimeter per minute (both extremely abnormal). We had no trouble getting him hospitalized and evaluated by a kidney specialist. He is now getting dialysis and waiting for a kidney transplant. Since he needs dialysis, he will soon qualify for Medicare. Finally he gets his health insurance.”
Health Care Meltdown is a persuasive and convincing book on the problems of health-care delivery in the United States. The book is straightforward, engaging, and lively from well-placed humor. Regardless of how one feels about the American health-care system, anyone reading this book will end up having a better understanding of this complex economic, political, and moral issue.
Footnotes
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COPYRIGHT © 2008 by the Society of Nuclear Medicine, Inc.