The lack of health insurance and human casualties: is the number large enough to justify benchmarking against war casualties?
Healthcare, price and results. A lot has been written about the United States’ healthcare crisis, its ability to deliver the most progressive healthcare services, its failure to deliver optimal prices and outcomes on the national level, and comparisons between its national health outcomes and those of other developed countries (Gluckman et al., 2008). For example, Davis, Stremikis, Schoen, and Squires (2014) benchmark study of healthcare in 11 developed countries found that, at the price of $3,405 per capita, the UK delivered the best healthcare worldwide. According to the same study, US healthcare, with a price tag 2.5 times bigger ($8,508), was last on the list.
Business, health and ethics. We in the US may say that this is not the best business deal, but that it is how we do business here. We are spending 2.5 times more than the country that was shown to perform the best in the group, and our outcomes are suboptimal. Some of us may argue that this is OK because we have money at the present moment. However, even if we are OK with spending 2.5 times more than necessary, there are national health-related and ethical issues that we must consider.
National health and ethics are issues that have a long and continuous history. Therefore, this analysis focuses on the impact of the lack of universal healthcare over the last 85 years. As the analysis will show, the needs were defined a long time ago and the impact on life of Americans has been significant. In fact, it is probably larger than the impact of any, and all wars that the United States has participated in.
History. Before we continue, we should ask ourselves how US healthcare became such big business? Why is it so important? More than a century ago, due to the relatively low impact of medical technology, the extremely limited number of available drugs, and traditional social structures that provided healthcare (family, religious groups), the need for organized healthcare and health insurance was relatively low. With medical advances, that started to change significantly. Healthcare became powerful, costly, and complex. Today, it extends our lives, reduces our mortality, makes us more productive citizens, and consumes one-sixth of the US economy (significantly more than any other nation worldwide). As a result, the way we approach US healthcare has medical, public health, economic, and ethical/moral attributes.
Documented challenges. The challenges associated with US healthcare have been well documented since 1932, when the Committee on the Costs of Medical Care created its first report.
The report of the Committee on the Costs of Medical Care (1932) starts with this paragraph : “The problem of providing satisfactory medical service to all the people of the United States at costs which they can meet is a pressing one. At the present time, many persons do not receive service which is adequate either in quantity or quality, and the costs of service are inequably distributed. The result is a tremendous amount of preventable physical pain and mental anguish, needless deaths, economic inefficiency, and social waste. Furthermore, these conditions . . . are largely unnecessary. The United States has the economic resources, the organizing ability, and the technical experience to solve this problem.”
Today, 85 years later, that message seems as timely as it was in 1932; doesn’t it?
Universal vs. industrial care – a focus on nurturing health vs. a focus on fighting diseases. The report proposed well-coordinated universal healthcare in which physician groups delivered healthcare services and significant focus was put on preventive care. Dr. Ross (2002) explains that, although the recommendations were appropriate, at the time, US society was not ready to recognize the need for healthcare as a well-coordinated socio-economic model. The 1930s were an era of industrialization; industry was glorified. Therefore, the industrial model that perceived healthcare as an agglomeration of autonomous business units was preferred.
The industrial model follows the established business logic according to which the main “purpose of business is to create a customer” (Drucker, 2001). Profitability increases if we create a large number of loyal returning customers and sell them more products. The challenge associated with the model is that healthcare customers who need to purchase more products do that, almost as a rule, because they are sick. Therefore, from the business perspective, the goal is not to make people healthy – healthy people may not return to receive additional healthcare services.
Rewarded for sick-care visits. Drs. Marvasti and Stafford (2012) explain that, as a result, US healthcare uses a siloed, task-based model that rewards healthcare providers for “sick visits aimed at addressing acute conditions or acute exacerbations of chronic conditions.” This model poses a challenge because it views disease as a revenue generating tool. Therefore, it does not favour prevention – prevention may reduce the number of sick people and, ultimately, reduce profit. Drs. Farley and Cohen (2005) argue that medical care is currently designed for sick people – after they get sick. Therefore, it may be more appropriate to call it sick-care.
Preference for revenue generating procedural services. The list of potential challenges associated with the model does not stop there. Even if due to lack of preventive healthcare patients get sick, the system does not act optimally. The fee-for-service payment model that has been in use for a long time promotes the overuse of procedural services in place of cognitive tasks. Therefore, surgery is preferred to behaviour-change consulting focused on healthy eating and weight loss. Simultaneously, the medical conditions that do not fit any pre-described categories are ignored or the patient is placed in one of the “diseased” categories to facilitate drug treatment.
