Let me begin this sobering post by saying there are aspects of the U.S. healthcare system that are admirable, especially regarding the use of cutting-edge innovative medicines and medical procedures. In cancer care, in particular, the U.S. has been at the forefront of a number of advances which have delivered miraculous benefits to patients. Yet, on the whole, America’s healthcare system appears “woefully dysfunctional.”
The U.S. spends about twice as much on healthcare as other Organization for Economic Cooperation and Development (OECD) countries, but ranks near the bottom in terms of life expectancy, and that gap has widened sharply in recent years.
In 1980, life expectancy at birth in the U.S. was comparable to many OECD countries. However, since then, the U.S. has added only 4.6 years of life expectancy, while OECD nations have gained 7.9 years on average.
During the same time period, on a per capita basis, U.S. healthcare spending increased more than 12-fold, from $941 per person in 1980 to $11,172 in 2018. By contrast, the OECD average increase in healthcare spending since 1980 has been approximately 4-fold.
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So, among a group of peer nations, the U.S. is now a distinct outlier on two counts: relatively low (and currently diminishing) life expectancy, coupled with the highest growth rate in healthcare spending and greatest absolute expenditures.
The U.S. also has fewer physicians, hospital and psychiatric care beds than most other economically advanced countries. This points to much higher per unit costs of healthcare services in the U.S.
The recent trend showing a decline in life expectancy is particularly alarming. Here, the disconnection between increases in healthcare spending and decreases in mortality indices is conspicuous. This is not an acute crisis that can be blamed on one anomalous event, but rather a structural problem in desperate need of government and private sector intervention that takes the long view on addressing the so-called diseases of despair as well as socioeconomic determinants of health.
Certain causal factors related to relatively poor mortality and morbidity indices, such as the steady rise in obesity over the last four decades, have less to do with acute healthcare interventions than lifestyle issues. Indeed, acute care interventions are often less important determinants of health than behavior, the environment, and preventive measures. This accentuates the importance of public health, defined by the Centers for Disease Control and Prevention as the “science and art of preventing disease, prolonging life, and promoting health through the organized efforts and informed choices of society.”
At present, the federal government is doing precious little to remedy the problem. Less than four percent of U.S. healthcare spending is allocated toward public health. Recent deep cuts in federal and state spending on public health and research are making matters worse.
Improvements in public health aren’t as salient as a dramatic breakthrough in cancer immunotherapy (though public health measures are often the result of major advances). Frankly, there’s more money to be made by individual investors and venture capitalists in high-priced cutting-edge advances. On the other hand, for the most part, the return on investment for public health initiatives doesn’t accrue to individual investors. Rather, society as a whole benefits.
A societal perspective takes into account potential benefits to others not directly involved in the healthcare intervention. For instance, the decision to fund or invest in a technology may include items such as the impact on the economy or spending on non-health social services.
In the U.S. context it is challenging for health technology assessment entities to assume a societal perspective. The nation’s decentralized, pluralistic healthcare system doesn’t lend itself to a broad, all-encompassing viewpoint. Nevertheless, in light of disconcerting data on life expectancy coupled with ever-increasing healthcare expenditures, it is important to begin to at least envision ways of capturing a societal perspective.