3) HEALTH AND WELL-BEING: There are many different indicators of the overall health status and well-being of a country's population, but among the most commonly used measures are infant mortality rates, and life expectancy, particularly disability-adjusted life expectancy ("the number of healthy years that can be expected on average in a given population").¹⁵ As of 1998, the infant mortality rate in the United States was 7.2 infant deaths per 1,000 live births (identical to the rates for 1996 and 1997).^l6 Although this number is a historic low for the U.S., our infant mortality rate is nonetheless the highest among the OECD countries in Table One and Figure Two. In 1996, the U.S. ranked 26* among industrialized countries for infant mortality rates. ¹⁷

These infant mortality figures for the U.S. are somewhat misleading, however, since they obscure the persisting wide disparities among racial groups, based in large part on economic differences. As the U.S. Department of Health and Human Services indicates, the infant mortality rate for black children (14.3 in 1998) is more than twice that of white children (6.0 deaths per 1,000 live births), and it is higher still in some areas of the country.¹⁸ For example, the 1999 infant mortality rate for black children in Alabama was 16.0 infant deaths before age one, among 1,000 live births.¹⁹ Many health policy analysts consider such figures a shocking indictment of living conditions for segments of the population in the richest country on earth.

The WHO figures also show that the U.S. ranks very low (24*) on disability-adjusted life expectancy (DALE) among high-income OECD countries (see Table One); only Denmark ranked lower (28^th). The U.S. also has a very unequal distribution of disability-adjusted life expectancy; particularly among males (in which some segments have a much longer disability-free life expectancy than others)²⁰. This should not come as a surprise, however. When a sizable portion of the population lacks access to health care, particularly preventive care, one should expect that they would also be likely to experience more years of disability.²¹

FIGURE TWO:

Infant Mortality Rates in Selected High –income OECD Countries 1998

{Two small to paste here}

The U.S. has the highest rate for high-income people of 7.2.  Sweden has the lowest rate at 3.5, and Italy the second highest at 6.1.

4) RESPONSIVENESS: Based on WHO's international comparisons, the U.S. was first among the 191 member countries in the category of responsiveness, the extent to which caregivers are responsive to client/patient expectations with regard to non-health areas such as being treated with dignity and respect, etc. However, this figure almost certainly covers over the existence of extreme disparities in responsiveness among different populations. In particular, it is obvious that the millions of people with either no insurance or else very limited access to health care via Medicaid, etc., have far greater problems finding responsive caregivers than those with an adequate degree of private health insurance coverage.

5)  FAIRNESS IN FINANCING: This measures the degree to which financial contributions to health systems are distributed fairly across the population. Table One shows that while OECD counties such as Luxembourg, Denmark and Germany have health systems which are very fair in financial contributions to the system, other countries such as the U.S. and Italy have very unfair systems of health financing. The U.S was the lowest (least fair) of all the OECD countries in Table One; tied for 54^th and 55* place.

An unfair system of financing has consequences for much of the population, but especially for those who are uninsured or underinsured, and for the poor. As the WHO report states, "the impact of failures in health systems is most severe on the poor everywhere, who are driven deeper into poverty by lack of financial protection against ill-health."²²

6) ATTAINMENT AND PERFORMANCE: In addition to evaluating the world's various health care systems using these criteria and providing other relevant health-related information, the WHO also ranked the world's countries in terms of the overall attainment of their health systems (based on all five of the criteria, above), and the performance of their health systems - that is, how well a country's health system is performing, compared to how well it could perform given its levels of resources.  The results for overall attainment and performance were quite revealing: among the 191 countries listed, the U.S. health care system ranked 15th in the world for overall attainment (data not included in Table One), and 37* in the world for performance (see Table One).

7) SATISFACTION WITH HEALTH CARE SYSTEM: One more interesting question is the extent to which ordinary people are satisfied with their country's health care system. As shown in Table One, the two countries with the highest percentage of people who were either very satisfied or fairly satisfied with their country's health care system overall were Denmark (91 percent!) and Finland (81 percent). Italy was the lowest among the European Union countries surveyed in the "Eurobarometer" study, at 20 percent. The U.S. was comparatively low also, with only 40 percent of people who were satisfied with their health care system. Even the United Kingdom, which has had persisting problems with its national health service in recent years,²³ had almost 60 percent of its people saying they were either very satisfied or fairly satisfied.

Implications and Discussion

This paper has briefly described some of the most critical problems affecting the health care system in the U.S., such as access to health care, high costs, fairness, and effectiveness in bringing about good health in its population. There are many other major issues which also contribute to our mounting health care crisis, such as declining patient choices, the increased control in health care decisions by managed care companies as they seek to further limit access to care, the crisis in the nursing profession as nurses desert the profession in droves, and quality of care issues. It is becoming increasingly clear that these continuing dilemmas are unlikely to be solved without a thorough and creative overhaul of our present system.

