• How do we rate the quality of the US health care system – Conclusion

    If you haven’t read the introduction, go back and read it now.  That introductory post also included links to all the posts in this series on how we can rate the quality of the US health care system.  Each the pieces discussed another way to look at quality, and how the US compares to comparable countries in that domain.

    I expected more arguments for this series than for the cost one did.  After all, few dispute that we’re spending a lot of money on health care, but plenty of people think we’re loaded with quality.  Quality is important, though, perhaps more important than cost.  We can agree to spend a lot of money on health care, but you would hope that we’re getting our money’s worth.

    And there’s the rub.  If we’re going to spend way more than any other country on health care, then we should absolutely, positively have the best health care system in the world.  We don’t.  I don’t know how you could have read this series and still believe that we do:

    With the exception of available technology, we do not rate well against comparable countries.  And that’s the take home message.  We can argue about which metric is best to describe the quality of a health care system, but it almost doesn’t matter what you pick.  Don’t like population statistics?  Fine.  Choose another.  But unless you think the only important thing is how many MRI machines are available, we’re still going to look bad.  Not only does the system not perform up to snuff, but pretty much every stakeholder I discussed agreed that it’s not good.

    But even if you still want to quibble, you have to remember that we have a hugely expensive system.  Moreover, lots of people may have trouble accessing it.  So if we’re going to spend a ton and not provide universal coverage than it should be impossible to argue that we’re not the best.  The fact that we can even debate that point (let alone lose the debate) should be enough to convince you that we’re getting too little bang for the buck.

    Unfortunately it’s easier to correct access than quality. The PPACA focuses mostly on access, after all.  It’s also relatively (and I mean relatively) easy to cut costs.  But quality?  Hoo boy.  Getting all the moving parts to do a better job is not going to be easy.

    Some will make the argument that just improving access with improve quality.  I think there’s a reasonable chance that’s true.  But it’s not going to get us all the way there.  And until a significant portion of the United States is willing to stop plugging their ears and trumpeting as loudly as they can that “we have the best health care system in the world!” I fear that things won’t get much better.

    • Value?

      Are health care costs a bubble?

    • Aaron:
      nice series as was the one on costs. It is amazing there is not consumerist driven outrage at how much we spend per capita with all the evidence that we are not getting our monies worth. Culturally and in policy terms, the following questions need to become commonly asked:
      *does it improve quality of life?
      *does it extend life?
      *if no to both of these, why again are we doing it?
      *for all care, how much does it cost?
      I am not sure what the final calculus will be or should be in terms of how to use this information to make coverage/payment decisions. We have to hash that out…..we have no hope of getting there if we don’t learn to honestly talk about these questions.

    • We don’t. I don’t know how you could have read this series and still believe that we do:

      Yeah but the way that I see it they are all very bad and very costly for what they deliver. Seeing that more and more employers are dropping insurance (and when people buy health insurance for themselves they buy high deductible insurance) and raising deductibles and copays in the USA maybe we are on the dawn of correction. Should we repeal Obamacare, it could be that in ten years ours system is the best and the other all follow our lead.

      Very high deductible insurance could lead to a consumer push to easing licensing and to medical travel. It could lead to sharply lower consumption with minimal impact on health.

      Here is my compromise proposal:


      Here is an article that makes a similar proposal:


      The way I see it in other countries an organization like the USPO delivers healthcare in the USA it is delivered buy government enforced unions. Right now the government enforced unions are doing worse but that could change or we could stop encouraging and enforcing the unions.

      IMO we also need to stop encouraging employers to provide insurance.

      Now I would be OK with socialized health care because health care beyond the basics seems to deliver so little. A system like Canada or the UK would be OK but only if through it using monosopny we squeeze costs like they do way downs to about 1/2 what we currently spend. But I find Obamacare rather luke warm and so I want to vomit it out.

    • Aaron, this collected work is a treasure. It should really be promoted, and published more widely. Any thoughts about collecting it into book form — e- or otherwise?

