Cindy, I thought you had a well thought out discussion this week. I just wanted to speak on the
last paragraph of your post and play "devil's advocate." Is it advantageous for people to discredit
physicians and the power of positive thought? I only ask because there are many people who
consider themselves atheist (a person who disbelieves in the existence of God) or agnostic (a
person who claims neither faith nor disbelief in God) and still have had outlandish results or
positive outcomes without the reliance on God. With that in mind, I believe positive thought and
self-fulfilling prophecy play a larger role in our health than one would originally think which
directly connects to religious beliefs.
One of the main factors that shape the U.S. health care delivery system that I want to focus on is
cultural beliefs or values (Shi & Singh, 2019). It has been shown that religious thinkers tend to
affirm optimism in relation to their own health care (Andrade, 2019). One of the most notorious
philosophers was Leibniz who presented the world in an optimistic light and argued that it was
necessary (Andrade, 2019). Eventually a school of thought called "New Thought" was formed by
the 19th century. This school believed that our minds were powerful enough to bring what we
desire or, more closely associated with the phrase, "mind over matter" (Andrade, 2019). This was
further supported by the Christian Science movement.
The U.S. health care system is unique among advanced industrialized countries. The U.S. does
not have a uniform health system, has no universal health care coverage, and only recently
enacted legislation mandating healthcare coverage for almost everyone. Rather than operating a
national health service, a single-payer national health insurance system, or a multi-payer
universal health insurance fund, the U.S. health care system can best be described as a hybrid
system. In 2014, 48 percent of U.S. health care spending came from private funds, with 28
percent coming from households and 20 percent coming from private businesses. The federal
government accounted for 28 percent of spending while state and local governments accounted
for 17 percent. Most health care, even if publicly financed, is delivered privately.
In 2014, 283.2 million people in the U.S., 89.6 percent of the U.S. population had some type of
health insurance, with 66 percent of workers covered by a private health insurance plan. Among
the insured, 115.4 million people, 36.5 percent of the population, received coverage through the
U.S. government in 2014 through Medicare (50.5 million), Medicaid (61.65 million), and/or
Veterans Administration or other military care (14.14 million) (people may be covered by more
than one government plan). In 2014, nearly 32.9 million people in the U.S. had no health
insurance.
This fact sheet will compare the U.S. health care system to other advanced industrialized nations,
with a focus on the problems of high health care costs and disparities in insurance coverage in
the U.S. It will then outline some common methods used in other countries to lower health care
costs, examine the German health care system as a model for non-centralized universal care, and
put the quality of U.S. health care in an international context.
In Comparison to Other OECD Countries
The Organization for Economic Co-operation and Development (OECD) is an international
forum committed to global development that brings together 34 member countries to compare
and discuss government policy in order to “promote policies that will improve the economic and
social well-being of people around the world.” The OECD countries are generally advanced or
emerging economies.B Of the member states, the U.S. and Mexican governments play the
smallest role in overall financing of health care. However, public (i.e. government) spending on
health care per capita in the U.S. is greater than all other OECD countries, except Norway and
the Netherlands.
Drivers of Health Care Spending in the U.S.
Prohibitively high cost is the primary reason Americans give for problems accessing health care.
Americans with below-average incomes are much more likely than their counterparts in other
countries to report not: visiting a physician when sick; getting a recommended test, treatment, or
follow-up care; filling a prescription; and seeing a dentist. Fifty-nine percent of physicians in the
U.S. acknowledge their patients have difficulty paying for care. In 2013, 31 percent of uninsured
adults reported not getting or delaying medical care because of cost, compared to five percent of
privately insured adults and 27 percent of those on public insurance, including Medicaid/CHIP
and Medicare.
While there is no agreement as to the single cause of rising U.S. health care costs, experts have
identified three contributing factors. The first is the cost of new technologies and prescription
drugs. Some analysts have argued “that the availability of more expensive, state-of-the-art
medical technologies and drugs fuels health care spending for development costs and because
they generate demand for more intense, costly services even if they are not necessarily cost-
effective.” In 2013, the U.S. spent $1,026 per capita on pharmaceuticals and other non-durable
medical care, more than double the OECD average of $515.
Another explanation for increased costs is the rise of chronic diseases, including obesity.B
Nationally, health care costs for chronic diseases contribute huge proportions to health care
costs, particularly during end of life care. “Patients with chronic illness in their last two years of
life account for about 32% of total Medicare spending, much of it going toward physician and
hospital fees associated with repeated hospitalizations.” The National Academy of Sciences
found that among other high-income nations the U.S. has a higher rate of chronic illness and a
lower overall life expectancy. Their findings suggest that this holds true even when controlling
for socio-economic disparity. Experts are focusing more on preventative care in an effort to
improve health and reduce the financial burdens associated with chronic disease. One provision
of the Patient Protection and Affordable Care Act, commonly referred to as simply the
Affordable Care Act (ACA), implemented in 2013, provides additional Medicaid funding for
states providing low cost access to preventative care.
