December 16th, 2013
04:43 PM ET

How to make U.S. health care more efficient

By Jody Heymann and Douglas Barthold, Special to CNN

Editor’s note: Dr. Jody Heymann is dean of the UCLA Fielding School of Public Health, an elected member of the Institute of Medicine, and Distinguished Professor of Epidemiology, Medicine and Public Policy at UCLA. Douglas Barthold is an economics doctoral candidate in economics, and a doctoral fellow at McGill University's Institute for Health and Social Policy. The views expressed are their own.

Worried about what your new mandated health insurance will cost next year? We should all be worried, but it has little to do with the Affordable Care Act. Over the past two decades, the United States has run near the top of the pack in a competition no country wants to win – spending the most while getting the least.

The American Journal of Public Health published the results of our study examining health systems of 27 high income countries over 17 years, and their efficiency at turning dollars into extended lives. The United States was near the bottom, ranking 22nd. Every hundred additional dollars spent in the United States was associated with a gain of less than half a month of life. In Germany, more than four months of increased life expectancy were associated with every additional hundred dollars spent.

Not everyone does equally poorly in the United States. Our new study has the U.S. ranking 18th when it comes to the efficiency of investments in reducing men’s deaths.  Worse yet, when it comes to reducing women’s deaths, the U.S. ranks 25th.

This is not an abstraction. In previous research, Ellen Nolte and Martin McKee found that in a mere five years, between the late 1990s and early 2000s, the U.S. dropped four positions in global death prevention rankings. How much does it matter? If preventable deaths in the U. S. looked like the average across France, Japan, and Australia, more than 100,000 fewer people under 75 would die each year.

How did we end up with one of the advanced economies’ most inefficient healthcare systems? How do we manage to have so many preventable deaths?

The short answer is that we are willing to spend almost anything as a country once you are dying – not to make you more comfortable or to ensure you have more meaningful time with your family, but rather in an effort to keep you alive a few extra days at a time when the dollars yield little advantage.

More from GPS: U.S. health care's dangerous profit fixation

The problem is that, as a nation, we have not been willing to spend anything on preventing people from getting sick. And what really contributes to whether you’re likely to die prematurely is whether you get sick in the first place.

The U.S. spends $2.65 trillion per year on health care. The Affordable Care Act had earmarked less than 1/10th of 1 percent of this for prevention. The only thing both parties seemed to agree on was to eliminate that small amount of prevention dollars. The Republicans labeled it a slush fund, and the Obama administration, in the absence of other dollars for implementing the ACA, was all too ready to raid it. So the actual dollars spent on prevention in the ACA last year were less than half of the miniscule amount first allocated.

The Congressional Budget Office typically assesses a cost to prevention programs in any new bill, but usually does not allow the bill to count the savings that occur – they are considered too far out into the future.  As a result, prevention is often left out by legislative staff, to improve the CBO score.

Yet there’s a great deal we know about what works. If in the workplace and at school you take a 10-minute recess every day to exercise, your body mass index will go down, as will your risk of diabetes and heart disease. It’s free. There’s no company or stakeholder that will make money off of it. But you’ll be healthier, there’ll be fewer premature deaths in the U.S., and our healthcare will cost less.

When healthy food and fitness options are available in our schools, the epidemic of childhood obesity and early onset diabetes can be reversed. In its absence, we will continue to see the tripling of diabetes costs we saw in a generation. Policies that kept smoking out of schools, workplaces, and public places saw a dramatic decline in smoking rates in the U.S., and in illness and deaths associated with smoking. When we set our mind to it as a nation, we know how to make prevention work.

So yes, we need a health insurance system that covers all Americans. And we should all worry whether it is affordable. But the only way to make it affordable, and to improve the health of Americans, is if we start to seriously invest in preventing people from getting sick in the first place.

From CNN editors: This is an updated version of an article that was published earlier that incorrectly stated that corn syrup, rather than the production of the raw crop itself, received subsidies. CNN has removed the sentence referenced.


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Topics: Health

soundoff (12 Responses)
  1. JAL

    I appreciate all you do Fareed.

    December 16, 2013 at 7:48 pm |
  2. Let's use common sense to fix things

    The health care system in the US has been running contrary to common sense for decades! With the Federal and State Government agreeing to use taxpayer monies to pay for most of our healthcare, there is no incentive whatsoever for healthcare providers to reign in costs! In fact they have had a major incentive to bill the government as much as possible, because that's how they make even more money themselves........ no wonder it has been driving us into the "red" for decades..... and has allowed the "Medical Industrial Complex" (MIC) to grow into an unwieldy colossus almost as bad as the other MIC: aka "Military Industrial Complex"........ these 2 MIC's have bankrupted America, no question about it......... and how many Americans are willing to agree with this and get our politicians to change the status quo??????