    • @Rick

      Much appreciated. Austin and I are talking about it!

    • Great series. Thanks for putting in terms of data and not ideology. I recently heard someone comment that the US Healthcare System is set up as a Revenue Stream for the Medical suppliers (Equipment, Pharma, Service, etc).

    • Very good series. I think you got less debate than expected since you did not go into outcomes for specific care very much. I think that is what most people think of when they think about quality. What are the outcomes for CABG surgery in the US vs France? Five year survival for breast cancer in the US vs Germany. That kind of stuff.


    • Linked in from Andrew Sullivan…

      I appreciate any serious discussion of healthcare in our country and anywhere else for that matter. I remember when I had my appendectomy, and that afterword my boss cheerfully said “if this was 1910, you would have died.”

      Health care is THAT personal.

      But what frustrates me about this issue is its commonality with so many other big issues we face these days — except this issue is arguably the most important (more than the environment, economics, homelessness, etc., because it touches every single one of us, and with a hard gut-level frequency) — is that the analysis of problems and prescriptions always lack perspective as to the stake holders, the consumer experience, the reality of what people everywhere face under any health care system or a lack thereof.

      In short, the analysis is always strangely myopic.

      It seems to me that in an ideal world, the answer is pretty simple:

      Fund routine and preventative care for everyone directly through the government via our general tax revenue (as with defense), and require insurance coverage paid for by individuals and families for everything else, i.e. major illness, catastrophic care, the unexpected, et al.


      So why is this not in the cards? Because the stakeholders in the Medical Industrial Complex are powerful, certainly, but mostly because the legislators who craft law are individually and universally in the pocket of one stakeholder or another.

      Its a hot mess, and no intellectualizing about it will help one bit. Only clean, fierce pressure from the most important stakeholders of all: us.

    • Both this series and its predecessor are excellent. Thanks for putting them together. A couple of comments.

      1) A substantial component of the difference in life expectancy between the US and other nations may be due to historic tobacco abuse. Given the long lag time between cigarette smoking and many of its deleterious consequences, the key variable isn’t the amount of tobacco abuse now but the differences between American and other nations tobacco abuse in the past. Americans appear to have taken up cigarettes earlier and to a larger extent than non-Americans. See: http://www.prb.org/Articles/2010/ussmoking.aspx.
      Even if correct, this wouldn’t change your basic (and I think incontrovertible) point about the inefficiency of our system.

      2) The only quality measure on which we do well is technology availablity. But there is reason to think that this is not a particularly good measure. Widespread availability of many of these technologies, particularly imaging technologies, probably leads to overuse, neglect of clinical judgement, and in some cases, detection of unimportant findings that lead to further unecessary interventions and costs.

    • Thanks again for this series of posts! (I posted a comment earlier on the intro post … just got through the rest of the posts). Tomorrow, I will read your series on cost. I applaud your thorough research and your ability to share the information in an articulate manner.


    • If you do make it a book, you can quote soon-to-be Speaker of the House John Boehner on the cover. In a press conference on November 3, 2010, he proclaimed that the United States has “the best health care system in the world.” He’s been watching too much Hannity instead of reading this series.

    • We’re pretty much the worst and the most expensive. I suspect the problems originate with medical device and drug manufacturers pumping up prices as much as possible, pushing products through the FDA process with poor safety testing, and spending more and more on marketing. We’re “first” in available technology but rate dead last in population statistics. That gives us a clue as to where the $ is going and how much that benefits patients. Not much. But it does benefit the manufacturers. Our health system is set up to profit industry, not to care for human health.

    • I’ve tried to start a dialogue with right wing Americans on health care and simply encountered a wall of resistance. You are so right when you write: “. . . until a significant portion of the United States is willing to stop plugging their ears and trumpeting as loudly as they can that “we have the best health care system in the world!” I fear that things won’t get much better.”