Quality Counts

Insuring all Americans is just the first step toward solving our health crisis.

Take Gary and Betsy Rotzler, a couple from just outside of Cooperstown, New York–high school sweethearts, college graduates, young parents of three kids. Gary was a successful engineer for a big defense contractor that was taken over by a larger contractor and downsized. Gary got out, was hired by a rival firm, and then quickly was laid off. Eventually, he was rehired by the new parent of his old company. But by the time Gary was rehired, as a temporary worker, the company no longer offered health benefits, and Gary couldn’t afford them on his own. Suddenly, the Rotzlers were among the millions of uninsured families. Soon friends and family began to observe that “something was wrong with Betsy,” whose physical strength was legend. She began putting off regular medical exams, despite her chronic fatigue and back pain. Gary later realized that Betsy had feared the worst medically–and didn’t want to bankrupt the family with the big bills. By the time the lump in her breast was diagnosed as cancer, even after she was admitted to a major cancer center in New York City, it didn’t make any difference. Within days, Betsy fell into a coma. At the hospital that last night, Gary stepped away from her bedside to sign some forms, including one promising to pay the medical bills. By the time he got back to the room, the kids were arriving with “Get Well” balloons. But Betsy was already gone, leaving behind a grief-stricken family and tens of thousands of dollars of medical debt. Later, Gary recalled what it felt like “when you walk into a doctor’s office and you’ve got to say you don’t have insurance. There is a mood swing, there is a change, no matter how nice that person is behind the desk. You’re a different class of person.”

Americans get what this means: that if it can happen to people like Betsy and Gary, much less to kids like Deamonte, it can happen to you. It can happen to any of us–and is happening, as Cohn’s litany of non-coverage horror stories tells us, all too often. Cohn isn’t a polemicist, railing against the system, though he does document its insidiousness and unfairness as well as the randomness that hits some and not others. In each story, he presents not only a personal tale of ordinary Americans, but why their failures in insurance and care occurred. Each story, in other words, provides not only insight into one family’s struggles, but also into one aspect of the failing health care system: how the current health insurance market evolved, the advent and erosion of employer-based health coverage, changes in state and federal approaches to Medicaid, the pressures on hospital emergency rooms and outpatient clinics, managed care, and the demise of charity care. Cohn sees few if any real villains, although he does view hospital lawyers, insurance company executives, and President George W. Bush with particular disregard. (With respect to Bush, whose most recent State of the Union address acknowledged the importance of access to health care, it’s important to note that the system long precedes his appearance on the political scene.)

But as detailed a picture as Cohn portrays about America’s health care access crisis, he only touches on the fact that even when you can get care, its quality and outcomes are too often wanting. All Americans should have stable, affordable health care coverage. Achieving that would be monumental, but let’s not kid ourselves that it would automatically result in improved health. Most indicators of Americans’ health, for example, show that we’re far below the infant mortality and life expectancy rates of developed nations with which we usually compare ourselves favorably–countries such as Australia, Canada, France, Norway, and Japan. And we’re slipping, not improving. For infant mortality, the United States ranked 18th in 1980; in 2005, it had fallen to 25th, just above Hungary and Poland. We spend far more on health care on a per capita basis and as a percentage of our gross domestic product than any other nation–often twice as much or more.

Nor are all those bucks getting us nearly as much bang as they should. Americans tend to think that, once we have access to care, we get the best health care in the world, and that more care is better care. But neither more care nor more spending improves patient outcomes; indeed, the opposite is most often true. A seminal study by Beth McGlynn and other researchers at RAND indicates that Americans typically get only half the standard of care recommended by the physicians who determine what constitutes quality, evidence-based care for a wide variety of medical conditions. Jack Wennberg, Eliott Fisher, and their colleagues at Dartmouth Medical School studied records of 4.7 million Medicare patients hospitalized with conditions such as cancer, heart and lung disease, renal failure, and diabetes. They found not only huge variations in Medicare spending among different regions in the United States (spending per patient differed by more than 2.5 times from the lowest- to highest-cost region), but that less (but more efficient) hospital and physician resource use produced better patient outcomes. In fact, if every hospital in the country followed the standard treatment practices of the regions of the country with the best outcomes, they concluded, Medicare could save about $10 billion per year.

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