The fact of the matter is, compared to other first-world countries - and some third world countries - the healthcare system of the United States sucks.
It sucks at least a little for everybody.
And it sucks a LOT for certain people. (This is important because it explains why enough Americans continue to support a system that really sucks.)
There are a number of problems with the US system. These are well-known, and are not really debatable, although some right-wing ideologues will still try to lie and misrepresent the situation.
The problems with the US system:
Problem #1: Cost
Healthcare in the United States is the most expensive in the world, and it isn’t close. Note, this cost is per person for the entire population. Because we fail to cover millions of people (see below), the cost for each insured person is even greater.
The US spends at least 40% more than any other country, and we spend double the average for first world countries.
This is absurd. And it is a political choice to do so.
There are some reasons for this, which I may talk about in more detail in a future post. But some of the undisputed factors are that we pay far more for prescription drugs, and that our administrative expenses are far higher than for other countries. And, let us not forget, because health insurance is a for-profit industry, we also pay for profits to shareholders and giant salaries for upper management.
I would, from my professional experience, note that, while there are profits to be made in healthcare, they are very unevenly distributed. Insurers and some giant providers make huge profits. But most hospitals (which are either government owned or non-profit) teeter on the edge of bankruptcy. This is even more of a problem in rural areas and red states.
Another issue here in the United States is our pathological fear of death and demand for life extension at the expense of quality of life. And the more religious the person is, the more terrified of death the family is, believe it or not. Again, this may be a whole post. The US has both a systemic issue (the way we pay incentivizes futile treatment at end of life over preventative and earlier age care), and cultural (our sense of entitlement and fear of death.)
There are other ways that we are “penny wise and dollar foolish” - those are worth looking at too.
There is a lot more to say about all of this, and I may in the future. But suffice it to say that whatever the United States has as a healthcare system, it is disproportionately expensive. This is an issue that affects everyone, because we all pay one way or another.
This might be worth it if our care was better. But it isn’t, as revealed by the other problems in the system.
Problem #2: Uninsured People
The United States in 2023 (the most recent data I could find) had more than 25 million uninsured, of which nearly 4 million were children. That’s 8 percent of the population - about 1 in 11 of us.
What happens to those people? Well, they go without healthcare, mostly. Sure, in an emergency, they can go wait in the ER, but that doesn’t help chronic issues such as cancer, heart disease, diabetes, autoimmune diseases - in other words, things that will eventually kill or disable you, but aren’t killing you right now.
If you think that is meaningful access to healthcare, well, to borrow from Abraham Lincoln, I would like to see that tried on you personally.
There is one bit of good news here: the Affordable Care Act (aka Obamacare) significantly reduced that number - particularly for children.
Naturally, killing the Affordable Care Act has been the number one focus of the Republican Party since its enactment. Next year, the subsidies that have maintained the insurance exchanges will be eliminated (the Big Ugly Bill), likely throwing an additional 10 million people off insurance. Consider that when you vote. (I’ll definitely talk more about that in a future post.)
For this problem, though, the costs are borne mostly by lower income people, which means that middle class and the rich don’t tend to give much of a shit about it. We got ours, sucks to be them. But, as I will discuss below, any of us can join the ranks of the uninsured in a moment.
So, despite paying far more for our care, we leave a lot of people out of it. Does that sound like a good deal?
And this leads to the next problem.
Problem #3: Dead People
I know several people who either died or had family die because they couldn’t afford a timely diagnosis or treatment of their diseases. Literally, they are dead because of our healthcare system.
They are not alone, either.
Numbers vary, because it is difficult to “prove” exactly what killed someone. Particularly when there are confounding variables such as poverty, diseases of despair (suicide and substance abuse, for example), and other factors in play.
The low number seems to be just short of 50,000 unnecessary deaths, with three times that as the higher estimate, particularly before the ACA was enacted.
In any case, even the low number means more people are killed by lack of access to healthcare than die from either gun violence or motor vehicles. This is literally a public health crisis that we refuse to address.
Problem #4: Poor Outcomes
So, maybe we put up with some unfortunate deaths, because the rest of us get better outcomes, right? (That’s morally appalling, but Americans love taking morally appalling political positions. We are a cruel people.)
Unfortunately, the facts do not back this up. There are a few areas the US does well at - certain screenings and preventions (at least if you have insurance), but these aren’t due to our insurance system so much as it is our formerly robust public health organizations.
