A Critical Difference

You hear it all the time: "Our medical care is terrible and we get nothing for all we spend." This is a good example of...

You hear it all the time: "Our medical care is terrible and we get nothing for all we spend." This is a good example of how half-truths become myths. The reality comes when we realize the difference between medical care and health care.

The difference matters. It is true that the U.S. ranks 23rd in life expectancy in the world, but it is not because of our medical care. Rather, the major reasons for our terrible life expectancy are poverty, drug abuse and the high number of U.S. citizens who are uninsured and go without needed medical care. Life expectancy is an index of health care, not an indication of the quality of medical care. In the U.S., life expectancy is determined 40 percent by lifestyle (such as smoking and overeating), 30 percent by genetics and 20 percent by public health interventions (such as immunizations and seatbelts), and only 10 percent of life expectancy is attributed to medical care. Medical care is defined as what patients receive in health practitioners' offices and hospitals, such as coronary bypass surgery. Mortality after coronary bypass surgery is a medical care index, not a health index.

Some of the major determinants of health care are social: gross domestic product, socioeconomic status, level of education and occupation. In the United States, there are highly significant disparities in health care related to race, ethnicity, education, socioeconomic status and living in either rural or inner-city areas. For example, the life expectancy at birth for an African American man is six years less than for a white man. African Americans are more likely than any other racial or ethnic group to develop cancer, and 30 percent are more likely to die from it. Inequalities in income and education underlie many of the disparities in health and are related: The death rate for people with 12 years or less of education is more than two and a half times the rate for persons with 13 or more years of education, and lower income and education levels are associated with higher levels of violent crime and more deaths due to firearms, motor vehicle accidents and substance abuse. Higher incomes permit increased access to medical care and allow people to afford better housing and live in safer neighborhoods. All the medical care in the world will not change the fact that the life expectancy for an African-American man in Harlem is lower than the life expectancy in Bangladesh.

How about medical care? Although we hear lots of complaints about how bad the U.S. health care system is, how often do people go to other countries for their hip replacement or heart surgery? Not very often. That is because surgery and medical treatments are medical care: what doctors, other health practitioners and hospitals do. In fact, our medical care is among the best in the world. For example, in the United States, death after a heart attack has declined 75 percent over the last 50 years, and middle-aged Americans today can expect to live three to five years longer than they did in 1950 as a result of medical treatments for heart disease.

If we look at how our medical system serves sick Americans, we do pretty well, particularly in terms of how responsive our health care system is when we need medical care, and for certain treatments like cancer. In fact, our breast cancer mortality is the best in the world. But much of what our medical system provides overall is not as easily distinguished: The U.S. scores worst out of 18 developed countries in mortality from preventable disease. This mortality statistic sounds like medical care, but remember, much of what contributes to "preventable disease" requires effective "preventive care," which is actually provided only if a person has access to regular medical care through adequate health insurance coverage.

Does the distinction between health and medical care make a difference? You bet it does. Maintaining health includes not only medical care but also a large number of socioeconomic and environmental factors, such as poverty and lack of health insurance. Therefore, the ways of improving health care versus medical care are also very different. While it is tempting to "adjust" for infant mortality or life expectancy because of socioeconomic status (for example, comparing only U.S. white middle-class infant mortality with Sweden's infant mortality rate) or by using the crime rate in Harlem in order to make our population health numbers look better, we need to face the truth about our country.

We should not excuse or explain away our health care problems, but rather begin to admit that our social systems are among the worst in the developed world and attack them through improvement in our social and public health systems. A good place to begin would be to figure out a way to provide decent basic health coverage to almost 50 million Americans currently uninsured. We can most definitely improve our medical care as well, and we need to, but improving medical care may prove to be the easier task.

About This Column: Many Myths

Most of us interact with the health care system frequently, whether we are officials serving the public or individuals filling a prescription, making a doctor's appointment or undergoing treatment for a medical condition. We are all exposed to abundant health information, although much of it is only partially true and some of it is altogether false. This is because a lot of health information comes to us as overly simplified and stereotyped media "sound bites," which, when heard often enough, become accepted beliefs, or myths.

These commonplace health care half-truths are challenged in our book, Health Care Half-Truths: Too Many Myths, Not Enough Reality. Our aim was to debunk 20 of the most commonly held myths about the U.S. health care system as we posit realities in understandable language.

Each month, this column will present an excerpt from the book, highlighting a different health care myth. Some of the myths you will read about here are near and dear to many health care reformers' hearts -- for example, that prevention can save money (we argue that it usually doesn't but it is the right thing to do anyway). Others are less controversial, such as the myth that the uninsured get all the care they need in emergency rooms.

By exposing these and other myths here, we intend to challenge leaders at all levels of government, as well as those they serve, to become more involved in improving our health care system.