Every year in the United States, over 40,000 people die because of lack of health insurance (1). Among industrialized democracies, only the United States fails to provide universal health coverage. According to the U.S. Census Bureau, in 2010, 49.9 million Americans—over 16% of the population—lack health insurance (2). This is an increase in the uninsured, from 2008, of several million individuals, and an increase of over one percentage point of the nation’s total population. About 10% of American children under 18 were uninsured in 2009.

Among those with coverage, the number of people with employment-based insurance is falling. Due to recent job losses in the current economic downturn, another 2010 study by the independent Commonwealth Fund estimates that “nine million working-age adults—57 percent of people who had health insurance through a job that was lost—became uninsured in the last two years” (3). The study further notes that “an estimated 44 million people were paying off medical debt in 2010, up from 37 million in 2005,” and that “4 million declared bankruptcy because of medical bills.”

Most physicians are not experts on the topic of comparative medical systems. This chapter serves as an introduction, from one doctor’s perspective. The topic is huge and covered in detail by peer-reviewed journals such as Health Affairs, along with regular commentaries in The New England Journal of Medicine, frequently updated books and Web sites, and in-depth reports by national and international expert organizations such as the Institute of Medicine (IOM) and the World Health Organization (WHO).

Although we do not cover everyone in the United States, we spend far more per capita than other similar countries and yet have significantly worse outcomes. Figures from 2009 from the Organisation for Economic Co-operation and Development (OECD), whose 34 countries include most of the world’s wealthy industrial democracies, show total health expenditure per capita in the United States at currently nearly $8,000. This compares to an estimated $5,350 in Norway, the next highest spender, and $4,363 in neighboring Canada (4). In fact, the OECD notes that although US government spending on health care is less than half of total health care expenditures, at 47.7%,

In effect, one could say that we pay enough in taxes to achieve universal coverage, but do not receive it. Other analyses point to a significantly higher percentage of total US health care spending from taxes—as much as 60%— without universal coverage (5).

Despite our outlier expenditures, our results are significantly below average, compared to similarly wealthy nations. Our average life expectancy is 78 years, compared to 80.7 years in Canada, for example (putting Canada more than 1 year higher than the OECD average, of 79.5 years, in 2009) (6). Similarly, our infant mortality is 6.5 (in 2008, latest available), which is much higher than the average in other OECD countries, of 4.4 in 2009. Our infant mortality rate is much higher than Canada’s, which was 5.1 in 2007. The OECD notes that “… while life expectancy in the United States used to be 1½ year above the OECD average in 1960, it is now… almost 1½ year below the average of 79.5 years” (7) (emphasis in original).

There are numerous ways, aside from the standard overall statistics of life expectancy and infant mortality, to compare different countries’ medical systems and outcomes. One approach looks at “deaths from treatable conditions,” termed “amenable mortality.” A study comparing the United States with 18 other industrialized countries, evaluating “trends in deaths considered amenable to health care before age seventy-five between 1997-98 and 2002-3,” found a decline in all countries in amenable mortality over this period, averaging 17%. However, “the United States was an outlier, with a decline of only 4 percent” (8).

While our higher per capita health expenditures buy us more MRI and CT machines, on average, than other OECD countries, we have fewer doctors and hospital beds. The 2011 OECD comparison report notes that “in 2009, the United States had 2.4 practising physicians per 1,000 population, below the OECD average of 3.1.” The report notes that we have 2.7 hospital beds per 1,000 population in 2007 (latest year available), lower than the OECD average of 3.5 beds in 2009. We have 34.3 CT scanners per million population in 2007 (latest year available), much higher than the OECD average of 22.1, and 25.9 MRIs per million population, “more than twice the OECD average of 12.0” (9). But more machines, and fewer doctors and hospital beds, do not equate to longer life expectancy nor lower infant mortality.

Among other participants in the field, thousands of physicians, including this author, are active in Physicians for a National Health Program (PNHP.org), a nonprofit advocacy group working for single-payer national health insurance in the United States, also termed Medicare for All. My personal perspective, based on my reading of relevant research, is that such a system would provide the most rational and cost-effective solution to the problem of the uninsured. You will make your living as an otolaryngologist via compensation from our medical system (or fragmented parts of it, as detailed below), throughout your career. If your doors are open to them, self-pay patients—a euphemism for the uninsured—will likely present themselves in your clinic every week.

Through diverse approaches, the citizens of every industrialized democracy but ours have passed universal health coverage for their populations. We are also alone in having a predominantly for-profit health insurance industry, in which insurers are private corporations that (must) generate dividends for stockholders and multimillion-dollar incomes for top executives. Here, of course, any patient “can always go to the ER,” but this inadequate “safety net” approach does not constitute universal coverage.

