Why is it so hard to achieve an efficient health system within US?

Question

This paper (check ANNEX) places United States on 37th position in terms of medical systems "efficiency" (I cannot tell the date when this study was made).

Efficiency is computed using various factors such as health distribution, financing, responsiveness etc.

This happens in one of the most developed countries in the world (8th place in Human Development Index).

This article tries to grasp the main differences between three developed countries regarding Health Care Systems:

After examining the performance of the German system, we may question whether it is the United States or Germany that has the better system. Surveys of public opinion indicate that Germans by and large are satisfied with their health care system (as opposed to the U.S. where a large portion of the population thinks that system needs substantial changes).

However, this data seems rather old, since it talks about a great number of people without insurance:

The U.S. health care system [...] glaring weakness is exemplified by the fact that more than 42 million people are without health insurance.

This article tells us that the number Americans without health insurance just hit an all-time low:

The percentage of Americans that do not have health insurance now sits at 8.6%, the lowest on record, according to the Centers for Disease Control and Prevention (CDC).

However, this article tells us the plan to the system that created the situation illustrate above.

Question: Considering the US is a highly developed country, why is it so hard to achieve a system that is as efficient as in countries like France, Spain, Austria?

Health systems within these countries seem to be stable for years, so they are a good reference.

[EDIT] Although answers from the duplicate proposal may fit here, this question does not assume that US health system must be a national one in order to make it more "efficient". E.g.: This answer from Quora tells us that "Americans pay 30% to 300% more than Canadians for the identical drug made in New Jersey or California.". Theoretically, better regulation of drugs pricing might increase the cost efficiency of the health system, without changing other aspects.

I am interested in why there seems to be such a difference in the "efficiency" of the health systems between countries having similar economical development.

Answer 1

Short answer, healthcare is viewed as a privileged commodity in the US, not a right. We have a "for profit" system, which, of course, means paying for it. Having "access" to healthcare simply means you can have it if you can afford it, like a luxury car. Until and unless universal healthcare is adopted in the US, healthcare availability will increase only in direct proportion to one's wealth/income.

Answer 2

I don't know how that paper measured effectiveness (especially "responsiveness") but the important part to understand is that these are different systems, in different countries, with different priorities:

A designated study "Comparisons of Health Care Systems in the United States, Germany and Canada" explicitly admitted the weakness of such comparisons:

One should mention that data from different countries may not be directly comparable for several reasons and therefore, should be accepted with some skepticism.

For instance, no standard taxonomy exists across countries. Also in practice it is often very difficult to draw a line separating medical services such as acute and long-term care services.

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However, one measure that is important (not just statistically but medically) is wait times, and that is where US is ahead of most OECD competition, including in some measures, Germany:

• One study showed that USA has (anecdotally as there's no good reporting) lower waiting time than many of the countries you're comparing to

  4. Discussion
     A majority of the countries studied monitor national waiting times and have some type of national waiting time care guarantee. This implies that waiting time is an issue of concern. In a study from 2003 of waiting times in OECD countries, Siciliani and Hurst concluded that “waiting times” is a serious health policy issue in 12 of the countries included in that study (Australia, Canada, Denmark, Finland, Ireland, Italy, Netherlands, New Zealand, Norway, Spain, Sweden, and the United Kingdom). Waiting times were not recorded administratively in a second group of countries (Austria, Belgium, France, Germany, Japan, Luxembourg, Switzerland, and the United States) but the authors wrote that they were anecdotally (informally) reported to be low [21]. Our study shows that eight years later, the same countries still record waiting times.

• Other studies showed that wait times for things from elective surgery to specialists to tests are much longer in non-US countries.

  • From GetBetterHealth:

    The U.S. also did very well on measures of wait times for non-emergency or elective surgery. Only 8% of surveyed patients in the United States reported a wait time of four months or more for elective surgery, compared to 33% in Canada and 41% in the U.K. Germany scored the best, with only 6% reporting a long wait for elective surgery.

    The take-away message is that both the United States and Canada do pretty poorly, compared to most other industrialized countries, on how long patients have to wait to get a regular appointment with a primary care physician or after-hours care, but the U.S. does better than most on having shorter wait times for diagnostic procedures, elective surgery, and specialty care. Each of these countries, though, with the exception of the United States, has universal health insurance coverage, funded and regulated in large part by the government, so it doesn’t seem likely that government-subsidized health care, in itself, is the sole factor in determining how long patients are stuck in The Waiting Place. Other factors, like the numbers of primary care physicians and specialists in each country, may be more important.

  • From Fox News roundup (obviously, it's a biased opinion piece; but it mostly just rounds up quotes from studies on the topic instead of offering opinion):

    • 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;

    • 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.

    • 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.

Answer 3

Government

In the countries with the most "efficient" health care systems, the government pays for most if not all health care. The government has an incentive to keep costs down, as there is limited tax money and they'd like to spend it on other things. By contrast, in the United States (US), the government only pays for health care for three groups: the old (Medicare); the poor (Medicaid); and military veterans (Veteran Affairs).

