An interesting article by Karen Davis (President of the Commonwealth Fund; Head of Health Policy at the US Department of Health 1977-91) has appeared in the BMJ (17th February 2007 334:246-8) concerning the "uninsured" in America. It is a condensation of her 2006 Presidential address. I have seen figures of 30% or even 40% of Americans being not covered by health insurance. How true is this?
Strictly speaking there is 41% of the population who don't have health insurance: 54% have employer-based insurance and 5% individual insurance. But on top of that 12% are covered by the Federal Medicare program for those over 65 and those who have been disabled for 2 years or more. Then 13% are covered by State Medicaid programs, mainly children of low income families and in some cases their parents, as well as some long-term care programs, and some interaction with Medicare for low-income families. This leaves some 16% of the population without any cover, around 47 million people - about the same as the population of England and Wales.
Despite this, the United States spends far more on health per head of population than any other country - around $6100. In contrast Britain spends $2500, Australia $2800, Germany $3000, France and Canada $3100.
What does America get for the extra money? The 5 year survival for breast cancer in nearer 90% than the 80% that other countries achieve, but the life expectancy at the age of 60 is a year or two less than in most other countries, and whereas in most countries around 90% survive for 30 days after a heart attack, in the US it is closer to 85%.
I don't believe most of these outcome statistics that compare one country with another. Seldom are the statistics collected in the same way and apart from differences in disease definition (eg "hypotension" is a very common condition in Germany and consumes a large chunk of the drug budget even though it is virtually unknown in other countries), diseases like cancer have had artificial improvements in survival because of earlier diagnosis (breast screening and PSA). Nevertheless, it appears that America is spending an awful lot more money without a commensurate improvement in outcome.
This may be because outcomes are an average of superlative care for the insured and terrible care for the uninsured, but I would need to see some figures to convince me of this.
Those who don't have access to a Healthcare program are likely to be people between the ages of 18 and 64 in low-paid jobs. Healthcare insurance for a family is on average more than $11,000 per year: a large burden for a small employer to bear. It is a large burden for a big employer to bear and makes American industry less competitive. Accessing regular Healthcare options is more expensive for the uninsured who don't have the bulk-buying capabilities of the Insurance companies, though the uninsured would be well advised to shop around and negotiate.
Many of those who are uninsured are immigrants, often illegal immigrants, in casual jobs, often part of the 'black' economy; they are paid in cash with no questions asked. For health care they resort to Emergency Rooms in County Hospitals. They are likely to default on taking their medicines because they can't afford their prescription drugs. They are likely to take part in informal drug exchanges, swapping unused (sometimes out of date) drugs with others in the same predicament. Medicine cabinets of the recently deceased provide a constant supply: not a good omen.
I have seen statistics somewhere that the poorest 30 million Americans are no better off than they were 20 years ago: but it's not the same 30 million. People come to America to better themselves and most of them do. I hope it is not patronizing to say that it takes years for those coming from developing countries to free themselves from the lifestyles of their former abode and buy into the ways of a liberal democracy. America welcomes more immigrants than anywhere else. They come wanting what America can give and most of them will eventually get it. It should not be assumed that providing a 'free' health service to this group of the population will make the problems go away.
Britain has experienced unprecedented waves of immigration over the past few years. Apparently, London schoolteachers have to deal with children who speak 900 different languages. Healthcare is available free at the point of contact. Everybody is registered with a family practitioner.
For the past 3 years I have been privileged to attend at Kings College Hospital in South London. Kings is one of the world's top hospitals. The liver unit is world renowned for its pioneering work in hepatic transplantation; the neurology and hematology units are similarly famous. Kings sits in an area of South London rich in ethnic diversity - which is a euphemism for it's a mostly black area. Many of the patients I see there are illegals keeping their heads down. The area has recently been in the news because of a spate of teenage gun crime. I see at Kings diseases that had been almost eliminated when I was a young doctor and common disease appear in their late stages because they have been neglected. I previously practiced in Bournemouth, a middle class, mostly white, affluent community with an excellent health service, where we could worry about chipping off 0.1 per thousand from the infant mortality rate, where we could honestly say that we would not expect anybody to die from a stem cell autograft and that induction chemotherapy for acute leukemia was safe. The Hematology service at Kings is better than that; it takes on cases that middle class hospitals couldn't imagine.
Britain comes out bottom (with Ireland and Portugal) in the number of deaths before the age of 75 that would have been saved with appropriate medical treatment. These three countries (America is almost as bad) are almost twice as bad as France. I would put it down to lifestyle, but France is as boozy as Ireland and Portugal has a Mediterranean style diet. More likely this is an example of different methods of statistical collection or different definitions.
According to the statistics the French have one of the best health systems in the world. It is an insurance-based system like the American one. The French have a large immigrant population too, with many illegals. Why are they doing so much better? My suspicion is that they are manipulating the statistics (their figures on cirrhosis are notoriously unbelievable). But if not perhaps we should all be living on red wine, garlic and olive oil.