Letter from Glasgow

HEALTHCARE IN THE USA: BIG BUCKS, LITTLE BANG

I am sure I have told you before but I like visiting the USA. I may not be so fond of their political shenanigans which seem to traduce democracy but I do like American people. And while we are at it, I have often thought in English we should denote people from the USA as, for example, ‘USians’, or something a little more elegant so that Canadians, and central and south Americans are not offended by citizens of the USA calling themselves Americans.

I digress because as a public health doctor, I am interested in the healthcare systems of the countries I visit. That applies even more so to the USA. Before I travel there, I ensure that I am insured for any medical mishap. The recommendation from UK insurers is that for travel insurance to the USA, you should have medical cover for at least £5 million ($6.1 million, €5.9 million) and, ideally, double that cover if possible. Once I get to the USA I am always intrigued by the ubiquity of drug and medical device advertising directly to consumers, i.e. patients. More importantly, I am interested in observing how the healthcare system serves American people.

The last time I was in the USA, my ears pricked up as I overheard a conversation in the company about health insurance plans through their employment. It transpired one individual was paying a larger co-payment than a friend for a vital treatment of a long-term illness. They ascribed this to differential benefits provided by their employers’ health insurance. The difference had an impact on the individual’s income who was paying much more and, I suspect, affecting his mental health and well-being. They concluded the discussion by agreeing they were both lucky they had health insurance in the first place otherwise they would not get any treatment for their illnesses. Just as fools rush, so did I. I piped in that was not a discussion we had in Scotland or the UK—if you needed a treatment for an illness or disease, you received it without paying for it directly. I was not entirely sure how that was received.

While there may be a tendency to regard the healthcare system you work in through rose-tinted glasses, there are strengths to the National Health Service (NHS). I recognize that the NHS is not perfect—far from it if you look at the problems of racism within it, the running of the service at 90% plus occupancy with a resultant lack of surge capacity, or of managing the effects of the SARS-CoV2 pandemic on elective care. However, if there is an effective treatment that had been agreed for use in the NHS, then patients will get it. Some people talk about the NHS being ‘free’ and I love to be pernickety and point out that it is free at the point of use for the British population because it is funded by taxation. The principle of the NHS is of treatment and care based on need, not ability to pay. For all the faults of the NHS, that is an important principle to defend.

Healthcare is big business in the USA and I observed a myriad of healthcare facilities when I was there. I saw community hospitals (Beebe Healthcare) in Delaware serving the local communities and medical research campuses in, for example, Chicago and San Francisco with their tertiary hospitals and health research institutes working in tandem. This is as you would expect because the USA spends an enormous proportion of its gross domestic product (GDP), perhaps now just under 20%, on healthcare. But the question is what does it get in return?

There is a long history of comparisons between different healthcare systems focusing particularly on high-income countries, including personal experiences.^1–4 I think that evidence in the form of statistics, numbers and outcomes is important (I am a public health doctor after all!), but people also need to relate to the reality through narrative. Therefore, I liked the blog by the American Groce sisters (twins) who described their experiences of how their breast cancers were managed in the USA and UK healthcare systems. Too often we forget how healthcare affects individuals and we should never forget the perspectives of patients.

Once I returned from the USA, I started to refresh my reading and thinking on healthcare internationally. I came across a publication by The Commonwealth Fund entitled ‘Mirror, Mirror 2021: Reflecting Poorly–Health Care in the U.S. Compared to Other High-Income countries’.⁵ This is the latest of a series of ‘Mirror, Mirror’ reports by The Commonwealth Fund which form part of its ‘Improving Health Care Quality’ portfolio.

The 2021 report compared 11 high-income countries and analysed 71 performance measures of healthcare across five domains:

• Access to care

• Care process

• Administrative efficiency

• Equity

• Healthcare outcomes

The report notes that all countries have specific approaches and histories in the development of their healthcare systems. They have different funding models, varied providers, and differing levels and types of government support to name a few variables. The aim of the report was to synthesize and distil key attributes of high-performing healthcare systems with regard to the five domains above. The countries studied were Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the UK and the USA. The front-runners were Norway, the Netherlands and Australia. Not far behind them came the UK in a credible fourth place. The USA came last overall despite, as the authors state, spending much more of its GDP on healthcare. It was not all negative for the USA because on measures of care process it was ranked second. I wonder if that is because of the insurance-based nature of its system where the care process has to be identified and quantified for payment purposes.

The report concluded that there were four attributes of the top-performing countries that set them apart from the USA. These were:

• Provision of universal coverage and removal of cost barriers

• Investing in primary care systems to ensure equity of access

• Reducing bureaucracy that diverts from health improvement efforts

• Investing in social services, especially for children and working-age adults

These insights from high-income countries are important evidence for healthcare professionals, policy-makers and politicians in these countries. But they are also important for middle-income and low-income countries as they develop their healthcare systems in their unique ways. We all have our personal prejudices and mine include that the USA can do much better for the amount it spends on healthcare. In this case my prejudice seems to be justified!

No-one ever said that health services could not use more resources and money than they receive at present but it is not just how much you spend but how you spend it and what you spend it on that matters. At present, it seems that the USA spends big bucks on healthcare but gets a little bang in return. To change that it needs to be wiser to get better outcomes from the resources it spends on healthcare.