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Fighting the Wrong War
The biggest problem with the U.S. health-care system is that it has long been designed to respond to illness rather than prevent it. According to an analysis by the Commonwealth Fund, a foundation that funds health-care research, half of American adults in 2005 did not receive recommended preventive care, which includes vaccinations, cancer screenings and blood-pressure checks. When we do get our cardiac health checked, too often it's because we've been rushed to the emergency room suffering from chest pains. When we do get a cancer evaluation, too often it's a diagnosis of advanced disease that has spread beyond the initial tumor site.
Not only is this a deadly way to practice medicine, but it's also a breathtakingly expensive one. In 2005 Americans paid out a record 16% of our gross domestic product for health care — a cool $2 trillion — making us the world's top spender on health care per capita. You might think we'd be getting some bang for those bucks, but our leading killer remains what it has been every year since 1900 (with the exception of 1918, when influenza claimed more lives): heart disease, which kills nearly 650,000 of us each year. "The reason we rank so poorly is that we don't provide a basic-wellness infrastructure," says Dr. Mehmet Oz, director of the cardiovascular institute at the Columbia University Medical Center and a host on the Discovery Health Channel.
There are a lot of ways to measure the effects of America's after-the-fact health-care philosophy, but the most telling might be what epidemiologists call preventable deaths. Certainly, plenty of deaths due to illness are not preventable, but there are many other conditions that a decent health-care system should be able to detect and fix well before they become life-threatening. Most of the leading killers in the U.S. — including pneumonia, diabetes and stroke — fall into this category. According to a Commonwealth Fund report issued this year, 101,000 deaths from 2002 to 2003 could have been avoided with access to timely and effective health care. This rate places the U.S. 19th — last — among industrialized nations.
President-elect Barack Obama's first challenge in improving the U.S.'s health scorecard will be to transform this entrenched symptom-centric mentality into a more proactive one, embedding prevention and wellness programs more aggressively into primary care and ensuring that every American takes advantage of these services by expanding insurance coverage to pay for them — beginning with mandated policies for children. (Read about Obama's health-care plan.) That's a good place to start, since by many measures, it's kids — particularly the very youngest — who most need help.
In 2005, the most recent year for which data are available, about 7 babies out of every 1,000 live births in the U.S. died before their first birthday. That rate represents a 2% reduction in deaths from the year before, which continues the steady improvement seen throughout the 20th century. But globally, it still places us 29th in the world, behind Cuba and Singapore and on a par with Poland and Slovakia.
It's not just the tragic nature of a dying baby that makes those numbers so terrible. It's also that infant-mortality rates can stand as a valuable proxy for many critical features of a health-care system — how accessible basic services such as prenatal care and birthing are, as well as the quality and affordability of that care. And our rate exposes a familiar but ugly truth about our system — that those variables change depending on where you are and who you are. Non-Hispanic black women, for example, are three times as likely as Cuban-American women and twice as likely as non-Hispanic white women to suffer the loss of a baby — mostly because of a disparity in access to birthing and postnatal care. And infant-mortality rates along the two coasts tend to be lowest, where denser populations translate to greater availability of these services. The wedge that continues to widen these gaps is insurance; non-Hispanic blacks make up half our nation's uninsured, which leaves them without access to the regular health care that can educate mothers-to-be about proper nutrition and pregnancy care. Without such services, more babies are born in distress and are unable to survive their first few months.
Also driving the infant-mortality rate are women at the other end of the economic spectrum, who take advantage of reproductive technologies such as in vitro fertilization. Such procedures boost the chances of multiple births, which in turn increase the likelihood of premature birth and consequently put babies at risk. From 2000 to 2005, the number of preterm births increased 9%, and in 2005, about one-third of infant deaths were directly due to a gestation period of less than 37 weeks.
If deaths at the beginning of life are one critical measure of a nation's health, the number of years we get before the end of our life is another. Life expectancy in the U.S. has steadily increased since the early 1900s, from 46 years for men and 48 years for women to 75 years for men and 80 years for women in 2004. Improvements in sanitation, innovations in vaccines and antibiotics, and control of infectious diseases account for much of the gain. But again, not everyone has equal access to these extra years.
African Americans increased their life expectancy nearly 1% between 2000 and 2002, compared with a 0.3% increase among whites, but blacks were starting from a lower figure, and are still expected to live 5.2 fewer years than whites. For all races, additional golden years aren't necessarily healthy years, with seniors increasingly burdened by such chronic illnesses as arthritis, cancer, diabetes, kidney disease and heart disease. Part of that is simply because the more years you pile up, the more opportunity you have to develop diseases associated with aging. "We are living longer, but we are not living healthier," says Dr. Nancy Nielsen, president of the American Medical Association. "Many Medicare recipients now have five or more chronic conditions."