Misusing the medical profession. Dr. Solyom (2004) and many other physician leaders convincingly argue that the industrial model has misused the medical profession. That model has converted the noble profession of medicine – which is focused on health – into just one part of a sick-care industry in which sick-care services are commodities for purchase.
Fortunately, forces promoting the healthcare model over the industrial sick-care approach have been very active for a long time.
The Universal Declaration of Human Rights (UN, 1948) was another big win for the idea of universal healthcare. In 1948, the United States participated in writing and voting for the Universal Declaration of Human Rights. The declaration defines the “right to medical care” as one of the basic human rights. Unfortunately, although the United States was a leader in the creation and acceptance of the document, it is not an official US document. Therefore, it is not enforced in the United States.
Hence, it was important that, in 1952, the President’s Commission on the Health Needs of the Nation (1952) defined access to healthcare as “a basic human right.” It stated, “The same high quality of health services should be available to all people equally,” and explained, “The American people desire and deserve comprehensive health service of the highest quality and in our dynamic expanding economy the means can be found to provide it.”
Ethical & Moral Implications. Finally, during Reagan’s time, the tremendous ethical and moral importance of access to healthcare was confirmed. In 1983, the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1983) created the report, Securing Access to Healthcare – Ethical Implications of Differences in the Availability of Health Services. The report stated the following:
- Society has a moral obligation to ensure that everyone has access to adequate care without being subject to excessive burdens.
To summarize, since 1935, the importance and benefits of universal healthcare have been well known in the United States. The United States played a leading role in the definition of healthcare as a human right worldwide. There are documents that the US government created and approved that define healthcare as a human right. Finally, there is general agreement from the political spectrum as a whole that access to healthcare is an ethical and moral issue.
Let us be practical and precise. Ethical, moral, and human rights? That sounds very nice, but it is very theoretical and qualitative. Even if we add the terms “preventable physical pain, mental anguish and social waste” from the 1935 report, we need a measure. Therefore, the question is how many “needless deaths” and how much economic inefficiency did the healthcare insurance model in use cause?
Healthcare is a complex social phenomenon, and various factors moderate the impact of lack of health insurance. Lifestyle, the availability of health services focused on prevention, and the availability of free health services are just a few of them. To address the complexity, I will use 3 independent sources of data and methods in the assessment of the impact.
These sources and methods are:
- The undertaking of a series of studies to assess and compare the health and lifespans of uninsured Americans and insured Americans. That is to say, the undertaking of comparisons of different groups of Americans – cohort study;
- The study of changes in mortality after healthcare reform in Massachusetts. That is, the comparison of the lifespan before healthcare reform with that after healthcare reform – time series design;
- The comparison of life expectancy in the United States and that in comparable developed, English-speaking countries – comparative case study.
The health and lifespans of insured vs. uninsured Americans
Shorter lifespans and more health problems have been well documented in populations without health insurance. For example, Sorlie, Johnson, Backlund, and Bradham (1994) found that uninsured working men aged 25 to 64 years experienced a 30% increase in mortality in comparison to insured working men of the same age. In women, the increase in mortality was 20%. The Institute of Medicine (IOM, 2002, 2004) reported that uninsured adults had a 25% higher risk of dying. Based on that, it estimated that, in 2000, with a population of 40,000,000 uninsured, 18,000 excess annual deaths of adults aged between 25 and 64 years were associated with the lack of insurance.
Eighteen thousand excess deaths are just a part of the picture. The population pyramid shows that the sum of populations under 25 and above 64 years of age may be 5-8% smaller than the population aged between 25 and 64 years. However, pregnant mothers and babies, as well as the population aged above 64 years, are significantly more vulnerable to lack of health insurance. Therefore, it is fair to assume that the total number of deaths associated with lack of health insurance is almost double the one given.
Conclusion: The yearly casualties associated with lack of healthcare insurance per 40 million uninsured amount to ~35,000 American lives.
The impact of Massachusetts healthcare reform
In 2006, Massachusetts implemented healthcare reform that promoted almost-universal insurance coverage and significantly increased access to care. Sommers, Long, and Baicker (2014) found that, because of that law, absolute mortality in Massachusetts decreased by 8.2 deaths per 100,000 adults. For Massachusetts’ population of 6,811,779, that equals 559 lives a year. That number is relatively low because 86.4% of Massachusetts residents had health insurance before the law was implemented. If we focus solely on the population that did not have health insurance but gained it thanks to the reform, then, per Sommers et al. (2014), one life was saved each year per 830 newly insured adults (aged between 25 and 64 years).
