Why you can’t buy your way to better health

Despite all of the faults of our health care system, we assume that the status quo is working for some people. Sure, nearly 30 million people don’t have health insurance and we have the highest burden of chronic disease across developed countries. But the most privileged Americans must be getting the best care in the world, right?

As it turns out, even the 1% in America don’t have excellent outcomes in our health care system, a new study shows. In JAMA Internal Medicine, health policy professor at the University of Pennsylvania Ezekiel Emanuel and colleagues compared health outcomes for white Americans living in the highest-earning counties with outcomes for average citizens in other developed countries.

While the highest-income groups had better health outcomes than average Americans, on most outcomes measured, privileged white Americans had comparable or worse health outcomes compared to average citizens in other countries. The takeaway? “Even if everyone achieved the health outcomes of White US citizens living in the 1% and 5% richest counties, health indicators would still lag behind those in many other countries,” the authors wrote.

Health outcomes for the 1%

The authors measured the following health outcomes associated with access to care or quality of care: infant mortality; maternal mortality; 5-year survival of patients with colon cancer, breast cancer, and childhood acute lymphocytic leukemia; and 30-day case-fatality rates after a heart attack.

White Americans living in the highest-income counties had comparable or worse results for five of these outcomes compared to other developed countries. Here are a few key takeaways:

• Americans in the 1% highest-income counties had a maternal mortality rate of 10.05/100,000 births, much better than the US average of 26.4/100,000, but worse than the average rate for every other developed country.
• Infant mortality among those living in the top 5% of highest-income counties was 4.01/1000, higher than any of the other countries.
• The case fatality rate for heart attacks after 30 days for those in the 5% highest-income counties was worse than the median rate in all but two other countries. For those in the 1% highest-income counties, the rate was worse than all but three other countries.
• For those in the 5% highest-income counties, the 5-year survival rate for colon cancer was better than the rate for average citizens in 6 countries, comparable with that of average citizens in 4 countries, and lower than that of average citizens for 2 countries.
• For those in the 5% highest-income counties, the 5-year survival rate for childhood lymphocytic leukemia was about the same as the mean survival rate in 11 countries, and better than one country (Norway).

The one exception to the rule was 5-year survival for breast cancer, in which the outcomes for privileged Americans (and, in fact, average Americans) were better than all of the comparator countries. However, this pattern may not be because the US offers better cancer care, but because we screen many more women for breast cancer than other countries. Increased screening means that we find more small cancers that would not necessarily have led to harm, leading to a higher 5-year survival rate but not a lower overall breast cancer mortality rate.

What’s behind this pattern?

How could it be that even the most privileged Americans don’t see a greater benefit in their health outcomes? Emanuel at al. point out a few possibilities. High-income Americans can afford to see more doctors and go to hospitals with better reputations, but there are many stages at which care is provided, and the same level of quality cannot be ensured at all of them. Similarly, avoiding adverse events and malpractice is not usually about whether the individual doctor is skilled enough, but about the standard of processes and organization within a health system.

“Good care is less likely to be a matter of any one outstanding physician, and more the result of excellent systems of care.”

Ezekiel Emanuel et al.

There is also a real risk that high-income Americans may be subject to overuse, because we assume that more care means better outcomes. A good example of this is the prevalence of “executive screening programs” at top hospitals, which often offer cardiovascular tests not recommended for people without symptoms. These unnecessary screenings can lead to harmful cascade events.

This results of this research shows us that the health of our country depends not on expanding choice for the few, but access and quality for all. “A well-off US citizen cannot ‘buy out’ of the uneven quality of care provided by the US health care system,” the authors write. “To ensure the world’s best health outcomes requires improving care systematically, for all people at all facilities.”