Take a long enough lens – say 25 years – and it seems like healthcare in America is undeniably getting better.
People are living longer than they were a quarter of a century ago. The burden of illness, a measure that includes premature death and disability, has decreased. The number of avoidable hospital admissions and hospital errors is lower.
But beneath those rosy numbers lies the truth: American health care has lagged behind other countries in the developed world for decades.
Life expectancy has increased, but less so in the US than in affluent countries in Europe and Asia. The improvement in the disease burden is also less impressive than in comparable countries. Meanwhile, to achieve these mediocre results, the United States continues to spend more money on medical care than any other country in the world; While healthcare spending is not growing faster in the US than in other countries, it was initially higher and continues to rise. We have maintained a significant lead in health spending, with results that are worse than in countries that spend less.
And it was all true before the United States experienced one of the worst Covid-19 outbreaks in the world.
Researchers at the Kaiser Family Foundation recently warned of "further widening the gap" between the US and other countries as a result of the pandemic. Life expectancy in the US has stagnated in recent years, driven by an increase in drug overdoses and suicides; now Covid-19 will shorten it further. The burden of disease had risen in the US while it had declined elsewhere; The Covid-19 pandemic is likely to widen this discrepancy as well.
It could be said that the evolution of the American health care system before, during, and after the pandemic is similar to that of a single patient at risk: it was sicker to begin with, has been hit hard by Covid-19, and will deal with the long-term effects .
The US has already lagged behind the rest of the world in healthcare
America has slowly but noticeably fallen behind other developed countries when it comes to value for money in healthcare.
It starts with life expectancy, the sharpest measure of how well people are being cared for by their healthcare system. Life expectancy in developed countries has steadily improved over the past few decades, largely driven by major breakthroughs in the treatment of heart disease and other cardiovascular problems, which are among the leading causes of death in affluent countries.
But not as much in the United States as in other countries. According to a KFF analysis of health trends from 1991 to 2016, American life expectancy increased by 3.1 years during that period – a significant improvement, but significantly less than the 5.2 years gained in comparable countries.
Peterson-KFF Health System Tracker
And in the USA in particular, this progress has stagnated in recent years. With tens of thousands of people dying from opioid overdoses each year and the number of suicides continuing to surge, American life expectancy actually began to decline in 2014, according to an analysis published in JAMA in 2019. The gap between the US and other wealthy countries was widening even before the Covid-19 outbreak.
The disease burden had also steadily improved until a new downturn separated the US from other countries. The reasons for the improvement were the same: better medical treatment for chronic diseases. But again, America has not improved to the same extent as in comparable countries, it recorded an improvement of 12 percent compared to an average of 22 percent in other countries. In the United States, the burden of heart, lung, kidney, liver, and diabetes remains stubbornly high compared to the rest of the developed world.
And the reasons for America's recent stagnation are the same: suicides and drug overdoses, as well as an increase in the number of chronically ill adolescents, rob people of healthy lives for years.
The same pattern applies to medical errors. They have been declining in the US over the past 25 years, but are still more common in America than in comparable countries. Avoidable hospital stays and adverse drug events are declining, but not as much as in affluent European or Asian countries. Americans are about twice as likely to make mistakes in their medical care as their counterparts around the world.
One metric – known as healthcare accessible mortality – combines all of these characteristics and ranks a country's healthcare system based on how well it prevents disease deaths that should be manageable with timely access to healthcare. The USA ranks behind the largest countries in Europe and Japan in 2016.
Peterson-KFF Health System Tracker
A country like Taiwan, which did much worse than the US on the same metric 30 years ago, is almost on par today.
And for those mediocre results, the US still spends more on health care than other countries: nearly 18 percent of its GDP versus about 11 percent on average in comparable countries. Health care spending in the United States and its competitors have increased at the same rate over the past few decades, and yet, in these other countries, their health outcomes have improved.