Let us use that number to estimate the impact that the reduced access to healthcare coverage that H.R. 1628, the Better Care Reconciliation Act of 2017 proposes will have on people’s lives. The Congressional Budget Office (CBO.gov, 2017, p. 4) has reported, “The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law.” Based on that figure, we can assume that, in 2026, mortality due to decreased health insurance coverage will be 22 million/830 = 26,506 American lives a year.
The Congressional Budget Office (CBO.gov, 2017, p. 4) has also reported, “By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.” That means the total mortality rate associated with the lack of health insurance will be 49 million/830, which equals 59,036 American lives a year.
In sum, the new bill proposes that we increase the mortality rate by 26,506 American lives a year and tolerate the mortality rate of 59,036 lives a year.
To put these numbers in perspective, we can compare the estimated impact of the healthcare bill with the casualties resulting from the 9/11 terrorist attacks, that is 2,996 deaths (Ai, Cascio, Santangelo, & Evans-Campbell, 2005). The increase in the number of deaths due to reduced access to healthcare will be equivalent to almost nine 9/11 terrorist attacks every year (28,916/2,996 = 8.94), and the total mortality rate due to the lack of health insurance will be almost like twenty 9/11 terrorist attacks per year (62.651/2,996=19,7).
The limitations of this analysis follow: (1) Massachusetts’ 2006 experience may not reflect the situations in other states in 2017, (2) the complexity of the healthcare system and the way the reform law is implemented may significantly influence outcomes or perceptions of outcomes, and (3) the Massachusetts healthcare reform law of 2006 was focused on expanding private coverage, while the Affordable Care Act relies more on an expansion of Medicaid.
Benchmarking American healthcare and welfare against those of other countries
To address the aforementioned limitations, let us compare the impact of the US healthcare and welfare systems with those of 4 developed English-speaking countries: Canada, Australia, UK, and Ireland. The selection of English-speaking countries has to do with the fact that they are in many ways similar to the US. Since all the healthcare professionals are fluent in English, they can read international scientific journals and have access to the latest innovations and international communities of practice; the workforce’s mobility is significant; and the economy is strong. The main difference between the United States and all the countries in this comparison is that they have universal healthcare systems, while the US does not.
The Shorter Life Expectancy Casualties (SLEC) model. For the purposes of this analysis, I will introduce the Shorter Life Expectancy Casualties (SLEC) model. The SLEC number refers to the lives lost because the average lifespan in one country is shorter than that in another country that we are using as a benchmark.
Lifespan differences. While Americans on average live to be 79.3 years old, Australians have 4.41% longer lifespans (they live to the age of 82.8 years), Canadians have 3.65% longer lifespans (they live to the age of 82.2 years), the British have 2.39% longer lifespans (they live to the age of 81.2 years), and the Irish have 2.65% longer lifespans (they live to the age of 81.4 years) (WHO, 2016).
SLEC number? Let us determine what those differences mean at the scale of the US population. How many American lives are lost because the healthcare and welfare systems in the US do not perform as well as those in Australia, Canada, the UK, or Ireland? What is the SLEC number?
Lifespan casualties. If Americans lived as long as Australians (4.41% longer lifespans), over an average lifespan (79.3 years), the result would be the saving of 14,308,662 lives.
If we did the same calculation using Canadian data, the outcome would be 11,842,770 lives saved. With UK and Irish data, 7,754,581 lives and 8,598,176 lives, respectively, would be saved.
The yearly SLEC loss in American lives is 180,437 more than would be the case if the United States had the same life expectancy as Australia, and 149,341 more than would be the case if the United States had the same life expectancy as Canada. The table below provides more details for comparison.
Comparing these numbers with war casualties?
How do these figures compare to American military deaths? The 83 wars that the United States has participated in have resulted in a total of 1,426,349 deaths (wikipedia.org, 2017). That includes 750,000 casualties of the Civil War, 405,399 deaths associated with World War II, and 116,516 deaths associated with World War I. Comparing the total with the number of American lives that would be saved if Americans had similar healthcare and welfare systems to Australians and, consequently, 4.41% longer lifespans with total American war casualties would yield 14,308,662 / 1,426,349 = 10.03.
Conclusion. Observed through this lens, the impact of an improved healthcare (insurance) system would be 10 times larger than the number of deaths that 83 wars caused.
