Even Rich Americans Don't Get World-Class Health Care: Study

THURSDAY, Dec. 31, 2020 -- Even the most privileged people in the United States with the best access to health care are sicker and more likely to die than average folks in other developed nations, a new study finds.

People living in the highest-income counties in the United States are, on average, more likely to die from a heart attack or cancer, during childbirth, or to lose an infant than people in 12 other industrialized countries, according to findings published online Dec. 28 in JAMA Internal Medicine.

"We're talking about whites, and we're talking about whites living in the richest parts of the country," said lead researcher Dr. Ezekiel Emanuel, chairman of medical ethics and health policy at the University of Pennsylvania Perelman School of Medicine, in Philadelphia. "We were looking at the best in the United States, and comparing to average in other places. We're not better than other countries."

These results show that "our health care system has a lot of room for improvement," said Laurie Martin, a senior health policy researcher at the RAND Corporation, a California-based global policy think tank.

"We already knew that, but this adds to that discussion in that it really is comparing those in the U.S. who theoretically have the most privilege, the most access, the most choice, to individuals in other countries," Martin said.

The new study compared the health outcomes of white U.S. citizens living in the nation's 1% and 5% richest counties with outcomes in Australia, Austria, Canada, Denmark, Finland, France, Germany, Japan, the Netherlands, Norway, Sweden and Switzerland.

"No one's going to disagree these are well-off countries," Emanuel said. "They're our peers."

The researchers found that white residents of the targeted U.S. counties -- where the average household income is about $84,000 a year -- had better health outcomes overall than average Americans.

But in comparison to average folks in other nations, where the average income is much lower:

• Nearly 13% of privileged Americans aged 65 or older die from a heart attack, while the rate across Norway is 10% and in Denmark nearly 11%.
• Infant mortality among wealthy white Americans is 3.5 to 4 deaths per 1,000 live births. That's higher than all 12 comparison countries.
• Maternal death during childbirth also is higher among privileged white Americans, with 26 women dying for every 100,000 live births in the United States.
• Survival rates for colon cancer and childhood cancers in the 5% highest-income U.S. counties lag behind most other developed nations.

"In only one area was America the best in the world. That was breast cancer treatment," Emanuel said, adding that regular mammograms and decades of breast cancer awareness campaigns have given the United States an edge.

Even the nation's most well-off suffer from poorer health outcomes than other developed nations because the U.S. health care system is incredibly fragmented, Emanuel said. Patients must deal with multiple layers of doctors, specialists, pharmacists and insurers to have their ailments treated.

"We don't have a primary care-focused health care system, where every patient has a quarterback," Emanuel said. "In the United States, if you're on Medicare and you have multiple chronic illnesses, you can have more than 10 doctors. Well, that isn't good. That actually creates more fragmentation and less coordination. Everyone thinks someone else is taking care of any given problem."

In other nations, health care is more streamlined and patient data is more easily shared between doctors. For example, specialists often are employed at hospitals and work alongside other doctors, while in the United States, they have separate offices outside the hospital, hampering coordination, Emanuel said.

"That may be one reason why we do better in some cancers, because in my experience once you have cancer, it's the oncologist who takes over and coordinates everything, because that's your most serious illness," Emanuel added. "Whereas if you have multiple other illnesses, you've got some arthritis or heart disease or lung disease, everyone is taking care of their little part but no one is looking after the whole."

Martin said that the fragmented nature of U.S. health care means that patients are forced to advocate for themselves, a task that even the most privileged find daunting.

"You have to be able to navigate insurance and referrals, and understand complex medication regimens and manage all aspects of care to ensure you're getting what you need in a timely manner," she said. "Those are complex tasks. That's challenging even on days when you're completely healthy and you're fine, but when you're now faced with the stress and worry of a major health scare for yourself or your loved one, this becomes even more difficult."

More information

The Commonwealth Fund has more about U.S. health care compared with other nations.

SOURCES: Ezekiel Emanuel, MD, PhD, chairman, medical ethics and health policy, University of Pennsylvania Perelman School of Medicine, Philadelphia; Laurie Martin, ScD, senior health policy researcher, RAND Corporation; JAMA Internal Medicine, Dec. 28, 2020, online