Finally, high administrative costs are a contributing factor to the inflated costs of U.S. health
care. The U.S. leads all other industrialized countries in the share of national health care
expenditures devoted to insurance administration. It is difficult to determine the exact differences
between public and private administrative costs, in part because the definition of
“administrative” varies widely. Further, the government outsources some of its administrative
needs to private firms. What is clear is that larger firms spend a smaller percentage of their total
expenditures on administration, and nationwide estimates suggest that as much as half of the
$361 billion spent annually on administrative costs is wasteful.BIn January 2013, a national pilot
program implemented under the ACA began. The aim is to improve administrative efficiency by
allowing doctors and hospitals to bundle billing for an episode of care rather than the current ad
hoc method.
Health Insurance in the U.S.: Uneven Coverage
While the majority of U.S. citizens have health insurance, premiums are rising and the quality of
the insurance policies is falling. Average annual premiums for family coverage increased 11
percent between 1999 and 2005, but have since leveled off to increase five percent per year
between 2005 and 2015. Deductibles are rising even faster. Between 2010 and 2015, single
coverage deductibles have risen 67 percent.BThese figures outpace both inflation and workers’
earnings.
The lack of health insurance coverage has a profound impact on the U.S. economy. The Center
for American Progress estimated in 2009 that the lack of health insurance in the U.S. cost society
between $124 billion and $248 billion per year. While the low end of the estimate represents just
the cost of the shorter lifespans of those without insurance, the high end represents both the cost
of shortened lifespans and the loss of productivity due to the reduced health of the uninsured.
Health insurance coverage is uneven and often minorities and the poor are underserved. Forty
million workers, nearly two out of every five, do not have access to paid sick leave. Experts
suggest that the economic pressure to go to work even when sick can prolong pandemics, reduce
productivity, and drive up health care costs.
There were 32 million uninsured Americans in 2014, nine million fewer than the year
prior. Experts attribute this sharp decline in the uninsured to the full implementation of the
ACA in 2014. Of American adults who had health insurance in 2014, 73 percent had one
or more full-time workers in the family and 12 percent had one or more part-time workers
in the family. Just 49 percent of American adults reported getting health insurance from an
employer in 2014.
Coverage by employer-provided insurance varies considerably by wage level. Firms with
higher proportions of low-wage workers are less likely to provide access to health
insurance than those with low-proportions of low-wage workers.
In 2014, 11.2 percent of full-time workers were without health insurance. However, the
percentage of part-time workers without insurance was 17.7 percent, a significant decrease
from 24 percent in 2013, thanks in part to the Affordable Care Act. The uninsured rate
among those who had not worked at least one week also decreased from 22.2 percent in
2013 to 17.3 percent in 2014.
Smaller firms are significantly less likely to provide health benefits to full or part-time
workers. Among all small firms (3-199 workers) in 2015, only 56 percent offered health
coverage, compared to 98 percent of large firms.
After the Affordable Care Act allowed for many young adults (19-25) to remain on their
parents’ health plans, there was a statistically significant increase in the percentage of
insured young people from 68.3 percent in 2009 to 82.9 percent in 2014. Over the same
period, the percentage of young people aged 26-34 with insurance increased from 70.9
percent to 81.8 percent.
Minorities and children are disproportionately uninsured. In 2014, 7.6 percent of non-
Hispanic Whites were uninsured, 11.8 percent of Blacks were uninsured, 9.3 percent of
Asians, and 19.9 percent of people of Hispanic origin were uninsured. The Kaiser Family
Foundation has found that about 80 percent of the uninsured are U.S. citizens. Among
children, six percent were uninsured in 2014. These children are 10 times more likely than
insured children to have unmet medical needs and are five times as likely as an insured
child to go more than two years without seeing a doctor.
Women in the individual market often faced higher premiums than men for the same
coverage. Beginning in 2014, the Affordable Care Act banned this practice, as well as
denying coverage for pre-existing conditions.
In 2014, 19.3 percent of the population living below 100 percent of the poverty line
($23,550 a year for a family of four) was uninsured. According to the Kaiser Family
Foundation, 90 percent of the uninsured have family incomes within 400 percent of the
federal poverty level. This makes them eligible for either subsidized coverage through tax
credits or expanded Medicaid eligibility under the Affordable Care Act’s state health
exchanges.