When it comes to life expectancy, we are pretty damn low. For outcomes to specific diseases, we tend to be about the same as other countries, but not noticeably better.
In others, however, we are truly horrible. For maternal mortality, we are #62, behind countries you may not expect, such as Russia.
We aren’t much better when it comes to infant mortality: we are #57, significantly behind Cuba and other far poorer countries.
So, we aren’t getting better outcomes for our high costs.
How do we perceive our system? We pretty much hate it. But we refuse to adopt a better system - universal socialized medicine. (See my previous posts.)
Problem #5: Bankruptcies
What is the number one cause of personal (non-business) bankruptcy in the United States?
Medical costs. Followed by loss of income from injury or illness. These cause a half a million bankruptcies every year.
Some 14 million Americans owe significant medical debt - this is 6 percent of the population.
This has been my experience in 25 years of working with clients on healthcare issues.
ALL of us (except the obscenely wealthy) could become uninsured in an instant. One bad accident. One diagnosis. One heart attack. One stroke.
We lose our health, we then lose our job, and then we lose our health insurance. This is the unfortunate progression I have seen thousands of times over the years.
Any of us could at any time face this - it is a cost we pay to have our current system.
Problem #6: Denial of claims
While any system can have this issue - and indeed Medicaid denials are a real problem, and other countries have their own issues - the fact that our medical insurance system is profit-based is an open invitation for insurers to deny needed care. That’s literally the business model.
I wasn’t able to find a specific number; I don’t think there has been systematic study of the issue. But we all know someone who was denied coverage for something they needed. Some of those have died, others have suffered.
As I discussed in my prior installment, the problem is that we refuse to treat healthcare as infrastructure. That is, a service that needs to be provided, not a good to be sold at profit.
As long as healthcare is treated as a profit-making enterprise, there will be a strong financial incentive to deny care.
Note that there is a difference here between wages and profit. Medical providers are incentivized to provide services - that is how they get paid. Insurers, in contrast, are incentivized to collect premiums while denying care, so that the shareholders (aka, people with money) can rake in profits.
This is a cost that we all will pay sooner or later. While mine is minimal compared to many, I have been denied a medication that I pay for out of pocket. It’s stupid, IMO, and not cost effective, but here we are.
Problem #7: Coverage of long-term care
The US is weird in what it doesn’t cover. For example, “healthcare” doesn’t include eyes and teeth. You have to insure those separately. Which is ridiculous.
But another absurd gap is long term care. This is a specific area of my legal practice, and the US simultaneously overspends and covers too little.
Because long term care is not covered by Medicare, it has to be covered with other sources. For nursing homes, this is almost entirely Medicaid. But because Medicaid is “means tested,” people who receive it pay most of their income toward care first, and often have to spend down most of their assets to qualify. (This is a gross oversimplification - Medicaid law is complex, and varies greatly by state. Do NOT use this post for legal advice on your Medicaid situation. Seek advice from an attorney who practices in this area.)
What this means is that in many cases, developing a chronic disease that prevents you from safely living alone at home means the loss of one’s assets and much of one’s income.
Furthermore, for people who lack sufficient assets and income to pay for less restrictive levels of care, such as assisted living or in-home care, the nursing home is their only option. This is essentially a segregation of our senior citizens by income level, placing the poor in the most restrictive and institutional settings, while the more wealthy can (at significant expense) live in a more home-like environment.
I could write a whole post about this, but the bottom line is that there are profound economic consequences for becoming old and frail. These consequences fall harder on women than men both because of the sexist regulations regarding spousal income and because women tend to live longer.
The difference between, for example, dying of a heart attack, and dying of Alzheimer’s can mean hundreds of thousands of dollars in costs.
Other countries have chosen to cover long term care for the elderly. We have, largely, refused to do so; instead shifting the burden of care onto the elderly and their often overstretched families.
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So, to summarize, we have a system that:
Costs all lot more
Doesn’t cover everyone
Kills tens of thousands every year
Delivers outcomes that are at best the same and often are much worse
Bankrupt a half million a year and place millions in debt
Denies care to boost profits
Treats the elderly poorly by impoverishing and institutionalizing them
We could fix all of the above by adopting universal healthcare - “socialized medicine.”
Why don’t we? I will (eventually) get to that.
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Previous installments:
Americans Claim to Hate “Socialized Medicine” But They Actually Depend on It
Why Healthcare (and a lot of other things) Needs to be “Socialized”
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