It was the best of times, It was the worst of times,

It was the age of wisdom, it was the age of foolishness,

It was the epoch of belief, it was the epoch of incredulity, …

starts Dickens’ Tale of Two Cities. 

That’s what came to my mind when reading the latest global health report from the OECD, Health at a Glance 2019, which compares the United States to other nations’ health care outcomes, risk factors, access metrics, and spending.

Some trends are consistent across the wealthiest countries of the world, many sobering, such as:

  • Life expectancy rates fell in 19 of the OECD countries. Stalled gains in longevity, with greater burdens of chronic disease and ill mental health, are growing risk factors throughout so many of the wealthiest nations on Earth
  • Increasing rates of obesity and diabetes are countering the positive impacts countries have made in stemming heart disease and stroke across the OECD but particularly in the U.S.
  • Opioid-related deaths grew some 20% since 2011 in the U.S. and are impacting mortality rates in Canada, Estonia and Sweden, too.

Now to Dickens’ lens over U.S. health care versus the OECD peer nations. For the U.S. in the “best of times” category, rates of death from heart attacks and strokes in the U.S. fall below the OECD average, and the proportion of people who self-report that they are in “good health” is the third highest in the OECD.

On the “worst of times” side of the global health ledger are the stark facts that gains in life expectancy in the U.S. fell in the last five years. Furthermore, 1 in 2 children in America are overweight, the highest level among OECD peer countries.

What of the “Age of Wisdom” in American healthcare? We can point to Americans doing a good job of quitting smoking relative to health citizens in other wealthy nations, as well as America receiving high ratings for effective cancer care versus the rest of the developed world.

“The Age of Foolishness” in U.S. health care corresponds to the nation’s tremendous waste baked into the system when it comes to administration, fragmentation and dis-continuity of care, unsafe prescribing regimens, and under-investment in a strong primary care backbone. Our OECD peers generally invest more in primary care access than America does. One sign of this under-investment and disparity of primary care access is that the U.S. fell to the bottom of the roster when it came to measuring service coverage for primary care: the share of U.S. adults with a health care need visiting a doctor was the second lowest among OECD countries.

Health Populi’s Hot Points:  The epochs of belief vs. incredulity are the last two Dickensian observations which are counter to each other. Americans used to believe they enjoyed the “best health care system in the world,” but this has eroded due to challenges of access, high costs that can be an access barrier for patients, and medical bills that have recently motivated a market among patients to launch GoFundMe campaigns to help fund families’ health care costs.

That’s the incredulity part of this scenario — that no longer can mainstream Americans believe that their country has “the best health care in the world.”

An October 2019 CBS News Poll on how Americans feel about U.S. health care found that 3 in 4 people believe the U.S. health care system needs either fundamental changes or should be “completely rebuilt.”

The fourth graph illustrates OECD nations’ life expectancy versus health spending. Note the USA is an outlier on this chart in a quadrant representing higher health spending and lower life expectancy.

America is the lone country in this plot of OECD nations.

The U.S. is at a cross-roads in health care, a tale of two nations of health care have’s and have-nots with health disparities that separate Americans across many chasms, including but not limited to…

  • Rural vs. non-rural
  • White people vs. people of color
  • Men vs. women
  • Higher educated people vs. people with high school or less
  • People employed in large companies that provide health insurance versus people in the gig economy or smaller firms
  • Millennials compared to Boomers,

and so on.

The last chapter of my book, HealthConsuming, addresses the question of whether Americans can morph from health consumers to “health citizens.” Today, I’m speaking on that very topic at the Microsoft Envision Forum Healthcare meeting addressing stakeholders representing the many touchpoints in the U.S. health care system. (Follow tweets of the meeting using hashtag #MSEnvisionForum)

Dickens concludes A Tale of Two Cities (spoiler alert!) where the protagonist named Carton sees a future where his personal sacrifice of his life allows those, “for which I lay down my life [to be] peaceful, useful, prosperous, and happy,” and where France, in the midst of the bloody and divisive French Revolution, will be ultimately restored to peace and order.

The U.S. could do worse than to learn from the French health care system, which spends only 11% of its GDP on health care (vs 18%+ in the U.S.) but has life expectancy 2 years higher than the OECD average. Furthermore, patients-out-of-pocket spending is only 2% of household spending compared with about 20% for U.S. families.

Can, or will, American policymakers foster a nation of health citizens by assuring universal health care, granting patients control over their health data, and assuring privacy of that data especially as our digital selves generated more health-helpful data outside of the healthcare system?

We’re just one year out from the 2020 election which will be strongly influenced by voters driven to polls to express their personal and family values for a fairer, affordable, accessible health care system. Will health care voters “Great Expectations” for better health care be fulfilled? We’ll be tracking this ongoing over the next 363 days….and beyond…

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