Despite the efforts of insurance companies and managed care companies to limit the range of political choices in health care reforms, there appears to be growing broad-based support in the U.S. for a single payer system which would greatly resolve some of the most serious problems of cost, access and fairness. Furthermore, recent studies have shown that a single payer plan would not only be economically feasible, but would be an enormous improvement over what we have. In 1991, for example, both the U.S. General Accounting Office (GAO) and the Congressional Budgeting Office (CBO) issued reports stating that a single payer system similar to that of Canada's would more than pay for itself, due to reduced administrative costs, as well as having universal access to health care, especially preventive care.²⁴ A single payer health insurance plan would not rule out a continuing role for private insurers, since it would probably provide only a basic level of coverage.²⁵ In addition, recent surveys in the U.S. have documented the growing frustration with our health care system, and an interest in exploring a single payer plan for health insurance with universal coverage.²⁶ Finally, recent efforts by Massachusetts health care policy analysts have shown that a single payer health care plan in Massachusetts would also be economically feasible²⁷.

One possible approach that has been advocated by some health care experts, for example, is to simply expand Medicare, an existing and highly successful public program which could be extended beyond the elderly to the entire population. Interestingly, Medicare costs for administration are currently less than two percent.²⁸ This and other alternative models need to be explored and discussed, with the help of current and unbiased information. It is clearly imperative, therefore, that policymakers and lay people alike educate ourselves on the issues, and to exercise our collective imagination and creativity in meeting these challenges.

We wish to acknowledge the helpful assistance of Ida Hollander, Physicans for a National Health Plan, and JoAnne Bailey, U.S. General Accounting Office.

THE UNIVERSITY OF

MAINE

A Member of the University of Maine System

Prepared as a public service by the

Bureau of Labor Education

University of Maine

Orono, Maine

Summer, 2001

' World Health Organization, The World Health Report 2000 - Health Systems: Improving Performance (Geneva: WHO, 2000).

² Ibid., p. 27-35. Data from this study are also analyzed in Gerard Anderson and Peter Sotir Hussey, "Comparing Health System Performance in OECD Countries". Health Affairs; Vol. 20: No. 3 (May/June 2001); pp. 219-232.

³  WHO (ibid), p. 35.

⁴ OECD, OECD Health Data 2000: A Comparative Analysis of Twenty-nine Countries (Paris: OECD, 2000).

⁵ These studies, including Eurobarometer 49 (1998) and the Harvard School of Public Health, are described in: Robert J. Blendon, Minah Kim, and John M. Benson; "The Public Versus The World Health Organization on Health System Performance"; Health Affairs; Vol. 20: No. 3; (May/June 2001); pp. 10-20.

⁶ The data in Figure One replicate OECD cost data in Table One (source: OECD; Anderson and Hussey, ibid.)

¹ Steffie Woolhandler, M.D., M.P.H. and David U. Himmelstein, M.D., "The Deteriorating Administrative Efficiency of the U.S. Health Care System"; New England Journal of Medicine 324:1253-1258 (May 2), 1991. In contrast, administrative costs in Canada are from 8.4 to 11.1 percent of health care spending. The high level of administrative costs in the U.S. are due in large part to the additional personnel needed for billing and processing of private insurance, as well as advertising, market analysis, and tracking patients. (David Hackney and Debra Rogan, "A Single Payer Health Care System for the United States", American Medical Student Association, July 1, 2001). (http://www.amsa.org/hp/sp.cfrn)

⁸ Steffie Woolhandler, M.D, M.P.H.. and David U. Himmelstein, M.D.; "Costs of Care and Administration at For-Profit and Other Hospitals in the United States"; New England Journal of Medicine 336:769-774 (March 13), 1997. In another stunning example demonstrating how for-profit health care contributes to high costs, Physicians for a National Health Plan reports: "When U.S. Healthcare merged with Aetna in 1996, the $967 million received by CEO Leonard Abramson could have provided health insurance to every uninsured child in the state of Massachusetts until they reached puberty." (Hackney and Rogan, ibid., citing Physicians for a National Health Plan, 1996).

⁹ "Health Insurance Coverage", Current Population Reports, U.S. Census Bureau, September 2000.

'⁰American College of Physicians-American Society of Internal Medicine (ACP-ASIM), "Statement for the Record of

the Ways and Means Health Subcommittee Hearing on the Nation's Uninsured", April 4,2001.