Most otolaryngology residents see patients in the ER who have delayed seeking medical attention due to lack of health insurance. Of course, this delay often worsens their prognoses and outcomes. A study of over 60,000 laryngeal cancer patients in the National Cancer Database from 1996 to 2003 found that “individuals lacking insurance or having Medicaid are at greatest risk for presenting with advanced laryngeal cancer” (10). (The study’s authors further note that “results for the Medicaid group may be influenced by the postdiagnosis enrollment of uninsured patients.” Medicaid is the public insurance program for the poor, jointly funded by federal and state governments.) They comment that “in multivariate analysis, the type of health insurance remained the strongest predictor of stage at diagnosis and tumor size.”

The authors of the laryngeal cancer study also looked at over 40,000 oropharyngeal cancer patients in the same national database. They found that, “after controlling for other sociodemographic characteristics, patients with advanced oropharyngeal cancer at diagnosis were more likely to be uninsured (odds ratio 1.37; 95% confidence interval 1.21-1.55)” (11). They noted that, after “controlling for covariates [patient sex, age, race, treatment facility type, zip code-based education and income categories, and U.S. Census region],” this association reached a very high statistical significance, with a value of P < 0.0001.

From my own residency, I remember more than one patient with laryngeal cancer who waited until experiencing acute airway compromise, after having been hoarse with odynophagia for weeks or months, before coming to the ER. These patients then usually needed a total laryngectomy for their T4 tumor. An earlier diagnosis would likely have required a less extirpative treatment. In a long-standing free annual community head and neck screening clinic conducted by the University of Michigan Department of Otolaryngology, “lack of insurance (P = 0.05) was a significant predictor of a lesion suspicious for malignancy” (12).

The IOM, the health arm of our National Academies, has noted for a number of years that, “for adults without health insurance [emphasis in original], the evidence shows: … adults are more likely to be diagnosed with later-stage cancers that are detectable by screening or by contact with a clinician who can assess worrisome symptoms” (13). The IOM physician representative who testified before Congress on its most recent report on the uninsured, Dr. John Ayanian of Harvard Medical School, noted in his testimony that “Uninsured adults are 25 percent more likely to die prematurely than insured adults overall, and with serious conditions such as heart disease, diabetes or cancer, their risk of premature death can be 40 to 50 percent higher” (14).

Lack of insurance, of course, is not the only factor contributing to the delay of diagnosis and treatment in seriously ill patients, including head and neck cancer patients. There are what have been termed “patient delay” factors, including vague or nonurgent-appearing symptoms. There are also “professional delay” factors, attributable to clinicians initially evaluating head and neck malignancies, in diagnosis and/or referral. These delays have been
identified for over two decades as a contributing factor in the advanced stage at which oral and oropharyngeal carcinomas are often diagnosed (15), for example.

There are numerous different classification schema for comparing countries’ medical systems. With his permission, I borrow a classification system published by the journalist and author T.R. Reid, a longtime correspondent for The Washington Post. He served as chief of the Post’s Tokyo and London bureaus, and hence lived in those countries, and utilized their health systems, for extended periods of time. He recently spent over a year surveying other rich countries’ health care systems, using his own stiff and painful shoulder as an entrée for a personal evaluation of these other systems. He also interviewed many physicians and policymakers, in many industrialized democracies.

He detailed his experiences and conclusions in a television documentary and a best-selling book. The documentary aired on the PBS program Frontline, entitled “Sick Around the World—Can the United States learn anything from the rest of the world about how to run a health care system?” (16). The countries’ systems differ quite significantly, from one to the other, but they each provide universal coverage. One section of the program’s website is entitled “Five Capitalist Democracies & How They Do It.” His subsequent book is entitled The Healing of Democracy: A Global Quest for Better, Cheaper, and Fairer Health Care (17) and provides an entertaining and very readable introduction to comparative medical systems. Michael Moore’s 2007 popular movie Sicko (18) also compared our system to other countries and includes numerous personal vignettes of American uninsured individuals.

Reid writes at length about his conversations with the Harvard economist William Hsiao, who has been involved in setting up health care systems in over a dozen countries. Hsiao (19) has coauthored a prominent textbook, Getting Health Reform Right, and his “team of health system analysts was commissioned by the Vermont Legislature to develop and evaluate three options for health system reform and determine which option would best achieve the stated goals” (20). His team “found that the system capable of producing the greatest potential savings and achieving universal coverage was a single-payer system.” Hsiao was very involved in setting up Taiwan’s relatively new single-payer system. Reid reports that his conversations with Hsiao focused on first principles:

As Reid notes, “all the developed countries except the United States have decided that every human has a basic right to health care.” He divides health care systems into four basic models: