The Myth of ‘Best In The World’

Not to be heartless or anything, but let's leave aside the dead babies. In international comparisons of health care, the infant mortality rate is a crucial indicator of a nation's standing, and the United States' position at No. 28, with seven per 1,000 live births—worse than Portugal, Greece, the Czech Republic, Northern Ireland and 23 other nations not exactly known for cutting-edge medical science—is a tragedy and an embarrassment. Much of the blame for this abysmal showing, however, goes to socioeconomic factors: poor, uninsured women failing to get prenatal care or engaging in behaviors (smoking, using illegal drugs, becoming pregnant as a teen) that put fetuses' and babies' lives at risk. You can look at 28th place and say, yes, it's terrible, but it doesn't apply to my part of the health-care system—the one for the non-poor insured.

That, in a nutshell, is why support for health-care reform is fragile and shallow. Yes, many people of goodwill support extending coverage to the 47 million Americans who, according to the Census Bureau, had no insurance for all or part of 2006. An awful lot of the insured, though, worry that messing with the system to bring about universal coverage, even if it allows more newborns to survive, might also hurt the quality and availability of care that they themselves get ("If I have trouble getting my doctor to see me now, what will happen when 47 million more people want appointments?"). This is where you start getting the requisite genuflection to the United States' having "the best health care in the world." One problem: a spate of new research shows the United States well behind other developed countries on measures from cancer survival to diabetes care that cannot entirely be blamed on the rich-poor or insured-uninsured gulf. None of this implies a specific fix for the U.S. health-care system. It does, however, say that "the best in the world" is a myth that should not be an impediment to reform.

How widespread is the "best in the world" view? In a survey of 1,026 U.S. adults, the Harvard School of Public Health and Harris Interactive reported last week, 55 percent said they thought the United States has the best quality care of any country. (Fewer called the U.S. system the best overall, due to poor access and high costs.) "Health-care reform has failed before and will fail again if middle-income people with insurance think it will make quality go down," says Harvard's Robert Blendon.

One thing Americans love about their system is the availability (for the insured) of high-tech equipment and the latest procedures. But there is abundant evidence that these are not necessarily beneficial. I remember breast-cancer patients screaming bloody murder in the 1990s when they were denied access to bone-marrow transplants. Sadly, once the treatment was subjected to rigorous study, it was shown not to extend life. But it made women who worked the system to get it (some private insurers agreed to cover it) suffer even more than they already were. In a centralized system such as Medicare, science more than the market shapes what treatments are available. "Some of the things patients scream for," says Blendon, "aren't going to help them." Though they do run up the U.S. medical bill. At $6,697 per capita in 2007, it is the highest in the world (20 percent more than Luxembourg's, the next highest) and more than twice the average of the 30 wealthy countries in the Organization for Economic Cooperation and Development.

If only it bought better care. Only 55 percent of U.S. patients get treatments that scientific studies show to work, such as beta blockers for heart disease, found a 2003 study in The New England Journal of Medicine. One reason is that when insurance is tied to employment, you may have to switch doctors when you change jobs. In the past three years, says Karen Davis, president of the Commonwealth Fund, 32 percent of Americans have had to switch doctors. The result is poor continuity of care—no one to coordinate treatment or watch out for adverse drug interactions. Such failures may contribute to the estimated 44,000 to 98,000 annual deaths from medical mistakes just in hospitals, and to "amenable mortality"—deaths preventable by medical care. Those total about 101,000 a year, reports a new study in the journal Health Affairs. That per capita rate puts America dead last of the study's 19 industrialized countries.

Other data, too, belie the "best in the world" mantra. The five-year survival rate for cervical cancer? Worse than in Italy, Ireland, Germany and others, finds the OECD. The survival rate for breast cancer? You'd do better in Switzerland, Norway, Britain and others. Asthma mortality? Twice the rate of Germany's or Sweden's. Some of the U.S. numbers are dragged down by the uninsured; they are twice as likely to have advanced cancer when they first see a doctor than are people with insurance, notes oncologist Elmer Huerta of Washington Hospital Center, president of the American Cancer Society. But the numbers of uninsured are too low to fully explain the poor U.S. showing.

It isn't realistic to expect America to be the best in every measure of medical quality. And none of this tells us how to reform the U.S. system. But it does say the "best in the world" is misguided medical chauvinism that should not block attempts at reform.

© 2008