Due to federal failure to enact meaningful healthcare
reforms, this article reviews states that are making a difference. Three states
which have taken steps to control the cost of healthcare without adversely
impacting patient outcomes are Maryland, Montana, and Oregon and this article
reviews what they have done. But before we get to that let’s review the current
status of U.S. healthcare.
Washington State’s 2022 report on evidence-based methods to
control costs, increase equity, and improve industry transparency and
regulation stated three truths that should shock the nation, if voters were
only aware. Globally, U.S. healthcare continues to be the most expensive
healthcare but health quality metrics continually show the results are not worth
it. In 2019, the U.S. spent 16.8% of all gross national product (GNP) on
healthcare. Norway, the top scoring nation for health outcomes spent 10.5%. How
much longer are the American people going to have to listen to how more
expensive their health care will be in a national healthcare system-clearly
this is not the case. Here are the Commonwealth Funds 2021 findings for the latest
metrics on global healthcare outcomes compared to the rest of industrialized
nations: (Eric C. Schneider, 2021)
U.S. ranks last in healthcare outcomes (we spend
60% more on healthcare than Norway, the top nation for outcomes)
1. Highest infant mortality
2. lowest life expectancy
3. Lowest rate of reduction in avoidable deaths (which is what healthcare is supposed to do)
4. Last on access to care
5. Last in administrative efficiency
6. Last in health equity (discrimination in health services)
7. Second on measures of care process (we are tracking it all as the outcomes decline)
The Commonwealth Fund has for years done an excellent job of
finding methods to compare different healthcare systems and this latest report
reviewed 71 measures for 2019 to arrive at its conclusions. Nations reviewed
were: U.S., Switzerland, Germany, France, Sweden, Canada, Norway, United
Kingdom, Netherlands, Australia, and New Zealand. Here are the metrics reviewed:
Cost-U.S. Healthcare is 50% more expensive than other
industrialized nations
Gross domestic product, which is essentially a measure of
all goods services produced over a specific period of time for the country is a
measure of wealth and how much of that wealth is spent on things, such as
housing, education, and healthcare. It is one measure to assess a cost comparison
for health systems which has been widely used. New Zealand spent the least on
its healthcare, at 9.1% and one could argue that it is a tiny nation and not
comparable to the complexity of the U.S., but Australia, also spent 9.4%. For
nations with larger populations, France spent 11.1% of its GNP on healthcare
and Germany spent 11.7%. And unlike the U.S. these nations cover most of their populations and their residents don't pay thousands of dollars out of pocket for services.
Infant Mortality-U.S. Deaths are 70% higher than
other industrialized nations
Infant mortality is a measure of babies who die and is a
direct reflection on maternal child healthcare and access to care. In this
forlorn measure, the U.S. has 5.7 deaths per 1,000 infant births, compared to the
other nations, which had less than 4 deaths. Switzerland boasted only 3.3 deaths per 1,000 births.
Maternal Mortality-U.S. deaths are 5 times higher than
other industrialized nations
The U.S. also has an abysmal maternal mortality rate, which
is going to increase with the latest century rollback of women’s health in many
states, which seek to outlaw termination of pregnancy for any reason. To be
clear there were 17.4 American women who died as a result of childbirth per
100,00. France loses only 3.2 women, even if you are math impaired that is five times the number of women who die
from childbirth in the USA. Expect more to perish from ectopic pregnancies, hemorrhaging
(bleeding out), cardiac conditions, and other preventable causes. In 2020, 24
women per 100,000 died from childbirth in the United States.
In 2021, 32 women out of
100,000 died from childbirth, an astounding increase of 25% in preventable
deaths. The Centers for Disease Control 2022 analysis found that 4 out of 5
pregnancy related deaths are preventable-80%. (Centers for Disease Control and
Prevention, 2022)
This is an appalling statistic! The U.S. is ranked 55th for maternal
mortality-a metric that clearly shows how little our females are valued. U.S. legislators would rather a women die as a
result of childbirth than alter a pregnancy. Current maternal mortality in the
U.S. is equivalent to many less developed countries including: Mexico, Egypt,
and much worse than Cuba (which has a national healthcare system). (Ritchie,
2023)
While
evaluating healthcare outcomes for women more than a decade ago I was astounded
to learn of the disparities in maternal mortality and the high rate of deaths for
pregnant women in Washington D.C. is seared into my mind.
Seemingly people don’t want to believe how bad things are for pregnant women in
the U.S. or they don’t care. It feels like people are looking away as they do
for the poor souls living in tents in every U.S. city.
Life Expectancy-Americans pay more for their healthcare
and don’t live as long
The Commonwealth metrics uses the number of years attained
on average by nation as the measure of life expectancy. All of the top nations
had average life expectancies beyond age 80, but Americans (83.1 years) can
expect to live 2.5 years less than the rest. And only in the U.S. are there
sharp differences based on race, mortality for black (74.9 years) and American
Indian (73 years) populations are much worse than the average.
