Guest column: The other side of the Affordable Care Act

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By Alan Keller, Ph.D.


Guest commentator Lynn Wilson analyzed the U.S. healthcare system and prescribed remedies. In full recognition that at their best U.S. health services are high-quality models for the rest of the world, I would nevertheless argue that Wilson presented a partial, sometimes misleading portrayal of the challenges we face in meeting America’s health needs.

He began by “exposing” three of what he believes are “myths” — the first being that U.S. healthcare is the most expensive in the world. He reasoned that if Americans get the healthcare they want when they want it, then it is not expensive. However the unpleasant facts are that U.S. per capita healthcare costs (the total of public and private care) are as much as twice those in western Europe (with the exception of Switzerland), Canada, and Japan and consume 18 percent (and increasing) of U.S. gross domestic product (GDP).

Wilson’s second “myth” is that other countries obtain better outcomes with lower expenditures. He argued that other countries are only able to achieve lower costs by providing inferior and limited services and/or by paying low wages. However, numerous studies demonstrate that response to urgent medical emergencies is just as fast in those other countries as in the U.S.

Waiting times for optional tests/procedures (such as some orthopedic interventions) are longer in some countries than in the U.S., in part because some have fewer sophisticated diagnostic instruments available. Yet it is precisely an over abundance of such tools that unnecessarily drives costs in the U.S. (too many providers in some localities trying to pay off too many machines sometimes translates into over prescription of tests).

In any case, the gold standard of good outcomes is life expectancy, and the uncomfortable fact remains that the U.S. has lower life expectancy than between 33 and 51 countries depending on the year and scoring system. Wilson argues that this unfavorable outcome is only because the U.S. population includes groups with poor health habits. However, that explanation fails since several of the countries with higher life expectancies are also quite diverse.

More importantly the longest-living group in the U.S. white women lead shorter lives than the entire populations of several of the other countries cited.

So are Americans really happy paying pay twice as much for middling results? Are we happier with our system than citizens of other countries? Survey after survey in most of the countries with lower costs show that residents, although not entirely happy with their insurance/care systems, do not want major changes and feel that overall they get the care they want -- at half the cost we pay.

Wilson’s third “myth” is that millions of people without health insurance can not access the care they need and/or have to declare bankruptcy to get it. His reasoning is that he personally knows of no such bankruptcies and that since there is considerable charity care available, people do not go without. However, it is difficult to find any studies which do not report what professionals working in institutions catering to the uninsured immediately confirm, namely that inadequate insurance too often keeps clients from seeking attention until medical problems become unbearable. In fact, the tendency to delay medical consultations until problems become unnecessarily costly is an important driver of U.S. medical costs. As for bankruptcies, studies consistently implicate medical costs as a major factor in knocking lower and middle class families into severe economic difficulties including bankruptcy.

Several other aspects of Wilson’s analysis, such as presenting certain costs already covered by insurers and taxpayers as “new costs” under the Affordable Care Act, merit detailed consideration impossible here because of word limitations.

Sufficient to say the Affordable Care Act will continue to encounter rough seas and require changes. However, Wilson’s suggested alternatives would certainly fall far short of fixing the system. Health savings plans are unrealistic alternatives for a significant segment of the population earning too little to purchase them. Many well designed studies conclude that lack of tort reform, although justifiable on its own merits, contributes no more than 1-3 percent of health care costs, and it should be noted that states with advanced tort reform, such as Texas, continue to experience rapid increases in health costs. Wilson’s desire to encourage more living wills to reduce extraordinary expenditures in the final months of life would be a good first step but would have to be reinforced by reducing insurance coverage of late life treatments offering very low probabilities of improving or extending life.

Efforts to rationalize U.S. healthcare delivery to improve outcomes while managing costs so that they will not overwhelm us will require more changes than either Wilson or the Affordable Care Act offer.

© 2014 All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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