It was the best of care, it was the worst of care

Right around Thanksgiving, the King of Saudi Arabia flew to New York City for medical treatment.  He had a herniated disk and needed back surgery, which he chose to receive at NY Presbyterian Hospital.

This is not so surprising, as there has been a history of world leaders seeking major medical care in the U.S. when they have faced serious medical conditions. In fact earlier this year, Danny Williams, premier of Newfoundland and Labrador (the Canadian Province not the dog), traveled to Florida to undergo fairly routine heart surgery, creating a serious uproar in Canada where they are quite fond of their own national health system.  Williams was reported to have said, “This was my heart, my choice and my health,” he told the Canadian Press from his condominium in Sarasota, Fla., where he was recovering from surgery. “I did not sign away my right to get the best possible health care for myself when I entered politics.”

Not that I am proud to quote Fox News, but their response to the Williams story was, “It is a fact beyond dispute that the United States remains the global destination for patients from all over the world.”

I think that many Americans would heartily echo that sentiment.  We often think of ours as the best, most sophisticated medical system on earth.  Why else would foreign leaders and celebrities come here in their hour of need?   I mean, seriously, they aren’t coming to New York in November for the weather or Florida in February for the culture.

The problem with this line of thinking is that there is a wide gulf between having some of the most advanced medical care in the world and making it available to our own citizenry.  While world leaders beat a path to our hospital doors, Americans know all too well that  great healthcare is not as accessible to those who travel without a crown or at least an entourage and a hockey stick.

A recent story in  Health Affairs described an 11-country survey focusing on health care access, cost, and insurance coverage which found that adults in the United States are by far the most likely to: go without care because of costs, have trouble paying medical bills, encounter high medical bills even when insured, and have disputes with insurers or payments denied. The chart below highlights the findings of the survey, which was done by the Commonwealth Fund.  Interestingly, Premier Williams would no doubt be delighted to see that the U.S. is twice as bad off as Canada on every measure listed, even if he did manifest his delight in sunny Florida.

It is interesting to note that a wide variety of different kinds of healthcare systems are represented in the above chart; these countries have everything from completely private to completely public healthcare systems, as well as those in between (hybrid public/private).

Key findings from the Commonwealth Fund’s study of 19,000 adults (surveyed in 2010) include:

• One-third (33%) of U.S. adults went without recommended care, did not see a doctor when sick, or failed to fill prescriptions because of costs, compared with as few as 5 percent of adults in the United Kingdom and 6 percent in the Netherlands.
• One-fifth (20%) of U.S. adults had major problems paying medical bills, compared with 9 percent or less in all other countries.
• Thirty-one percent of U.S. adults reported spending a lot of time dealing with insurance paperwork, disputes, having a claim denied by their insurer, or receiving less payment than expected. Only 13 percent of adults in Switzerland, 20 percent in the Netherlands, and 23 percent in Germany—all countries with competitive insurance markets that allow consumers a choice of health plan—reported these concerns.
• The study found persistent and wide disparities by income within the U.S.—even for those with insurance coverage. Nearly half (46%) of working-age U.S. adults with below-average incomes who were insured all year went without needed care, double the rate reported by above-average-income U.S. adults with insurance.
• The U.S. lags behind many countries in access to primary care when sick. Only 57 percent of adults in the U.S. saw their doctor the same or next day when they were sick, compared with 70 percent of U.K. adults, 72 percent of Dutch adults, 78 percent of New Zealand adults, and 93 percent of Swiss adults.
• U.S. German, and Swiss adults reported the most rapid access to specialists. Eighty percent of U.S. adults, 83 percent of German adults, and 82 percent of Swiss adults waited less than four weeks for a specialist appointment. U.K. (72%) and Dutch (70%) adults also reported prompt specialist access

As I looked at the data I wondered to myself: has any world leader ever flown to the Netherlands or New Zealand to get medical care?

So how does all this misery jive with the view that the U.S. has the best medical system in the world?  It seems to me that part of the answer lies with the semantics that separate the words, “medical care” from the words “health care”.  When people think of “medical” they think of doctors and hospitals and treatments that save lives.  They think Cleveland Clinic and Mayo Clinic and Dr. McDreamy.  When people think about “healthcare” they think about insurance and bills and the truly annoying act of accessing “medical” care.  They think about claim forms and pre-authorization denials and waiting room magazines that have been there since the Truman era.  Amazing that there is such a gulf between two words that are, for all intents and purposes, synonyms in reality.   I wonder if King Abdullah would have flown here for treatment if he had to fill out his own claim forms?

It is possible that the Affordable Care Act (ACA) will ameliorate some of the problems identified in this Commonwealth Fund survey, notably the lack of insurance for many that leads to unaffordable and or unattainable care.  However, it is worth noting that even those with insurance weren’t feeling so hot about their healthcare experiences and that the ACA does little to solve the challenges related to primary care access, paperwork, hassles or cost.  We are going to have to make serious strides in improving the way we prevent illness, deliver care and manage care in a patient-centered (rather than disease-centered) way if we are going to make a real difference over the next 50 years.

I find it troubling that people (Congress: this means you) spend so much time on the political front arguing about whether people do or don’t have a right to be insured or whether the government should pay for healthcare when the real debate should be about how we foster public health in a meaningful way.  All those lobbying dollars focused on how health insurance is or isn’t regulated could be put to meaningful use (and I use that term intentionally) to improve food and nutrition policy, foster preventive health and early disease detection, increase the number of primary care healthcare providers, and/or teach children how to live a healthier life than their parents may have done.  What will it take for our leaders to cooperate in the development of public policy that addresses the root causes of our sick healthcare system and not just the symptoms?