SLEC casualties compared to individual wars. Because the Australian lifespan is 4.41 % longer than the American lifespan, during one lifespan, 19 times more Americans will die than those who died during the Civil War, 35 times more Americans will die due to SLEC than those who died during WW2, and 246 more Americans will die than those who died during the Vietnam War.
The number of SLEC casualties per generation – 97,788 to 180,437, depending on which of 4 countries we compare the United States to – is significantly larger than the number of casualties associated with any of the wars we mentioned except the Civil War and World War II. The number of casualties associated with World War I is approximately similar (116,516). Wars that follow in the list of wars are ranked by the total number of American military deaths. The Vietnam War and Korean War, with 58,209 and 54,246 associated American deaths, respectively, are just one-third of the yearly SLEC in comparison with Australia.
Note: The human lifespan in the SLEC calculation is 79.3 years. Therefore, if somebody dies aged 35 years, that is “half-life lost.” Casualties reported in wars are usually adults, and loss usually occurs at significantly lower ages than 79.3 years.
In summary, we have 3 different estimates of the number of American lives lost due to lack of healthcare insurance: 35,000, 59,036, and 180,437.
The first two numbers are relatively close, and it is possible to attribute part of the difference to the existence of different populations of uninsured people. The figure of 35,000 yearly American casualties is based on the estimate of 40 million uninsured people in 2000, while the figure of 59,036 casualties is based on the estimate of 49 million uninsured Americans in 2017. If we adjust the population numbers, the difference is 37%. That difference can be partially attributed to the growing impact of healthcare on human life, a 5-year longer lifespan (WHO, 2016), and the consequently greater damage resulting from the lack of healthcare insurance.
It is possible to arrive at significantly bigger lifespan differences through the Shorter Life Expectancy Casualties score. That is to be expected as the universal healthcare concept allows nations to systematically approach healthcare as a national interest. Therefore, through the lens of the national healthcare system, strategic investments in preventive medicine, sports, nutritional programs, education, and coordinated healthcare are much better than focusing on sick-care for acute patients. A wealth of data proves that those strategies can significantly extend human lives while reducing costs (Chapman, 2016; Gluckman et al., 2008; Lu & Hsiao, 2003; Richard, West, & Ku, 2012).
Longer life and significant savings. As a result, Australians have 4.41% longer lifespans than Americans but pay significantly less for their healthcare services (Davis et al., 2014). On average, Australians save $4,708 dollars a year per capita or $389,822 per capita during their lifetimes (82.3 years). As for Canadians, their 3.65% longer lifespans accompany yearly per capita savings of $3,986 or lifetime per capita savings of $327,649. The British, who have 2.69% longer lifespans, receive yearly savings of $5,103 or lifetime savings of $414,363. Finally, the Irish, who experience 2.65% longer lifespans, receive yearly per capita savings of $3,850 or lifetime per capita savings of $313,390.
So, what are your thoughts? Is the possibility of saving 50,000–180,000 American lives a year and $3,986–$5,235 per capita a year or 327,649–$414,000 per capita during one’s lifetime while receiving better healthcare and welfare a good enough reason to consider making the change?
The main limitation of this research is that the calculation does not include all factors that influence the lifespan. For example, nutritional habits and lifestyle play important roles in improving the health of a nation. However, since universal healthcare is a framework for addressing national health, programs that focus on improving nutritional and lifestyle habits are usually stronger in countries that have universal healthcare services. Therefore, nutritional habits and lifestyle are variables associated with universal healthcare.
Moreover, this research excluded countries where English was not the main language. Therefore, it did not include the 4 highest-ranking countries (Japan, Switzerland, Singapore, and Spain). Future research may consider how universal healthcare has shaped the population’s health in these countries.
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Moodle/Totara community started Project Inspire. The goal is to create “transparent next-generation learning analytics that go beyond simple descriptive analytics to provide predictions of learner success, and ultimately diagnosis and prescriptions (advisements)” to learners, teachers, content experts and CME/CPS professionals. That sounds great. Right?
As a vibrant open source community, with 106+ million users, Moodle is well positioned to create a powerful learning analytic engine. At this moment, Project Inspire is collecting anonymized user data they can use to train the machine learning engine (+ develop and test additional analytic algorithms). So far bunch of schools and universities contributed anonymized copies of their sites. I’m proud to say that my Alma Mater, the University of Zagreb, contributed the first full data set to Project Inspire in April.
If you use Moodle/Totara 2.7+ you can join the project. Here you can find more about it:Read More