Contemporary Public Health: Principles, Practice, and Policy

11. International Lessons for the United States on Helath, Health Care, and Health Policy

11 International Lessons for the United States on Health, Health Care, and Health Policy Stephen C. Schoenbaum, Robin Osborn, and David Squires For many years, health care has been significantly more costly in the United States than in other countries. Nonetheless, overall U.S. health system performance and population outcomes often fall short of achievements in other countries.1–3 Among sixteen member countries of the Organization for Economic Cooperation and Development (OECD), the United States had the highest death rate from conditions that are potentially preventable or treatable —the so-called mortality amenable to health care. Although the death rate from these conditions has decreased in each of these countries, the rate of decline was lower in the United States than elsewhere (figure 11.1).4 But within the United States there is also an enormous amount of variation in performance. Indeed, for an outcome such as “mortality amenable to health care, there are states within the U.S. (e.g., Minnesota) whose outcomes are as good as, if not better than, the best of the OECD countries.”5 And it is well known that one can receive excellent care at a variety of U.S. health care institutions. It is important to keep in mind that no single country or health care delivery system excels in every aspect of health care, health system performance , and health outcome. Ultimately, the objective is for the United States as a whole (and for other countries) to achieve increasingly better results and obtain greater value for its health care expenditures. To do so, it is important to examine best practices, wherever they occur. In every country, multiple factors contribute to health outcomes, including (1) the prevalence and severity of illnesses in the population (particularly chronic conditions); (2) access to care and services when needed, including 76 88 89 81 88 99 97 109 116 106 97 134 115 113 127 120 55 57 60 61 61 64 66 67 74 76 77 78 79 80 83 96 0 20 40 60 80 100 120 140 1997 – 1998 2006 – 2007 Figure 11.1. United States lags other countries in mortality amenable to health care. Source: Adapted from Nolte E, McKee M. Variations in amenable mortality—trends in 16 high-income nations. Health Policy. 2011;103(1):47–52. International Lessons for the United States   229 preventive care, acute and transitional care, and chronic care; and (3) the effectiveness , safety, and efficiency of services when they are provided. The prevalence and severity of chronic conditions are increasing in developed countries around the world, and the U.S. rates of chronic conditions and multiple chronic conditions are very high. In the 2005 Medical Expenditure Panel Survey, 55 percent of Americans aged 20 to 64 reported having no chronic conditions. In contrast, only one in eight Americans aged 65 and older (12.5 percent) reported having no chronic conditions, and disturbingly , almost half reported having three or more chronic conditions. In a similar survey, the percentage of Australians aged 65 and older who reported having no chronic conditions was also relatively low (18.4 percent), but the percentage of older Australians who reported having three or more chronic conditions was less than half the U.S. percentage (22.9 versus 47.6 percent).6 Such results have significant implications not only for population outcomes but also for overall health care costs, public health programs, and health care delivery systems. Among developed countries, the issue of large numbers of uninsured and underinsured has been unique to the United States. But with the advent of health care reform, the United States is on the threshold of implementing changes that will significantly reduce these numbers, which should have significant implications for health system performance.7 For example, in 2005 about half the general population of adults in the United States reported receiving all recommended screening and preventive care for their age group, compared with only one-third of uninsured adults.8 Among sick adults, one in two reported forgoing needed medical care because of the cost; that is, they did not see a doctor, did not fill a prescription, or failed to get recommended tests or follow-up care.9 These gaps should be reduced by covering the uninsured and improving coverage for the underinsured. Indeed, there is direct evidence from the Oregon Health Insurance Experiment (a randomized study) that previously uninsured persons who gained coverage obtained...