In other words, they are getting more value from their health systems than the US.
“One could conclude from this that the increase in value of the comparable … countries was greater,” wrote the KFF researchers in 2018, “although they assumed a higher threshold for better results and a lower percentage of GDP was consumed for this. ”
One possible explanation for America's poor performance is that we are underinvesting in social spending and spending too much on medical care compared to other developed countries. When you combine social and health spending, the US and its competitors spend roughly the same amount, a little over 30 percent of their GDP. But in these other countries, spending is more likely to be spent on social services, while America is spending more on medical care.
Peterson-KFF Health System Tracker
America's underinvestment exacerbates the gaps between the haves and the haves: 18 percent of Americans live in poverty versus 10 percent in other affluent countries. We know that people on lower incomes have structural challenges – access to healthy food, clean water and fresh air, first of all – that lead to poorer health outcomes. When they get sick, they have a harder time finding a doctor and getting their medical care.
"Economic inequality is increasingly associated with inequalities in life expectancy in the distribution of income, and these inequalities appear to increase over time," wrote the authors of a 2018 review of relevant research in Health Affairs. Poor health also tends to lead to lower incomes, creating a feedback loop known as the “health poverty trap”.
And these differences – between rich and poor, white and black – only worsened during the Covid-19 pandemic.
Covid-19 will have long-term consequences for American health
The gap between the U.S. and other wealthy nations is expected to widen due to the pandemic. America has lost more than 600,000 people to Covid-19, the highest confirmed death toll in the world. When adjusted for population, the US has lost more people per capita than most of the European and Asian countries it is compared to.
Official death numbers can be somewhat arbitrary as they depend on tests to identify cases. Excessive deaths – the number of deaths from all causes that is higher than what would be expected in an ordinary year – is considered by experts to be a more reliable measure. On this metric, too, and considering population size, the United States comes in at the bottom of the wealthy nations.
"The oversized impact of the pandemic on the US is likely to widen the existing gap in death rates between the US and peer countries," wrote the authors of an October 2020 analysis of Covid-19 death rates and life expectancy.
America is also likely to experience a higher burden of disease (those years of quality of life lost to premature death and disability) as a result of its pandemic failure. People under the age of 65 have died more often from Covid-19 in the United States than their peers elsewhere.
Peterson-KFF Health System Tracker
Persistent mental crisis can persist after a year of disrupted social life and isolation. More than 4 in 10 Americans reported having symptoms of anxiety or depression in 2020, according to US census surveys.
Health care spending actually slowed in 2020, a historical anomaly, as people postponed medical care during the pandemic. But medical spending wasn't slowing as much as the rest of the economy: by October 2020 it was down 0.5 percent, down from an overall decline of 1.8 percent. Even as spending fell, health care was likely consuming an even larger proportion of American GDP than in previous years.
And the short-term decline in spending could have long-term consequences. Last year, in a census poll, 24 percent of Americans said they did not receive needed medical care during the pandemic, and 33 percent said they had delayed care. To take an example, early cervical cancer screening levels fell about 80 percent from normal levels in the spring of 2020, and while they recovered later in the year, they were still down 25 percent by the end of September.
Although patient volumes have generally recovered, we still don't know what the long-term effects will be if people are not cared for or receive a late diagnosis. And there are tens of millions of people recovering from Covid-19 infection; According to a new analysis in the New England Journal of Medicine that Long described Covid-19 as "our next impending public health disaster", up to 15 million of them could face "long covid" for the foreseeable future. These direct health aftershocks from the pandemic will continue to weigh on the U.S. healthcare system long after the coronavirus itself has subsided.
Long-term spending trends have already pushed health plans to shift the cost of health care more on to patients. Deductibles and employee bonuses have been rising for years.
After Covid-19, healthcare, at least as a relative share of the economy, is consuming even more of the country's resources. America's health outcomes have been set back by the pandemic and the spending crisis is deepening.