Reduction of Avoidable Deaths-U.S. ranks the worst
The Commonwealth Fund 2021 Report on global health outcomes
reviewed the reduction of avoidable deaths and Switzerland reduced avoidable
deaths by 25%, five times the U.S. rate, which was only 5%. The next worst
performer in this group of 11 nations was Germany which still reduced deaths by
13% This is another metric where the residents of the states, who are gouged and underserved
for health care should be electing officials who are going to take action.
Leaving it to the marketplace isn’t working.
Administrative Efficiency-U.S. ranks the worst
Anyone who has had to obtain healthcare in the United States
knows what a nightmare it is to find affordable insurance, obtain a clinician
whom is accepting new patients, and choke down the copayments and fees from excluded
charges for anesthesiologists, labs, and other out-of-network care thrust upon them.
We know what we must do to improve healthcare outcomes:
1. Provide universal coverage to remove cost
barriers to obtain health care-stop gearing health care investments just for
wealthy suburbs.
2. Invest in primary health care systems-not money
makers for huge hospital corporations
3. Reduce administrative burdens on patients and
clinicians-integrated health systems work best
4. Invest in social services-nutrition, education,
childcare, safety, housing, transportation
State Actions to Control Healthcare Costs
Capitation-fixing fees
Maryland enacted a regulatory body to control hospital costs
in an all-payor-model and all hospitals must participate. Maryland received a
CMS waiver to use this model instead of the DRG system adopted by most other
states, which is highly inflationary. The agency reviews hospital rates and has
the ultimate authority on approval of changes. This governing authority has not
resulted in hospital closures or patient care, but it has produced the lowest
hospital prices in the country. This model is a capitation model which has
worked for Maryland and was launched in 2014.
Linking fees to a multiple of Medicare Rates
Montana, through the leadership of Marilyn Bartlett pegged
state employee healthcare costs to a percentage of Medicare rates and saved the
state thirty million dollars. Even the Republicans in Montana appreciate a taxpayer
savings. Barlett had to fight the deep pockets of the healthcare industry, to
enact this contract provision, but she won. Prior to her administration,
hospitals were charging the Montana State Employees Plan five times the
Medicare rates. Barlett, a CPA, has taken her leadership skills on the road
advising states and business coalitions on methods to control costs. (Walker, 2021)
Payment caps and Reference based pricing
Oregon caps state employee health plan payments for 24 of
its 62 hospitals, because of differing needs of rural hospitals, critical
access hospitals (urban trauma centers), and hospitals that served 40% or more
of Medicaid patients (low income). Oregon also plans to limit cost increases to
3.4% per member per year. (Rakotoniaina, 2021)
Washington’s report concludes with four recommendations to
reduce the costs of healthcare including: targeted price growth regulation,
expanded transparency and cost-growth benchmarks, strengthened anti-trust
enforcement and consumer protection, and improved drug affordability. At least,
on the latter, the federal government did finally come out with some affordable
insulin mandates. But what really needs to happen is for the government to be
restored to the people, by overturning the Citizens United ruling which allows corporations to make unlimited political donations. Given the current makeup of the Supreme Court,
who seem intent on settling their own scores versus representing the will of
the people, this seems unlikely. However, lifetime appointments does not mean we can't take administrative action under the constitution to remove court members from hearing cases. It’s time to bring in the back bench of the
federal courts.
And this is the healthpolicymaven signing off encouraging
you not to sign blanket releases when obtaining medical care, do stipulate that
for which you agree and for which you decline. For example, if your hospital
refuses to recognize your medical directive, find another one for your procedure.
Roberta Winter is an independent health policy analyst and journalist,
who has published this blog since 2007. In 2013 her guidebook to the U.S.
healthcare system was published by Rowman and Littlefield.
References
Centers for Disease Control and Prevention. (2022,
September 19). Four in 5 pregnancy-related deaths in the U.S. are
preventable. Retrieved from Centers for Disease Control and Prevention:
https://www.cdc.gov/media/releases/2022/p0919-pregnancy-related-deaths.html
Eric C. Schneider, A. S. (2021). Mirror Mirror
2021; Healthcare in the U.S. Compared to Other High Income Countries. The
Commonwealth Fund. Retrieved May 9, 2023, from
https://www.commonwealthfund.org/publications/fund-reports/2021/aug/mirror-mirror-2021-reflecting-poorly
Rakotoniaina, A. (2021, August 31). How Oregon is
Limiting Hospital Payments and Cost Growth for State Employee Health Plans.
Retrieved from National Academy For State Health Policy:
https://nashp.org/how-oregon-is-limiting-hospital-payments-and-cost-growth-for-state-employee-health-plans/
Ritchie, M. R. (2023, May 9). Maternal Deaths By
Country. Retrieved from Ourworldindata.org:
https://ourworldindata.org/maternal-mortality#maternal-deaths-by-country
Walker, D. G. (2021, February 18). Montanas
Health Policy MVP Takes Her Playbook on the Road. Retrieved from Kaiser
Family Foundation Health News: https://kffhealthnews.org/news/article/montanas-health-policy-mvp-takes-her-playbook-on-the-road/
