As I write this, my husband and I are returning from a bike and barge tour in the Netherlands. It was an eyeopening trip. We were expecting to be the oldest bikers on our tour and in the Netherlands. Much to our surprise, there were several couples on the tour who were in their late 70s, and even more surprising were the numbers of older residents of the Netherlands who used bikes as a primary means of transportation. Bikes are everywhere: moms cycle with their children on the bike or peddling alongside; all cyclists have panniers; they are used for marketing, going to and from workplaces, and hauling everything imaginable. This was true in the cities as well as the countryside. Using bikes as an alternative means of transport contributed to less air pollution and noise as well as an apparently healthy population.
More startling in the Netherlands was the visible absence of obesity in residents young and old. There were three obvious reasons: 1) exercise (walking, biking, stair climbing), 2) diets with abundant fresh fruits and veggies and fewer fast food and processed food options, and 3) a general focus on health. Another observation was the absence of homeless, destitute, and impoverished persons and areas even in cities. There were no food deserts (areas where healthy food markets are rare) nor were there large supermarkets. In the city as well as the villages, street markets and small stores offering fresh produce, dairy products, meats, and staples were readily available. Bakeries offering whole grain breads and cereals were common.
These observations led us to talk with residents and international visitors on our tour as well as hosts in our bed and breakfast accommodations. We found those who live in countries with some form of universal health care were more than satisfied with care access, quality, and cost. They were also well aware of the current health care reform controversy in the United States. They were genuinely perplexed by U.S. sound bites and stories about the dangers of “big government” controlling health care and had questions such as, “How can you let insurance companies control health care without regulation?” They had a depth of understanding of our health care challenges that many in the U.S. do not have. Given the fact that many survive on a diet of sound bites, it is a challenge in the U.S. to find indepth analysis of issues that do not include bias that is often not clearly acknowledged. Our European acquaintances offered examples of excellent holistic care when surgery was needed. Such care included follow-up home visits by professionals. They also talked about care for senior citizens where every effort is made to allow them to stay in their homes versus moving to nursing homes or assisted living. Universal health care offers the option of home health care aids three times per week. This certainly seems to be a high-quality option as well as a cost-effective one. As we cycled through the countryside and cities, we did not see nursing homes or assisted living organizations. We also talked with someone who had lived in the U.S. for many years and paid three times as much for health insurance with less care provided than is now available under universal health care in the Netherlands.
The Europeans we spoke with were quite aware of the political forces in the U.S. that are fostering the controversy over our incremental approach to health care reform in the Patient Protection and Affordable Care Act (PPACA). In industrialized Europe, fee-for-service methodology is not used; there is less of a legalistic overlay and health care is a right, not a privilege. So every citizen has the same health care benefits. In the U.S., health care is seen as a commodity available to those who can pay for it, usually through employer plans or for those who are impoverished, a veteran, or elderly. Fee-for-service is a driver for increased visits and tests as well as cost, plus it promotes less focus on quality. First and foremost in the U.S., opposition to universal health care comes from health insurance companies with lobbyists. In Europe, where the Bismarck model provides the framework for health insurance support for universal health care in countries such as Germany and Switzerland, overhead and profit by insurance companies is capped (Frontline, 2008). Currently in the U.S., health care insurance companies can take as much as 20% (or 20 cents) or more out of every health insurance dollar for overhead and profit, while Medicare overhead (and no profit) is closer to 3% (Cohen, 2009). PPACA will cap this at 15% in large group markets (Davis et al., 2010). Is it any surprise that health care in the U.S. consumes 17.4% of our gross domestic product (GDP) given just insurance overhead and profit? In industrialized Europe, health care costs range from 8.5% to 12% of GDP (Squires, 2012). Not only is this costly for us as citizens, but it also makes the price of our products less competitive on the world market.
