You Can’t Always Get [What You Pay For]

But if you try real hard— you might do better than Venezuela!

Providing healthcare to [some] Americans is the best economic development bonanza going. Alas, here in the exceptional USA, many people do not have access to mainstream healthcare.  Worse however, as pointed out in today’s Wall Street Journal [yes, I do subscribe], nearly all Venezuelans needing even standard medical or surgical care are plum out of luck— unless they can find and then afford to buy their own medical supplies from insulin to heart valves.  It sounds awful. Hyperinflation makes already overpriced medical devices and drugs impossible to afford. An exodus of physicians, including those whom were loaned by Cuba, makes matters worse. The situation is beyond frustrating for both patients and physicians alike.  At least our feared but imaginary American death panels would have actual choices to make!   Venezuelans are in very real death-spirals of the flesh, not the death-spirals health insurance companies face when they are left holding the bag for sick people when healthy and less ill people fail to enroll in their plans.

The disheartening article included the following graphic showing Venezuela at the bottom of the list of Latin American countries, spending in 2012 only 1.6% of its gross national product on healthcare (and that was 2 years ago). The numbers from the World Bank are only slightly different.  If fact, according to that source, its healthcare spending in 2012 puts Venezuela at the bottom of the list of every other ranked country in the world, occupying a healthcare category all of its own.  That country is suffering the melt-down that apocalyptic American alarmists either warn of, or alternatively fantasize about as a starting point from which to rebuild from the ashes.

How do good countries rate?
I was curious to see how North America stacked up against the numbers of our southern neighbors. The accompanying thematic map from the World Bank illustrates the wide range of spending amounts.  The percent GNP spending in 2012 for healthcare in Canada was 10.9% with a recent small decline; in Mexico was 6.1% and rising; and in the USA was a world-beating 17.9% and still rising. In this, the USA is what we medical scientists call an outlier.  As much as I would like to think we are a shining example to the world, most outliers in other such spending or payment comparisons indicate that something is wrong.

In terms of actual per capita 2012 spending in US Dollars, and subject to currency manipulations, only Norway and Switzerland spent slightly more than the USA’s robust $8895 per capita.  In Canada the number was $5741, in Mexico it was $618, and in Venezuela its was $593. Turkey does better than these latter two at $665 per head.

Worse than waste.
It is often said that we U.S.-Americans pay a lot for healthcare but do not get our money’s worth.  Count me among those. In fact, it is painfully easy to find examples of how spending more and doing too much can lead to worse outcomes than doing little or nothing at all. Overspending encompasses more than just waste and fraud, and includes what I call medical-mischief— looking for trouble only to create the same!  In medical science, we refer often to a “J-curve.” Too much or too little of the same drug or medical treatment can both yield worsening results.  So it is with the green poultice of medical spending. Venezuela is at one end of the curve and we in America are rising on the other.

Let me count the deaths.
For example, as a possible consequence of its meltdown, maternal mortality is rising in Venezuela. In 2013, the rate of maternal mortality was 110 maternal deaths per 100,000 live births, rising from 93 per 100K in 1990.  Among the Americas, only Bolivia has a higher rate at 200, but at least Bolivia’s rate is declining. Among the 250 or so other countries listed by the World Bank, only the very poorest of the world’s undeveloped ones had higher maternal mortality rates.   During the same interval of 1990 to 2013, maternal mortality in Mexico fell from 88- to 49 per 100k. Despite much higher spending, maternal mortality in Canada actually rose from 6- to 11 per 100K; and in the USA it rose from 12- to 28 per 100K!   Our maternal mortality is worse than virtually every developed country in the world except China and certainly worse than the countries of Europe.  Compare the USA to the United Kingdom at 8-, France at 12-, or even Puerto Rico at 20 per 100K.

And why might that be?
As far as I can learn, our lousy maternal mortality rates are not explainable by better record-keeping or by different definitions of maternal mortality. Experts can dissect out the possible effects of induced labor, hysterectomy rates, fertility treatment, or other technical aspects of childbirth.  For all I know, our rates would be even worse without these “modern” additions to nature’s own way.  I believe we have been digging for gold in the wrong places.  Despite the abundant lip service we give as a society towards making healthcare for expectant mothers and children a priority, exclusion from full participation in the American healthcare system has left many behind– before, during, and after pregnancy.

We are living in an time of expanding medical knowledge that tells us that non-medical determinants of health status are as, or are more important than the things that hospitals and doctors like me are able to provide. A shorthand example of saying the same thing is that the zip code of where one lives is as predictive of individual health status as anything else. Money spent to fuel the medical-industrial complex is not available for public health, safe places to live, schools that can more fully meet the social and health promoting needs of our students, safe streets, healthy diets, ameliorating structural racism, or the like. If we want to reduce maternal and child mortality, indeed the burden of all other ills and diseases, we need to make a very different distribution of our health care dollars. To get what we need, we will have to sing a different song.

Peter Hasselbacher, MD
President, KHPI
Emeritus Professor of Medicine, UofL
March 15, 2015