    December 16, 2013 at 8:56 pm |
    • ✠RZ✠

      Never quite looked at that way. One MIC to wound you, and the other MIC to make you all better. That's almost as good as taxing you when you make money and taxing you when you spend it.

      December 17, 2013 at 12:14 am |
    • SpyvsSpy

      Lofty thoughts, to be sure. But let's be realistic. First, voters in America appear to have no ability to alter the trajectory of the government. And second, the MIC lobby will never allow spending to decrease. America has become a virtual banana republic with most politicians for sale, America is far, far from a democracy today.

      December 17, 2013 at 1:51 am |
      • Let's use common sense to fix things

        Very good comment, spot on, my friend! Abraham Lincoln defined Democracy as: Government of the people, by the people, for the people....... what America has devolved into is: Government of the disenfranchised Sheeple, by crooked politicians with Swiss Bank accounts, for the greedy Plutocrat Corporatocracy! When a once great nation has obviously strayed and lost its way, we, the increasingly unhappy and confused and angry Americans, are faced with 2 choices: continue our downward spiral and crash into rubble, like Rome in 476 AD, or figure out how to turn the behemoth around, a herculean task indeed, and clamber back up onto the "high road" of success. Unfortunately, the 5 D's: divorce, drugs, debt, decadence & deception seem to have ensnared us Americans and lashed us to the "low road"..........

        December 17, 2013 at 11:57 am |
    • StanCalif

      Glaxo (big pharma) just announced they would stop paying doctors a "bonus" for every Glaxo prescription they write! What about all the other big drug companies? This bonus system has been going on for decades, then we wonder why Americans take more prescription drugs than people in any other country! Prescription drugs have ruined our country! Now our water sources are polluted with "passed through" drugs! Side effects? Who cares. If you become suicidal or mentally unbalanced taking these powerful drugs, you are free to go buy some guns.
      Our medical establishment expects you to recognize side effects on your own, then report them to your doctor! What a joke! I know from personal experience that side effects sneak up on you and are not recognizable! Today's prescription drugs are powerful and not fully understood. Then we wonder why supposedly "decent people" go on killing sprees then end their own life! There really is no mystery here!

      December 18, 2013 at 6:55 am |
  3. Let's use common sense to fix things

    Wanna get healthy, without too much BS with any healthcare system???? First of all, take a long,close, good look at yourself in the mirror........... if you see a lazy, fat, spoiled, decadent SOB........... wow, you are being really honest with yourself!!!!!!! So, now what??? wanna fix the problem???? Well, first of all, you gotta start working out........ and you don't have to join an expensive gym either........ go for a jog, walk 3 miles, do some sit ups, push ups and leg ups in your own bedroom......... and then take a close look at what you are eating......... too much pizza, hamburgers, Taco Bell and Pioneer Chicken/KFC???????? Well, stop ingesting food that can kill ya!!!!!!!!!! Start eating more vegetables and fruits.......... yes, it is indeed that simple........... we don't need no PhD or MD or MBA to help us figure things out.......... all we need is to use is our own common sense!!!!!!!!!!!!!

    December 17, 2013 at 6:31 pm |
  4. very good.

    very good. prevention is the right answer.

    December 18, 2013 at 12:32 am |
  5. joe anon 1

    single payer.
    get rid of the middle men insurance cos.
    hang ceos of the pharmaceuticals.
    more medical schools, more drs.
    reimburse them fairly. they deserve it.

    December 18, 2013 at 1:57 pm |
    • joe anon 1

      should add:

      hang 530 members of congress. will assume 5 have some redeeming value.

      December 19, 2013 at 3:24 pm |
  6. rosie386

    I am not a follower of politics. I am usually listening with half an ear to political debates, Obama bashing, and water cooler talk. I am a middle class Mom married to a blue collar working man. Together we make approx $75,000 with 3 children. I received our 2014 insurance renewal. Our deductible tripled. Our coinsurance went from 80/20 to 70/30 and our Dr. visit cost doubled. I called the company and asked them WHY? They told me that since everyone must now have coverage, the companies costs have skyrocketed- therefore it is being passed on to the employees. Consequently, my husband, who is in management, has been told to only hire people part time and split the day into shifts so that more employees would not be eligible for health coverage. I am now in a position where I will have to really make a judgement call before taking my kids to the Doctor or the emergency room. I am terrified one of us will require serious medical care. How has Obamacare helped people like me? I now cannot afford to get sick. Ever.

    December 20, 2013 at 1:17 pm |

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