While the U.S. has the most expensive health care, it is also very ineffective and Americans have limited access to care. The World Health Organization (WHO) ranks the U.S. as #37 in the world in health care (Murray & Frenk, 2010). Much of this ranking is based on poor access to care in the U.S. Outcomes of care in the U.S. are not nearly as good as those in other industrialized countries (Shea, Holmgren, Osborn, & Schoen, 2007), where they have been using research evidence to standardize care. In the U.S., it takes an average of 17 years to put evidence into practice and we have a high incidence of errors (Institute of Medicine, 2000). In addition, in the U.S., care is most often provided for acute illnesses because we have insurance systems that are focused on sick or acute care versus preventative care. Again, the PPACA has many provisions for health promotion, wellness, and prevention. Many of these provisions were modeled on those in place in industrialized Europe. In past columns, we discussed the wellness plan available to all Medicare patients under the PPACA, also the screenings for early detection of disease in children, women, and men that are free. Also, included in PPACA provisions are initiatives for early detection and intervention for chronic diseases such as diabetes, heart disease, and hypertension.
There are other powerful stakeholders who stand to lose or need to change practice with implementation of PPACA provisions and thus are not supporters; pharmaceutical companies are an example. Today, such companies do direct marketing to consumers to create demand for drugs that may or may not be most effective for acute or chronic conditions and may also have very severe side effects. The cost of such drugs also drives up the cost of care if physicians succumb to patient pressure to prescribe. The PPACA has provisions that demand comparative effectiveness analysis for drugs and treatments, so only the most effective are those that are prescribed (Zycher, 2011).
The PPACA Insurance Mandate discussed in the May/June ViewPoint “Health Care Reform” column (Haas, 2012) is a good example of the use of sound bites to sway public opinion on the value of the PPACA. The Insurance Mandate would financially affect only 3% of U.S. citizens, but offers potential for universal coverage for all. Opposition to the Mandate has been brought to the U.S. Supreme Court, largely as a means of maintaining the status quo or business as usual. Will “overturn” of the Mandate or the entire PPACA and health care reform in the U.S. come about as a result of sound bites? In the next column, we will discuss the Supreme Court’s decision that was made in June.
Cohen, D. (2009, March 29). Why are health insurance companies afraid of competition? Retrieved from http://www.huffingtonpost.com/donald-cohen/why-are-health-insurance_b_17...
Davis, K., Guterman, S., Collins, S.R., Stremikis, K., Rustgi, S., & Nuzum, R. (2010). Starting on the path to a high performance health system: Analysis of the payment and system reform provisions in the Patient Protection and Affordable Care Act of 2010. Retrieved from http://www.commonwealthfund.org/ Publications/Fund-Reports/2010/Sep/Analysis-of-the-Paymentand- System-Reform-Provisions.aspx
Frontline. (2008). Sick around the world: Can the U.S. learn anything from the rest of the world about how to run a health care system? Retrieved from http://www.pbs.org/wgbh/pages/frontline/ sickaroundtheworld
Institute of Medicine. (2000). To err is human: Building a safer health system. Washington, DC: National Academies Press.
Murray, C., & Frenk, J. (2010). Ranking 37th – Measuring the performance of the U.S. health care system [Electronic version]. The New England Journal of Medicine, 362, 98-99. Retrieved from http://www.nejm.org/doi/full/10.1056/NEJMp0910064
Shea, K.K., Holmgren, A.L., Osborn, R., & Schoen, C. (2007). Health system performance in selected nations: A chartpack. Retrieved from http://www.commonwealthfund.org/usr_doc/Shea_hltsys performanceselectednations_chartpack.pdf
Squires, D. (2012). Explaining high health care spending in the United States: An international comparison of supply, utilization, prices, and quality. Retrieved from http://www.commonwealth fund.org/Publications/Issue-Briefs/2012/May/High-Health- Care-Spending.aspx
Zycher, B. (2011). Comparative effectiveness reviews: Quantitative analysis of research and development investment effects. Retrieved from http:// www.pacificresearch.org/docLib/20110715_ Zycher_CER_F.pdf
Sheila A. Haas, PhD, RN, FAAN, is a Professor, Niehoff School of Nursing, Loyola University of Chicago, Chicago, IL. She can be reached at firstname.lastname@example.org