Glaring Problems in Our Health Care System

The number of COVID deaths in the United States dwarfs that of any other country. According to Statista.com, as of April 11, well over 1 million Americans have died. The United States is a large country, so a high number of deaths might be expected.

But the U.S. also ignominiously ranks in the top 10 in the number of deaths per capita, along with much poorer countries such as Chile and the Philippines, according to Johns Hopkins’s Coronavirus Resource Center.

There are many reasons for America’s failure to help its citizens enjoy good health and avoid succumbing to COVID, but one thing is clear: Glaring systemic problems in the way we deliver health care in the United States are a big part of the problem.

America spends an enormous amount of money on health care. According to the Commonwealth Fund, health care in the United States is more expensive than anywhere else in the world, by a lot, with nearly 17 percent of the GDP spent on it. And that spending includes a huge amount of government funding, with the third-highest per-capita public health care expenditures in the world. That means that per person, the U.S. government spends more on health care than every country in the world except Germany and Norway.

And yet, despite that huge public investment, and then a significant private investment from employers and households, the United States has abysmal health statistics. A lack of health insurance, problems accessing care even when you do have insurance, and overtreatment plague our system.

Lack of Insurance Leads to Unnecessary Deaths

In 2002, the Institute of Medicine found that an average of 18,314 people between the ages of 25 and 64 die every year because they didn’t have health insurance.

In 2008, researchers from the Urban Institute used the same method that the IOM had used and found that the number has risen to 22,000. Using another method these researchers thought was more accurate, they uncovered that the number of adults in America who died unnecessarily was closer to 27,000.

A 2009 study from Harvard Medical School, which analyzed data from Centers for Disease Control and Prevention surveys, put the number closer to 45,000 annual deaths, with the uninsured being 40 percent more likely to die than those who were privately insured.

So how is it that while the United States is putting more tax dollars toward health care per-capita than Canada, Finland, or Sweden, it has thousands of deaths each year due to people being unable to afford health care? And that happens despite employers and individuals also paying huge sums on health care.

No Insurance, and a System Even Insured Can’t Afford

At least 31 million people still don’t have insurance. That’s partly because of the families that fall through the cracks, households that don’t make enough money to pay out of pocket for health insurance but make too much money to qualify for state-funded care.

The median income for a family of four in 2008 was $67,019, according to the U.S. Census Bureau. Wages since then have only risen about 26 percent (to $84,443). Between monthly premiums of about $1,403 and deductibles of about $8,000 annually, the average family of four could expect to pay about $17,000 in 2019 for unsubsidized health insurance coverage, and up to $25,000 before they saw any real benefit from it. That’s hard enough for a median family to pay for. For the 50 percent of families that fall below the median, it’s all but impossible.

High health care costs are also frequently cited as the most common reason for personal bankruptcy filings. It’s hard to get accurate data on that because people are not required to list a reason when they file for bankruptcy, but a 2015 study from the Kaiser Family Foundation found that about one-fifth of people with medical bill problems (about one-quarter of Americans aged 18–64) declared bankruptcy at some point. According to a 2011 estimate from Debt.org, the average 65-year-old couple faces $275,000 in medical bills throughout retirement, despite Medicare coverage.

Aiden Ekanayake’s family has health insurance. But after the 14-year-old received the second dose of the Pfizer COVID vaccine, he began having chest pains. He was hospitalized with myocarditis (swelling of the heart muscle).

Since Aiden was discharged from the hospital, his mom has had to take him to endless rounds of doctor visits. Now, his family is facing thousands of dollars in hospital and doctor bills, despite having insurance, as reported by National Geographic.

Insured But Denied Coverage Anyway

Even if everyone were adequately insured, it wouldn’t solve many of the problems inherent in the American medical system. Even when Americans have insurance, we face barriers to accessing care, several recent studies have found.

Insurance plans vary widely and generally contain lots of clauses, exceptions, and confusing language regarding procedures, medications, doctors, and hospitals that the plans will cover.

Many insurers make it a point to avoid paying claims as often as they can. This has been shown to be the case even with state-funded insurers that are purportedly not driven by profits, as a 2016 investigation I did for Jefferson Public Radio revealed about low-income pregnant women in Oregon being denied health care.

Doubtless, you’ve also experienced having your valid insurance claim unethically denied firsthand. I know I have.

After my mother had a stroke, we brought her back from the hospital in an ambulance to fulfill her explicit wish to die at home in Amherst, Massachusetts. But her insurance company refused to pay for the ambulance ride.

I had not only cleared it with her insurance beforehand by telephone, but I knew the exact page number in the written policy manual that indicated that the ambulance would be covered.

I fought the denial and won. But doing so caused a huge amount of stress during an already incredibly difficult time. And many people, especially those who are not health literate, don’t know how to advocate for themselves or their loved ones in this way.

