Medicine: Nice Care if You Can Get It

By SAM URETSKY

On the list of unappreciated government jobs, somewhere between IRS auditor and meter maid, you can fit in anything connected with the Agency for Healthcare Research and Quality. This is an agency that makes a living pointing out the obvious. According to the 2012 National Healthcare Quality Report (May 2013): “...Americans too often do not receive care they need, or they receive care that causes harm. Care can be delivered too late or without full consideration of a patient’s preferences and values. Many times, our system of health care distributes services inefficiently and unevenly across populations. Some Americans receive worse care than others. These disparities may occur for a variety of reasons, including differences in access to care, social determinants, provider biases, poor provider-patient communication, and poor health literacy.”

Among the findings in the 2012 report was this – while overall quality of care is improving, overall access to care is deteriorating. “In 2002, 24% of Americans encountered difficulties accessing health care; by 2009, this had increased to 26% of Americans.” On the other hand, racial disparities had improved a bit. The racial pattern — Caucasians have better access than Hispanics who have better access than people of African ancestry — remained, but the gap was closing (Asiatics had about the same overall access as Caucasians, but worse in some respects better in others.) The gap between low and middle income people was considerably smaller than the gap between middle and high income people.

There are distinct regional patterns in quality of care — but these may be subject to change based on political decisions. The report measured overall quality of care, preventive care, acute care and chronic care. Generally, the states of New England out-performed the Southern states, but few states did well by every measure. Two states that topped the rankings were Minnesota and Wisconsin, but while Minnesota has shown bi-partisan support for Obamacare, Republican Gov. Scott Walker of Wisconsin has proposed rejection of the Medicaid expansion provided by the Affordable Care Act and plans to move more people near the poverty line into private insurance. According to the Wisconsin State Journal, Wisconsin has in the past provided Medicaid coverage to people at 200% of the poverty level, and Obamacare would bring this down to 138% of the poverty line (about $15,000/year for a single person). Even so Gov. Walker wants to reduce that to 100% of the poverty level ($11,490/year). Anyone above that would be expected to buy private insurance through the exchanges.

The problem there is that private insurance, even through the exchanges, requires a deductible that would be unaffordable to people with such low incomes. Hospitals are predicting that, rather than pay the increased costs of care, patients close to the poverty line would present themselves at emergency rooms in order to get free care. This anticipated result of Gov. Walker’s policies would make health care less accessible for people near the poverty level while worsening the quality of care, but with Republicans in full control of state government, the governor’s proposals are expected to be approved.

Another disparity which has grown larger, according to the AHRQ report, is in the quality of care for advanced state breast cancer between Caucasian woman and those of African descent. Race is sometimes used as a surrogate measure of income, but in this case there may be a genetic factor which exacerbates the problem. There is a relatively rare, but particularly aggressive form of breast cancer known as inflammatory breast cancer. Although this type only represents 1% to 5% of all cases, it is disproportionately seen in women of African ancestry. According to the National Cancer Institute, “Because inflammatory breast cancer usually develops quickly and spreads aggressively to other parts of the body, women diagnosed with this disease, in general, do not survive as long as women diagnosed with other types of breast cancer.” From 1988 to 2001, women diagnosed with inflammatory breast cancer had only about a 33% chance of surviving for 5 years after diagnosis, while women with other forms of breast cancer had an 87% likelihood of 5-year survival. In this case, reduced access to care, delayed care, translates to death.

There are many identified areas for improvement listed in the ARHQ report, but this may be the most significant: “Of the quality measures related to treatment of acute illness or injury, more than 80% showed improvement. In contrast, only about 40% of quality measures related to preventive care and chronic disease management showed improvement.” Once a person has been admitted to an acute care hospital, the American health system may actually be the best in the world, but in the basics of health, preventive care, a healthful diet, immunizations, our system is in decline for all but the most affluent. In his book, The Price of Inequality, Prof. Joseph Stiglitz writes “Economists marvel at our health care sector and its ability to deliver less for more: health outcomes are worse in the United States than in almost all other advanced industrial countries and yet the United States spends absolutely more per capita, and more as a percentage of GDP by a considerable amount.” Obamacare, fully implemented, if not undermined by right wing governors and pizza barons, will improve the system, but not enough. The marvels of American health care show no signs of abating, and that’s a national shame.

Sam Uretsky is a writer and pharmacist living on Long Island, N.Y. Email sdu01@mail.com.

From The Progressive Populist, July 1-15, 2013