£http://www.acponline.org/hpp/ways_rneans.htm)

"Stephen M. Ayres, M.D.; Health Care in the United States: The Facts and the Choices. Chicago and London:

American Library Association: 1996, p. xii. South Africa, while providing universal coverage in principle, has not

extended universal access in practice to all of its townships. (Ida Hellander, personal communication, 6/25/01,

Physicians for a National Health Plan).

¹² Ibid., "Health Insurance Coverage", U.S. Census, Sept. 2000. During 1999, 15.5 percent of the U.S. population was without health insurance coverage during the entire year. The three states with the highest percentage of uninsured people were Texas, Arizona and New Mexico. Minnesota, Rhode Island and Hawaii had the lowest.

¹³ The ACP-ASIM statement to the Ways and Means Subcommittee Hearing on the Nation's Uninsured (ibid.) also points out that more than 80 percent of the uninsured are in working families.

¹⁴A recent study by the Commonwealth Fund also found "sharp disparities in access to health care" among income groups in the U.S. In this survey, almost half (48 percent) of people with below-average incomes in the U.S. reported that it was "extremely, very, or somewhat difficult" to get medical care when they needed it; far higher than in the other four countries surveyed. (Cathy Schoen, Karen Davis, Catherine DesRoches, Karen Donelan, Robert Blendon, and Erin Stumpf; "Equity in Health Care Across Five Nations: Summary Findings from An International Health Policy Survey", May 2000. (http://www.cmwf.org/programs/international/schoen 5natib_388.asp).

¹⁵  WHO; (http://w3.whosea.org/healthreport/pdi7dale.pdf). Disability Adjusted Life Expectancy (DALE) "summarizes the expected number of years to be lived in what might be termed the equivalent of 'full health'." (http://www-nt.who.int/whosis/statistics/dale/dale.cfin?path=statistics,dale&language=english)

¹⁶ U.S. Health and Human Services, "Preventing Infant Mortality", 2001 and 1997.

¹⁷ The most recent complete comparative data analysis for infant mortality rates are from 1996, according to both the National Center for Health Statistics and the U.S. Department for Health and Human Services ("Preventing Infant Mortality", HHS Fact Sheet, U.S. Department of Health and Human Services, April 18, 2001.) The HHS fact sheet also points out that gains in medical research, public health and social services have produced a sharp decline in infant mortality rates in the U.S. since 1960. Figure Two replicates data in Table One (source: U.S. Census Bureau, ibid.)

¹⁹ News Release, Alabama Department of Public Health, "Alabama's infant mortality rate improves in 1999;" (http://www.alapubhealth.org/press/pr081600.htm).

²⁰  Ibid., WHO; World Health Report 2000, ibid., p. 31.

²¹  In addition, the U.S. has fairly high rates of H.I.V. infection, violence, coronary heart disease, and tobacco-related illnesses, compared to most industrialized countries. (WHO Press Release, "WHO Issues New Healthy Life Expectancy Rankings: Japan Number One in New 'Healthy Life' System"; June 4, 2000.) (http://www.who.int/inf-pr-2000/en/pr2000-life.html)

²² World Health Organization Press Release, "World Health Report 2000: World Health Organization Assesses the World's Health Systems", June 21, 2000. The report adds, "The poor are treated with less respect, given less choice of service providers and offered lower-quality amenities. In trying to buy health from their own pockets, they pay and become poorer." (p. 2). (http://www.who.int/whr/2000/en/press_release.htm).

²³  In 2000, the U.K. government unveiled "The NHS Plan", a new plan for reforming its National Health Service, in part to repair the damage from years of underfunding by previous governments. The British Council, "Health Insight August 2000". (http://www.Wtishcouncil.org/health/themes/insight/augOO/aug.htm)

²⁴ Physicians for a National Health Program, "How Much Does Single Payer National Health Care Cost?" PNHP Newsletter, October 1999. (http://www.thirdworldtraveler.com/Healtn/HowMuchSPCost.html)

²⁵  In Canada, most of the population carries additional health insurance through employers for services not covered by the provincially administered national insurance program. Karen S. Palmer, M.P.H., M.S.; "O Canada, Health Care Myths from the Great White North"; California Physicians Alliance, January 13, 1999. (http://www.thirdworldtraveler.com/Health/O_Canada_KP.html)

Palmer, ibid. For example, 79 percent of Americans in a 1999 survey said that health care should be a right.

²⁷ Massachusetts Medical Society House of Delegates Report 207, A-99 (B), cited in Physicians for a National Health

Program, ibid., "How Much Does Single Payer National Health Care Cost?"

²*A Profile of Medicare: Chartbook 1998, U.S. Health Care Financing Administration; May 1998, p. 27.