Insurance companies are also notorious for denying any treatment they can claim is “experimental,” even if the doctors recommending it consider it the standard of care. They will also often deny certain procedures outright with the justification that the procedure is “elective,” even when the procedure is medically indicated or even life-saving.

That’s what happened to Erika Giduturi. She was diagnosed with a rare cancer that affects the duct between the liver and small intestine. While the hospital cleared her for a life-saving liver transplant, her insurance provider refused to cover the operation, citing a bureaucratic technicality, Inside Edition reported in January.

The U.S. Department of Labor estimates that one in every seven insurance claims made under employer insurance plans is initially denied.

Insurance companies count on people either not knowing how to appeal these denials or not bothering to do the paperwork necessary to do so. The more hurdles placed in front of the claimants, the fewer who will try to clear them.

At the same time, a study from the Government Accountability Office found that when the denials are challenged, almost 50 percent are reversed.

Even when claimants are careful to choose a covered hospital and get pre-approval for a procedure, the doctor who performs the procedure may not be covered. A 2016 study in the New England Journal of Medicine found that 22 percent of patients who went to hospitals covered by their insurance company received bills from doctors who weren’t in their network.

The highest bill in the study was more than $19,000, but Michael Trost of Dingman’s Ferry, Pennsylvania, received a surprise bill for $32,325 from the cardiologist who had repaired his mitral valve.

Unnecessary Interventions

Just as troubling as necessary surgical and other procedures being unfairly denied, people with private insurance are often subjected to unnecessary surgery and other unneeded overly aggressive treatments.

That may be in part due to the culture in any given hospital, as well as the long lag time between new information and clinical changes (on average it takes 17 years for doctors to integrate research into a better standard of care). But it’s also true that the more surgeries are performed, the greater the income for a particular doctor, the doctor’s practice, and the hospital where the surgery is performed.

In his 2019 book, “The Price We Pay: What Broke American Health Care and How to Fix It,” Marty Makary explores how this provides a powerful incentive to perform surgery even when it isn’t necessary or there are good, less invasive, alternatives.

Importantly, Makary doesn’t think more public health care dollars will fix the problem. The real solution is transparency. Even after President Donald Trump’s regulatory changes to ensure health care providers and insurers tell patients how much a service will cost before they get it, many patients still find it all but impossible to know beforehand what a procedure will cost. That makes it impossible to shop around and put the free market to use.

The result is that the United States, despite being a leader in medical advances and medical education in many health fields, is often providing taxpayers with the worst possible combination of a free market and government-funded health care plan.

That can lead to some disturbing phenomena in the delivery of medical care, including overtreatment.

Many surgeries popular with doctors and hospitals are for issues that can be often easily treated less invasively. Maybe you’ve even had one. These include:

• Abdominal surgery for childbirth: at least 600,000 unnecessary C-sections are performed every year
• Arthroscopic surgery for knee pain: According to a 2020 article by Harvard University’s Robert H. Shmerling, 750,000 knee operations are done each year “at a cost of $4 billion” but this surgery doesn’t help most people who undergo it, and involves many risks
• Gall bladder surgery: a 2017 study published in the American Journal of Gastroenterology found that 70 percent of people who keep their gall bladders despite having acute pancreatitis had no future problems

How to Get Better Care

While individual consumers can’t fix the broken system, there are things you can do to advocate for yourself and your loved ones to insure you get better, safer, and more necessary health care when you need it.

1. Interview Prospective Docs

When you’re looking for a new doctor, don’t just make an appointment for care. Most doctors offer free initial visits to prospective patients. This face-to-face meet-and-greet is your chance to interview your potential care provider and get a sense of whether your values are in alignment. Ideally, you will be able to find a doctor in your network who is on Team Health, not Team Money.

2. Always Get a 2nd Opinion

You’re in pain and you want to solve the problem quickly. But there may be better, safer, and less invasive options than what your doctor recommends and what your insurance is willing to cover. A 1982 study published in the journal Medical Care found that mandatory second opinions led to a 20 percent drop in the surgeries that are most likely to be performed unnecessarily, such as hysterectomies.

3. Arm Yourself With Information

Even if you’ve never picked up a book in your life, a health crisis is the perfect time to start reading and educating yourself. Books, especially those written by integrative medical doctors who combine the best of western medicine with insights from other modalities, can help you learn about your specific condition and how to treat it.

So, for example, if you’re suffering from an autoimmune condition, get a copy of Amy Myers’s 2015 “The Autoimmune Solution” out of the library. The late Robert Mendelsohn’s “How to Raise a Healthy Child in Spite of Your Doctor” is as relevant today as when it was first published in 1984 and will help you keep your children healthy without going to the doctor. And Jerome Groopman’s 2007 “How Doctors Think” will provide you with invaluable insight into what’s going through your doctor’s head and how best to talk about your health conditions with clinicians.