An occasional column of faculty opinion

The U.S. Health Care System: High Cost, Poor Performance

By Thomas A. Pearson

America likes to be No. 1--in military, economic, and even sports confrontations.

So, it came as a shock that America ranked 37th among the nations of the world in the performance of its health systems, according to a recent World Health Organization report.

And that was so even though U.S. health care is by far the world's most costly. We spend one in every seven dollars on health care, and this figure is expected to continue rising. Our spending per person is one and a half to three times greater than that of similar countries with similar or better health results.

The World Health Organization findings are consistent with many statistics suggesting that America lags behind countries spending much less money on health care. For example, the life expectancy for American men now ranks 25th; countries such as Costa Rica and Cuba

rank higher. Likewise, American women rank 19th in life expectancy.

To better understand how the United States could spend so much and yield so little, visualize health care as a pyramid.

At the top is hospital treatment of acutely ill patients by specialists using sophisticated technology.

In the middle is the primary care system, in which generalists use moderate technology to treat chronically ill patients or administer counseling or therapeutics to prevent illness.

The base of the pyramid is the public health system, in which the entire population, with and without disease, receives interventions to prevent disease, or is given education about healthy lifestyles.

It is widely accepted that our biomedical technology (the top of the pyramid) is the best in the world. Patients come to America from all over the globe (if they have the means) to receive a dazzling array of diagnostic and therapeutic wizardry.

These technologies are often costly, but for those with access to them they are used at high rates. Some California counties have often been cited as having more heart surgeons than the entire British Isles. So, it is not surprising that our rates of heart surgery are several-fold higher than other countries'. Most other countries feel they cannot afford this expense.

Our primary care system, the middle of the pyramid, is less distinguished relative to other countries, many of which assure patients a regular source of care.

Here, two problems arise.

• Most experts believe that the United States has a large oversupply of specialists, and an undersupply or a barely adequate supply of primary care providers.

  The balance between preventive services and acute services often suffers, as more patients seek acute care services from a smaller number of primary care physicians. Reimbursement for physician services often favors such acute care services, rather than preventive care.

• Some 42 million Americans do not have health insurance. And, 23 percent of Americans do not have a usual primary care provider, according to the federal government. This is especially true of minority groups. For example, 36 percent of Hispanic Americans do not have a source of primary care.

The World Health Organization report ranked the United States 54th in the world, tied with Fiji, according to whether payment for health care is fair, equitable, and based on the people's ability to pay.

From a public health standpoint, adequate housing, a stable family structure, quality education, freedom from exposures to toxins and violence, and a rewarding job also have huge impacts on health.

Inequities in income and education, along with poor access to primary health care in these same people, lead to possibly the single most apparent reason for poor health results in the United States: the enormous disparity in disease across racial, educational, and income groups.

Health statistics for well-educated, white, middle-to-high-income Americans would compete with any country in the world. However, a sizable portion of Americans who are minorities, poor, or poorly educated have a level of health similar to people in a Third World country. This large subpopulation's needs must be addressed if our health system is to improve.

Thomas Pearson is Albert D. Kaiser Professor and chair of the Department of Community and Preventive Medicine and professor of medicine. He received his M.D., M.P.H., and Ph.D. degrees from Johns Hopkins University.

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