- Gilbert Simon, MD
Ripped Off - Foreword by Alan S. Greenglass, MD
One hundred years ago, within the lifetime of the grand- and great-grandparents of many of us, the average life expectancy of an American was about 55 years. Today, that figure is 78 years.
In 1920, the third leading cause of death in our country was tuberculosis (TB); about 97,000 people died from it each year. The only treatment was to send victims for rest and fresh air treatments, or to isolate them in sanitariums. Today, only about 500 Americans die each year from TB.
The great, worldwide influenza (flu) pandemic that began in 1918 and lasted two years killed an estimated 20 to 50 million people worldwide, and 675,000 (.65% of the population at the time) in the United States. Today thanks to the flu vaccine, other preventive measures, and better treatments, the death toll has averaged 42,000 people per year over the last eight years.
One hundred years ago, there were no medications for depression or other mental or behavioral illness. It was thought that the patients were weak, lacking moral conviction, and the unfortunate who suffered most were locked away in asylums.
There was no insulin to treat diabetics. Adults succumbed to infections, gangrenous legs were amputated, and they suffered with kidney and heart disease. Children with diabetes usually died within a year.
The list of horrors goes on and on (did I fail to mention cholera, typhoid, and even some malaria in New York City, paralysis from polio, blindness and pneumonia from the measles, male sterility from the mumps, as only a few of the other examples?).
We are so much better off today, right? What’s the big deal? Why should we care that Dr. Gilbert Simon has written this exquisitely detailed book about health and healthcare in the United States?
One reason is that the life expectancy of an American has actually gone down a bit over the last ten years. And, for lower income and minority citizens, that expectancy can be five to ten years less than for the general population. Although our average lifespan had been similar to that of other developed nations, theirs has continued to rise (81 in Germany and Great Britain, 82 in France, and 84 in Japan), while ours has plateaued or fallen, especially for the poor.
Other reasons to care include:
Our infant mortality rate, 58 per 1,000 live births, which ranks us 55th below the best in the world
The number of Americans with diabetes continues to climb, now affecting one out of every ten of us (although death is less frequent than 100 years ago, type 1 diabetics generally live ten years less than the general population, Type 2 diabetics five years less).
Asthma is increasing, and due to this disease American children miss over 10 million days of school each year, and adults miss over 14 million days of work (at an estimated economic cost of $85 billion per year).
And, among these and a myriad of other challenges to our health and well-being, bankruptcies due to debts for healthcare expenses number about 350,000 families each year, contributing to about two-thirds of all personal bankruptcies.
We now spend more per person for health care than any other country. And, as Dr. Simon points out, this cost is being paid directly and indirectly by everyone. The per capita expenditure, about $10,600 (in the aggregate 18% of our gross domestic product), now saps monies that could pay for better housing, better food, and better education.
While it’s not inherently bad to spend what’s needed to keep people healthy, as Dr. Simon convincingly documents, we are spending up to a third too much. We were not always the leaders in the health care expense race. As recently as 1970, our expenditures were about equal to those of the average developed country.
Since then, we’ve jumped up by almost 5% annually, to the point at which our per capita expenditures are twice those of the average of similar developed countries. We probably would not be complaining if we were getting something better for the extra cost—it’s just that that’s not the case for most of us.
This book is special not just for the comprehensive and detailed look at the American health care system (if you can call a hodge-podge of overlapping, duplicative, contradictory, competing, nonconsumer-friendly, cottage industries a “system”), for the book helps us by providing salient take away messages at the end of chapters, as well as action steps we each can take to protect the health of ourselves, our families, our communities, and our wallets.
On a larger scale, this book begs the question of whether our current health care business model can be tweaked or adapted to serve us better than the big health care providers, insurance companies, drug companies, and physician lobbying groups. While much has changed in how people get their health care, little has changed over the last 50 years in how it is bought and paid for.
We now have a Jenga tower, or maybe a pick-up sticks pile, onto which we are adding more complexity, technology, and expense.
Much of the progress we’d made in our health over the past century was due to public health improvements (less smoking, better nutrition, better sanitation), preventive interventions (immunizations and testing for early warnings of disease), and some basic pharmaceutical interventions (for diabetes, high cholesterol, high blood pressure, cancer, and infections).
But the incremental improvements we now are achieving are burdened by outsized costs (less “bang for the buck”). Now the pace of medical advances has slowed down, and more and more such improvements need to be made by having healthier lifestyles and better access to those previously discovered innovations.
So, while much has been accomplished, we still idolize the world of Marcus Welby and Dr. Kildare, and behave in a business sense as though health care is something that heroic individuals and the free market can manage.
We are relying upon the benevolence of corporations and of physicians, and the result is that consumers don’t have or can’t use knowledge, power, and money to effectively navigate the present and the future.
The societal solution that Dr. Simon comes to is not a tweak, but a wholesale change. We need better health, better health care, and less expense. We’ve tried our current approach for a long time; there is little evidence that it can do any better.
But there is evidence from most of the developed countries of the world that there is a proven approach: universal access to and insurance coverage of health care, increased public spending on the social determinants of health, and a limit to the financial burden on the individual and family for care that can keep us well, and care that gets us better when we are sick or injured.
And Dr. Simon points out that there are examples in our own country in which the profit motive is secondary to serving the greater good, such as Kaiser Permanente, the Mayo Clinic, the Cleveland Clinic, and Intermountain Healthcare.
Many of us will remember from our American history books the Four Freedoms that President Franklin Roosevelt propounded in his 1941 speech to Congress:
Freedom of Speech
Freedom of Worship
Freedom from Want
Freedom from Fear
But do we remember and take to heed the Second Bill of Rights he spoke of in his 1944 State of the Union Address, saying that “Every American has the right to”:
An adequate wage and decent living
A decent home
Economic protection during sickness, accident, old age, or unemployment
A good education
Gil Simon shows us the reasons why we haven’t yet gotten to FDR’s vision and shows us a path to keep moving along to those goals.
Alan S. Greenglass, MD
President, Physicians for Social Responsibility, 2020