Rising Healthcare Premiums
Health insurance premiums in the U.S. are rising fast. From 2005 to 2015, average annual health
insurance premiums for family coverage increased 61 percent, while worker contributions to
those plans increased 83 percent in the same period. This rate of increase outpaces both inflation
and increases in workers’ wages.
In 2005, the average annual premiums for employer-sponsored health insurance were
$2,713 for single coverage and $8,167 for family coverage. In 2015, premiums more than
doubled to $6,251 for employer-sponsored single coverage and $17,545 for employer-
sponsored family coverage.
A growing number of workers face a deductible of $1,000 or more for individual plans. In
2015, 46 percent (compared to 38 percent in 2013 and 22 percent in 2009) of workers were
enrolled in a plan with an annual deductible of $1,000 or more. Employees at small firms
are more likely than those at large firms to have a deductible greater than $1,000.
Germany has one of the most successful health care systems in the world in terms of quality and
cost. Some 240 insurance providers collectively make up its public option. Together, these non-
profit “sickness funds” cover 90 percent of Germans, with the majority of the remaining 10
percent, generally higher income Germans, opting to pay for private health insurance. The
average per-capita health care costs for this system are less than half of the cost in the U.S. The
details of the system are instructive, as Germany does not rely on a centralized, Medicare-like
health insurance plan, but rather relies on private, non-profit, or for-profit insurers that are tightly
regulated to work toward socially desired ends—an option that might have more traction in the
U.S. political environment.
The average insurance contributions to German sickness funds are based on an employee’s
gross income, around 15.5 percent with an income cap at $62,781, and employers and
employees each pay about half of the premium. Generally, an individual employee’s
contribution is 8.2 percent and the employer pays the remaining 7.3 percent.
Premiums are not based on risk and are not affected by a person’s marital status, family
size, or health. Germans have no deductibles and low co-pays.
Doctors are private entrepreneurs and get a fee from insurers for every visit and procedure
they perform. However, they are tightly regulated. Groups of office-based physicians in
every region negotiate with insurers to arrive at collective annual budgets. Doctors must
remain in these budgets, as they do not receive additional funding if they go over. This
helps keep health care costs in check and discourages unnecessarily expensive procedures.
The average German doctor also makes about one-third less per year than in the U.S.,
around $123,000.
Government general revenues cover premiums for children, on the premise that the next
generation should be the entire nation’s fiscal responsibility, instead of just the
responsibility of the parents.
Germany reformed its coverage for prescription drugs in 2010 after costs for prescription
drugs continued to rise. Prior to reforms, drug companies set the price for new drugs and
were not required to show that the new drug was an improvement over previously
available prescription drugs. Pursuant to the reforms effective in 2011, manufacturers
could set the price for the first 12 months a new drug is on the market. “As soon as the
drug enters the market, a new process of benefit assessment begins.” Manufacturers must
establish, through comparative effective research that the new drug has an “added benefit
to the patient, compared to the previously existing standard treatment.” Drugs without
added benefit will be reimbursed according to a government pricing list. New drugs
without added benefits are available to patients, but the patient has to pay the price
difference. For drugs with added benefit, a price will be negotiated between health insurers
and the manufacturer.
An extremely helpful example can be seen in Cancer studies. Victor Frankl, author of Man's
Search for Meaning, made a strong case that those who found meaning in things (even pointless
ones) had a greater survival probability (Andrade, 2019). When a person actively participates in
positive thinking, they are more likely to act in ways that are beneficial to themselves, a.k.a. self-
fulling prophecy. Unfortunately, the opposite is also true; if people reflect pessimistically on
their health care they are more likely to act in ways that would impede their health progression.
Self-fulfilling prophecies may lead to increased mortality rates for patients who have a predicted
poor prognosis (Wilkinson, 2009). Doctors may feel partially responsible which could lead to a
compromise of honest communication with the patient and family (Wilkinson, 2019). In this
aspect the physician is actively contributing to pessimistic thinking and negative self-fulfilling
prophecy. There are short comings with the positive thinking movement though. Positive
thinking is considered an alternative medical treatment which presents problems when
substituted for evidence-based medicine (Andrade, 2019).
Based on this, I think it would be helpful to give equal credit to physicians, religious beliefs like
positive thinking, and ourselves. As Proverbs 17:22 states, "A joyful heart is good medicine, but
a crushed spirit dies up the bones." By no means am I taking any of the credit from God and
His plan for our lives, but He also gives us the gift of free will. We actively contribute to our
own health by acting in ways that either promote our health or impede it.
