Like all doctors, I am frustrated when I see my patients missing out on what could be years of good health. And our medical system is so dysfunctional that it’s tempting for doctors and patients to blame poor health outcomes on how we pay for medical care. But, our ridiculous payment system is a symptom, not the cause of our problems, and fixing our medical system is not going to vault us to the top of the healthiest countries list.
The quality of a nation’s health care system reflects its values, and as Americans, we value self-reliance, competition, and capitalism. Although often productive, these values have blocked not only the development of an equitable health care delivery system, but also public policies that address inequity more broadly, the real driver of our poor health outcomes.
The evidence of failure is all around us. For the second year in a row, U.S. life expectancy has declined after unchecked progress since the 1960s. The U.S. now ranks 30th in the world in life expectancy, between Costa Rica and Cuba. Our infant mortality rates are tragic and vary dramatically based on skin color and zip code.
The quality of the medical system counts. However, it doesn’t matter as much as one might think. Health is mostly determined by our race, environment, behaviors, upbringing, and genetics. It is estimated that 10 to 15 percent of preventable mortality would be fixed in the U.S. with excellent and universally accessible medical treatment. If we look at health outcomes across different regions of the United States, only about a quarter of the gap between the healthiest and least healthy counties is due to quality and accessibility of medical care. This confirms what we know about health outcomes in the 20th century — of the 30 years of increased life expectancy, only five can be attributed to improvements in medical care.
This makes intuitive sense. Few factors that predict a healthy life occur in the doctor’s office or hospital. And our medical system is not uniformly as bad as our outcomes would suggest. The United States excels in some areas that the medical system can control. If you have breast cancer, there is no better place for treatment. But when the main determinants of the health of our population are outside the medical system, we can’t expect fixing that system to create a healthy country.
Achieving better health outcomes will require going beyond mimicking payment systems used in healthier countries — nations where citizens and policymakers believe all citizens have the right to medical care and also support the non-medical policies that promote health and well-being.
Where countries value fairness and equality, believe health care is a right not a commodity, and are uncomfortable with a society with huge income gaps, you find health care systems similar to those enjoyed by the Dutch, the Japanese and the British. Following diverse paths, these countries all have achieved universal health coverage, but more importantly, the values that produced these systems also promote relative income equality, high-quality education systems, and strong social safety nets — the main drivers of good health outcomes.
The real issue is not what we can learn from the healthiest countries in the world about how to create a better health care system. We have the intellectual and financial resources necessary to create the best health care system in the world.
To achieve a truly healthy population we need to ask some important questions: What kind of country do we want to live in? Will it be a land of big winners and big losers or one that elevates equality and fairness in not just health care but in all our public policies?
Christopher J. Frank is a family physician.
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