The health care system in the United States has been called “a paradox of excess and deprivation” (Enthoven & Kronick, 1989). Some persons receive too little care because they are uninsured, inadequately insured, or have Medicaid coverage that many physicians will not accept.
James Jackson was unemployed for more than a year but unable to qualify for Medicaid because his state did not expand Medicaid under the 2010 Patient Protection and Affordable Care Act. At age 34, he developed abdominal pain but did not seek care for 10 days because he had no insurance and feared the cost of treatment. He began to vomit, became weak, and was finally taken to an emergency room by his cousin. The physician diagnosed a perforated ulcer with peritonitis and septic shock. The illness had gone on too long; Mr. Jackson died on the operating table. Had he received prompt medical attention, his illness would likely have been cured.
Betty Yee was a 68-year-old woman with angina, high blood pressure, and diabetes. Her total bill for medications, which were only partly covered under her Medicare plan, came to $200 per month. She was unable to afford the medications, her blood pressure went out of control, and she suffered a stroke. Ms. Yee’s final lonely years were spent in a nursing home; she was paralyzed on her right side and unable to speak.
Mary McCarthy became pregnant but could not find an obstetrician who would accept her Medicaid card. After 7 months, she began to experience severe headaches, went to the emergency room, and was found to have hypertension and preeclampsia. She delivered a stillborn baby.
While some people cannot access the care they need, others receive too much care that is costly and may be harmful.
At age 66, Daniel Taylor noticed that he was getting up to urinate twice each night. It did not bother him much. His family physician sent him to a urologist, who found that his prostate was enlarged (though with no signs of cancer) and recommended surgery. Mr. Taylor did not want surgery. He had a friend with the same symptoms whose urologist had said that surgery was not needed. Since Mr. Taylor never questioned doctors, he went ahead with the procedure anyway. After the surgery, he became incontinent of urine.
Consuelo Gonzalez had a moderate pain in her back which was relieved by over-the-counter acetaminophen. She went to an orthopedist who ordered an MRI, which showed a small disc protrusion. The doctor recommended surgery, after which Ms. Gonzalez’ pain became much worse. She consulted a general internist who told her that the MRI abnormality was not serious, that the surgery had been unnecessary, and that physical therapy might help. After a year of physical therapy, the pain subsided back to its original level.
In February 2015, a year after the Patient Protection and Affordable Care Act was fully implemented, 26 million people in the United States remained without health insurance, down from 41 million in 2013 (Carman et al., 2015). In addition, many people with health insurance have inadequate coverage. In December 2014, 46% of Americans surveyed reported having trouble affording health care (Rosenthal, 2015).
According to health services expert Robert Brook:
…almost every study that has seriously looked for overuse has discovered it, and virtually every time at least double-digit overuse has been found. If one could extrapolate from the available literature, then perhaps one-fourth of hospital days, one-fourth of procedures, and two-fifths of medications could be done without. (Brook, 1989)
A 2003 study found that elderly patients in some areas of the country receive 60% more services—hospital days, specialty consultations, and medical procedures—than similar patients in other areas; the patients receiving fewer services had the same mortality rates, quality of care, access to care, and patient satisfaction as those receiving more services (Fisher et al., 2003a and 2003b). In 2012, waste in health care was estimated at between $558 and $910 billion per year—from 21% to 34% of total health care expenditures (Berwick & Hackbarth, 2012).