As we approach the 2012 national elections, health care will likely be paramount in the voter’s decision process. The Affordable Care Act of 2010, with the subsequent legislative and judicial battles that have ensued since its passage, has kept this topic in the spotlight.
Consequently, many Americans are examining their own health care, including access, costs, and quality. Per capita expenditures for health care in the United States are double that of other developed nations and more than 10 times that of many underdeveloped countries.1 Despite the high cost, quality-of-care goals are consistently not met, especially for those on public insurance, leading to potentially preventable hospitalizations and an increasing number of medical complications.2,3
But despite its inefficiencies, our health system serves the populace well and is highly respected throughout the world. All one need do is compare our system to those in some underdeveloped countries to see the contrast.
While traveling to several less cultivated nations, I’ve had the opportunity to visit and evaluate the health care systems and care delivery models, especially in the more remote and impoverished areas of Central and South America. Additionally, I’ve had ample opportunity to interview many people from these regions who have immigrated to the United States for a variety of reasons, including inadequate health care and abject poverty.
Paraguay is a South American country of 6.5 million residents, with 40% living in rural areas.4 Although the government of Paraguay provides free health care through the public hospitals, those facilities are not easily accessible to rural areas, especially in the remote Chaco region.
Paraguay has 72 hospitals and more than 1,000 health clinics with varying capabilities, most of which are located in the capital city of Asunción.5 Automobiles are rare in the rural northwest districts; travel is usually via horse- or oxen-drawn carts or by foot, which makes the 300-mile trip to Asunción prohibitive.
During a medical mission to that country, a contingent of physicians, NPs, and dentists provided basic health care for more than 10,000 individuals living in Concepción and three surrounding communities. Many of those treated had never received any health care, and the mystique surrounding the “tools of the trade” was evident. The use of stethoscopes and otoscopes would incite fear and crying in many of the younger children.
Although medicines are available at local pharmacies, those we brought with us from the US were believed to be far superior and were coveted by the locals. The most commonly treated illness was ascariasis, followed by dental caries and minor respiratory illnesses. Chronic illnesses among this population are often treated sporadically, as medications are usually available only during similar humanitarian missions conducted by many different governmental and nongovernmental organizations.
Access to health care in many areas of Mexico, though improving, remains a significant issue. According to Pagán and Puig, 40% of individuals with diabetes older than 50 are not insured, and almost 20% will use folk healers or self-treatment rather than conventional medicine.6
Despite health care reforms in the country over the past several years, significant inequities in access and quality of care remain. Twenty-five percent of the population resides in provincial regions with limited access to care, resulting in nearly twice the infant mortality rate of that in urban settings.7
The Mexican government reports full implementation of the Popular Health Insurance (PHI), a national insurance plan designed to address inequities based on socioeconomic status by decreasing the amount of out-of-pocket spending for the severely impoverished and therefore increasing access to care.8 Contrary to this proclamation, residents of the areas describe ongoing limitations, with hospitals located several hours away in larger cities, requiring transport for even life-threatening conditions to be conducted via private automobile or taxi.
Upon arrival at the health care facility, many are still required to pay out-of-pocket for some services, exacerbating the disparity. According to the US Agency for International Development, out-of-pocket costs represent almost 30% of health care expenditures, despite the PHI.1 Many chronically ill individuals do not take disease management medications due to the expense, which is not covered by the national insurance at the local, privately owned pharmacies.
Belize, one of the more economically advanced countries in Central America, has a relatively large population of American and European expatriates, leading to a system that is better than most in the region. Belize is second in Central America for per capita income; despite this, 40% of the population lives below the poverty line.4
This income disparity also contributes to health care inequality, with those able to pay more out-of-pocket costs receiving better care, experiencing fewer limits on access, and having access to services otherwise not available. Although there is a national health insurance, it does not cover many services, including elective surgeries, some radiography, newer medications, and substance abuse treatment.5 Out-of-pocket costs constitute nearly 40% of the health care expenditures in Belize.1
The Orange Walk district in the northern part of the country hosts a large population of Mennonites, who continue the tradition of nonparticipation with modern machinery and technology. Consequently, many of these residents utilize the skills of lay health workers rather than travel to the public hospitals—although, if necessary, a trip to Belize City via horse-drawn carriage can take several hours. Transportation for most Belizeans is limited to bicycle or taxi, and the distance to Belize City further limits health care access for the disadvantaged.
Change in the US health care system is needed, whether that change is full implementation of the Affordable Care Act or another, as yet undeveloped, plan. Nonetheless, it is important for us to evaluate the health care system we currently have and understand that, despite the deficiencies and high cost, it is still one of the best in the world.
Most Americans have ready access to primary and emergent health care and are able to obtain it at a reasonable cost, either through the use of private or government-sponsored insurance, or on a sliding-fee scale in community health centers. Our health care provider education system is unequaled in the world, and much of the global health research and development is conducted within that system.
Despite our legislative battles and public debates about health care in the US, it is, and likely will continue to be, one of the premier systems in the world.
References
1. US Agency for International Development. Health Systems 20/20 (2011). healthsystems2020.healthsystemsdatabase.org. Accessed July 7, 2011.
2. Bethell CD, Kogan MD, Strickland BB, et al. A national and state profile of leading health problems and health care quality for US children: key insurance disparities and across-state variations. Acad Pediatr. 2011;11(3):S22-S33.
3. Jiang HJ, Russo CA, Barrett ML. Nationwide frequency and costs of potentially preventable hospitalizations, 2006. Rockville, MD: US Agency for Healthcare Research and Quality; 2009.
4. Central Intelligence Agency. The World Factbook (2002). https://www.cia.gov/library/publications/the-world-factbook/index.html. Accessed July 7, 2011.
5. Pan American Health Organization. Basic country health profiles for the Americas. www.paho.org/english/dd/ais/cp_index.htm. Accessed July 7, 2011.
6. Pagán JA, Puig A. Differences in access to health care services between insured and uninsured adults with diabetes in Mexico. Diabetes Care. 2005;28(2):425-426.
7. Barber SL, Bertozzi SM, Gertler PJ. Variations in prenatal care quality for the rural poor in Mexico. Health Affairs. 2007;26(3):w310-w323.
8. Knaul FM, Frenk J. Health insurance in Mexico: achieving universal coverage through structural reform. Health Affairs. 2005;24(6):1467-1476.