A view from a European medical academic who spends time in the US
Authors: Marc Feldmann
Journal: Journal of Clinical Investigation (2009)

American medicine has much to be proud of. Since World War II, the National Institutes of Health has sparked a revolution in academic biomedical research. There are world-leading academic hospitals delivering the best-quality health care, such as Johns Hopkins, the Mayo Clinic, Mass General, and the Hospital for Special Surgery, among others. Cancer care and outcomes are the world’s best. But there are also problems on a huge scale, which means that the US’s world-leading health expenditure (16% of GNP) is delivering health care that is worse than in much of Europe in terms of clearly analyzable indicators, such as infant mortality or length of life. European countries like the UK typically spend 8%–10% of GNP on health care. But that is not to say that European or British medical care doesn’t have its own problems, as certain aspects — such as the UK’s cancer survival rates — are worse than in the US. 

The lower-percentage cost of health care in Europe covers all the population, while the US’s 16% still leaves 45 million uncovered. Clearly there is an unanswerable case for major reform in order to deliver value for money, not just for the lucky ones able to avail themselves of the best hospitals, or of quality cancer care, but for all the population. The humanitarian principle — quality health care for all — that the European nations have espoused, though practised in different ways, leaves none of the population disadvantaged and uncovered.

The 16% of GNP spent on health care in the US is having dire economic consequences. That each of Detroit’s US car manufacturers’ vehicles allegedly has about $1,000 of health care costs in its price is hard to comprehend, but its consequences are apparent. Costs of 16% and rising are clearly unsustainable. That most personal bankruptcies in the US are due to health care costs is also amazing. From a distance some of the causes of the cost differences of the US and European systems can be seen. Three are worth highlighting. The greater litigiousness of the US has led to “defensive medicine,” with its unnecessary tests and treatment. This requires reform of the medico-legal interface to avoid blaming physicians for unfortunate but unpredictable events. Reducing claims and medical insurance costs would help reduce the total cost of health care. The culture of health insurers trying to make a profit from delivering health insurance is another problem that has been well documented; they cut costs by excluding coverage and care and having plans whose coverage is very difficult to understand. Wendell Potter, the Senior Fellow on Health Care for the Center for Media and Democracy, in his testimony to the US Senate Committee has clearly documented this problem (1). A controversial issue is the appropriateness of intensive care for late-stage terminally ill patients with no hope of recovery, with the Terri Schiavo case as a most dramatic example (2). Americans pay a huge cost for health care, and some estimate that half of lifetime medical costs occur in the last year of life; far more patients with terminal illness die after weeks in intensive care in US than Europe. 

Having been in the US on holiday recently (August 2009), I saw some of the televised town hall debates. It is sad to see firsthand the misinformation and misunderstanding of many angry participants, frightened of change, frightened of losing benefits, frightened of “socialized” medicine like Britain’s National Health Service (NHS), while not realizing what a poor deal they actually have from the current system, compared to their European and Canadian cousins.

The degree of misinformation is clearly illustrated by fears that chronic disease patients would be left to die. It was said by Investor’s Business Daily in July 2009 that prominent scientist Professor Stephen Hawking (with Lou Gehrig’s disease) would be left to die by socialized medicine in the UK’s NHS (3). This sadly reflects the gross politicization of this debate. Hawking, as is well known, lives in the UK and has been kept alive for an amazingly long time by the care and devotion of the NHS. Enough said. 

It is not appreciated by many that health care for the uninsured in the US is still paid for, by cross-subsidies. Instead of receiving lower-cost routine care from primary care physicians early in the disease process, these patients will eventually turn up when much more ill in the emergency rooms and then get very expensive care, costs that the hospitals recoup by averaging out over all their other, insured customers.

So there are plenty of problems to be solved. Perhaps the first step toward solving them is for an appreciation that there are proven ways of delivering health care that is both cheaper and better for most of the population than the current style in the US. There is no need to look across the Atlantic, where cultures are different. Just look closer, north, to Canada. The Canadians are all insured, there are no health care bankruptcies, and they live longer than in the US.

There is a strong case for major reform: it should provide a win for health and a win for the economy.