What the world doesn't know about health care in America

Like the Olympic tribute to Britain’s NHS, countries wear nationalized health systems as badges of pride.  In those same countries, assertions like “fifty million Americans have no access to care” and “US health care is scandalous” are widespread. Despite their frequency, these denunciations are wholly contradicted by facts.

No charge is repeated more often than this statistic: 16%, almost 50 million Americans, lack health insurance. But ten million were not even US citizens; millions more claimed to have no health insurance but were using insurance; and 13 million adults and 5 million children were already eligible for government insurance, but had not enrolled. Claims about uninsured Americans have been greatly exaggerated.

The truth is that health insurance does not equate with health care access. Statistics Canada stated “waiting time has been identified as a key measure of access.” Affirming 2005’s Chaoulli v. Quebec, in which Supreme Court justices famously concluded “access to a waiting list is not access to health care,” countless studies document grave consequences from prolonged waits. A growing list of European countries, including Denmark, England, Finland, Ireland, Italy, the Netherlands, Norway, Spain, and Sweden, have been forced by public outcry and laws to address unacceptable waits for care.

Meanwhile, it is understood that “waiting lists are not a feature in the United States,” as stated in a 2007 study and separately underscored by the OECD (“[the US is] a country where waiting time is not a policy concern”).  Indeed, Americans would be stunned to hear the reality of nationalized insurance:

• In its latest “care guarantee,” Sweden found it necessary to stipulate that patients must be able to see a doctor within seven days; patients should not wait more than 90 days to see a specialist; and treatment should be scheduled within 90 days…six months from presentation;

• Barua calculated that 941,321 Canadians in 2011 waited 9.5 weeks on average for necessary treatment, plus 9 weeks between GP and specialist…four months after seeing a doctor;

[pullquote]

• England’s 2010 “NHS Constitution” declared that no patient should wait beyond 18 weeks for treatment (after GP referral). Even given this long leash, the number of patients not being treated within that time soared by 43% to almost 30,000 in January. BBC subsequently discovered that many patients initially assessed as needing surgery were later re-categorized by the hospital trust and removed from waiting lists. Royal College of Surgeons President Norman Williams, calling this “outrageous,” charged that hospitals are cutting their waiting lists by simply raising thresholds.

How about preventive care and screening?

• Cancer screening: Confirming OECD studies, Howard in 2009 reported the US had superior screening rates to all 10 European countries (Austria, Denmark, France, Germany, Greece, Italy, the Netherlands, Spain, Sweden, and Switzerland) for all cancers. And Americans are more likely to be screened younger, when the expected benefit is greatest. Not surprising, for almost all cancers, US patients have less advanced disease at diagnosis than in Europe.

• Preventive care for heart disease and stroke:  Wolf-Maier reported treatment of diagnosed high blood pressure, the focus of preventing heart failure and stroke, was highest in the US (53%), lowest in England (25%), then Sweden and Germany (26%), Spain (27%), Italy (32%), and Canada (36%).  In 2010, drug treatment was higher in the US than all European countries, including Austria, Denmark, France, Germany, Greece, Italy, Netherlands, Spain, Sweden, and Switzerland. In 2011, nearly 70% of Britons with known hypertension were left untreated.

Cholesterol-lowering statins significantly reduce the risk of stroke. Of patients with high cholesterol in 2007, 88.1% of US patients received medication to control it, compared to only 62.4% in the ten European nations. In 2010, the US had the highest use of cholesterol-lowering drugs among all countries, including Australia, Canada, Denmark, France, Italy, Japan, Netherlands, and Spain.

How about serious diseases and specialists?

• Heart disease: Waits for diagnosis and treatment of heart disease, the leading cause of death in the US and Europe, plague nationalized health systems. OECD reported delays of several weeks to months for treatment in Australia, Canada, Finland, England, Norway, and Spain – not including waiting for specialist appointments. In 2008-2009, the average wait for CABG (coronary artery bypass) in the UK was 57 days. Swedes waited a median of 55 days, even though 75% were “imperative” or “urgent.”  Canada’s heart surgery patients wait more than 10 weeks after seeing the doctor, and two months for CABG even after cardiologist appointments.

“Most United States patients face little or no wait for elective cardiac care,” according to Ayanian. OECD acknowledged the US is “a country where waiting time is not a policy concern” for bypass surgery and angioplasty. For bypass, Carroll reported that zero percent of US patients waited more than three months, in contrast to all European countries. According to the US Department of Health, “low-risk patients scheduled for diagnostic [coronary artery] procedures sometimes have to wait all day or even be rescheduled for another day.” Even for non-urgent patients, required waiting for one day is remarkable. Waits for US cardiologists can occur for routine “heart check-ups” with no disease history, the lowest possible priority -only Minneapolis (ironically with half the uninsured rate of the nation) exceeds 30 days.

Despite worse outcomes and high risk for death, governments set extremely long “targets” for heart surgery. Wales targets up to eight months; England targets 18 weeks after referral; Canada benchmarks up to 26 weeks for bypass. Defined as acceptable by governments who set them, such targets propagate the illusion of meeting quality standards despite serious underperformance, endangering their (fully insured) citizens.

• Surgery and specialists: Delaying hip replacement is associated with adverse outcomes and severe pain. In 2010, Canada’s median wait for hip replacement was 20.4 weeks. Despite government’s “guarantee” of timely treatment, 60% of Swedes wait more than three months. In England, the median wait after referral for hip replacement in 2011 was 91 days. In contrast, nearly 90% of American patients (almost half are under 65) received hip replacement in less than three weeks; no patients waited six months or more.

The US was among only three countries (with Germany and Switzerland) where less than 10% of patients waited more than two months for a specialist. Three to four times more patients waited longer than two months in Canada (41%), Norway (34%), Sweden (31%), and France (28%).  In 2010, 60% of England’s NHS patients deemed ill enough by the GP waited more than two additional weeks and 31% more than one month for a specialist.

Yet, outrage was widespread when time to appointment averaged 20.5 days in the US for five specialties in 2009. Escaping that news was that those requests were for healthy check-ups in almost all cases, by definition the lowest priority.

Strikingly, the US wait for routine check-ups was significantly less than for Canadians with serious disorders like “probable cancer” of the gastrointestinal tract (26 days) or proven GI bleeding (71 days). Even for routine physicals, US waits are shorter than for sick patients in countries with nationalized insurance.

From the facts, Americans enjoy unrivalled access to health care— whether defined by access to screening; wait-times for diagnosis, treatment, or specialists; timeliness of surgery; or availability of technology and drugs. And, gradually, Europeans are circumventing their systems. Half a million Swedes now use private insurance, up from 100,000 a decade ago. Almost two-thirds of Brits earning more than $78,700 have done the same. But what might really surprise those who assert the excellence of nationalized insurance systems is that throughout Europe, from Britain to Denmark to Sweden, when faced with their inability to deliver timely access, the government’s solution is increasingly to enable access to private health care.