The federal government subsidizes state expenditures on the poor, matching funds if certain criteria are met. This encourages states to spend as much as they can get matched but discourages savings. States only get half the benefits of any savings while getting almost all the criticism.

If the federal government covered all the costs and managed the program, they'd have incentive to minimize costs. Or if the states did so, they would. By sharing the costs, they make it harder to make savings. The states are limited by their agreements with the federal government, and the federal government doesn't have actual management of the program. Neither can make changes easily. The federal government can make broad regulatory changes but can't make individual policy for handling patients. The states have more power over individual policy but are restricted by the broad regulations.

The federal government does manage the program for the old. But it's a reimbursement program embedded in the overall system. This takes away a lot of the control available in other systems. They can't hire or fire doctors nor change the way that hospitals operate.

In Veteran Affairs, the federal government controls the whole thing. But it still has to compete with private hospitals for doctors, nurses, and administrators. So it pays more than in countries where the only employer is the government.

Single payer systems often have systems where the government picks up the tab for college. Doctors do not have giant debts that they need to pay immediately, so they don't need high salaries immediately out of school that last throughout their careers.

Insurance

During World War II, the US instituted wage controls. To get around them, companies would offer non-wage benefits like health care. Prior to that, individuals had purchased health care themselves. The net result is that for more than sixty years, the way that the typical middle class person received health care was through an employer.

The patients didn't pay for health care, so they didn't care how much it cost. But they would select the doctor, who would choose how much to bill. In the short term, the insurance companies have an incentive to keep their individual costs down, but they have no incentive to keep the system costs down. The more expensive the system, the more they can charge. And they don't choose doctors, treatments, or procedures except broadly.

Employers want costs down, but they also want their employees satisfied. And their only control of costs is by choice of insurer and plan. To make things worse, if things go wrong, the patient can sue the doctor for making mistakes.

This separation of impact and responsibility leads health care in the US to be extraordinarily expensive. A lot of money is spent on things that don't improve care but protect doctors from being sued for missing a diagnosis. Expensive tests and unnecessary procedures are common. Less money is spent on things that have high impact but require help from the patients. In particular, the US spends less on nutrition and prenatal care.

Doctors

Another problem in the US is that doctors have incentives to maintain sparse schedules relative to other countries. Because wait times are visible to patients in a way that medical effectiveness is not, doctors, especially specialists, compete in wait times. But in order to do this, they have to see fewer patients and charge more per patient to maintain their salaries.

Summary

The US health care system is made up of kludges that no one has the actual authority to fix. There is no single authority that can make tradeoffs between expense and care. Because of this, there is no real incentive to hold down costs.

Answer 4

Unfortunately, the United States has several factors that make it difficult to have a centralized and unified healthcare system. That is not to say it is impossible however, but there are religious objections, and significant differences in policy between the two major political parties. So when I make this answer, I make it with no assumption that there is a 'right way', as it is such a divisive issue.

Firstly, the United States has many private hospitals, and public hospitals are by and large a minority. This is complicated by many of those private hospitals being non-profit religious in nature. So when discussing access to particular health services, things like blood transfusions or abortion procedures many be against the religious beliefs of those that run the private hospitals, and thus not be provided.

Secondly, the differences between the Democratic Party approach, and the Republican Party approach, and the differences between each State, make it difficult to actually pass legislation on health care, and health care regulation. This is exemplified by the great difficulties had in passing the Affordable Care Act. The reason for this is that each State has different health providers, and the voters and health providers in one state may support some form of Universal Healthcare, while in others support only a Private Health Insurance option. Compound this with the party line differences, with the Republicans opposed to UHC, and Democrats unwilling to accept a Private Insurance model that could leave many poor people without insurance.

Thirdly, politicians seem very uninformed on what health care models are actually available, and what they mean. For instance, in the last election, it was continuously claimed by politicians that Universal Healthcare meant no Private Healthcare, even though many countries with UHC actually still have private providers or simply have a public insurance option that provides access to private providers like Switzerland does. Likewise, there was little debate on the option of subsidizing operations and medicine, which are major causes of rising medical bills. This doesn't help, when you are trying to establish a health care model, as it muddies the issues, and gives the wrong message to the public.

Fourth, while the United States may spend more on healthcare than most other countries by per capita levels, it does not translate to a better standard of care for most people, but only the minority who have significant financial means. This is due to the complexities of US healthcare bureaucracy, inability to pay for treatment, as well as a lack of regulation on the prices of medical services, such as operations, medication, and the cost of seeing specialists. There are options around this, such as the government subsidizing care, or setting caps on what a health provider may charge for a service.

Finally, the United States does not have a health record controlled by the government, which is discreetly shared with the private and public health providers, if you access their services. This may complicate not only treatment, but also give less data for health providers to work with to provide better care. For instance, someone walking into a health clinic in some countries would be known on a public health ID number, which is accessible through a nationwide health care database. This may be a minor issue, but nonetheless, worth noting.