A Health System Failure?>
Be Well

A Health System Failure

by John Swartzberg, M.D.  

The U.S. is falling behind in many measures of health, according to a recent analysis published in the Journal of the American Medical Association(JAMA). We’re also falling behind in overall life expectancy as well as what is called healthy life expectancy, or HLE.

Healthy life expectancy is an estimate of how many more years of good health people at a given age can expect to have, on average. To me, this information is much more meaningful to both individuals and society as a whole than overall life expectancy statistics. After all, we're interested in how many "good" years we have left. The "bad" years can be miserable for the individuals and are a major cost to society.

In the latest report from the Centers for Disease Control and Prevention (CDC), which looked at state-by-state healthy life expectancy at age 65, Hawaii came in first (with an HLE of 16.2 years) and Mississippi last (10.8 years). Nationally, the average HLE for African Americans at age 65 is 3.2 years less than it is for white Americans. Whenever I read such statistics and generalizations, I think about people I’ve met who are representative of our failings. I’d like to introduce you to one of them.

Mr. S, an African American, recently visited the free clinic where I volunteer. Mr. S hadn’t taken his diabetes medication for a couple of months because he couldn’t pay for it (a benevolent pharmacist nearby offers drugs at a nominal price to the clinic’s patients, but even so, some of my patients find the low fees too costly). He handed me a scrap of paper with the drug’s name on it, saying that he could barely see the paper, let alone the writing.

His blood sugar was three times higher than it should be. But it was his physical exam that saddened me most. Diabetes can damage almost every organ, and Mr. S’s body was a testament to this. I could see in his eyes that the blood vessels in the retina had hardened and hemorrhaged. The nerves to his feet weren’t working; he had minimal circulation below his knees and an infected ulcer the size of a silver dollar under his right foot that he could not feel. He was in trouble, both short-and long-term.

Mr. S has been married for 20 years and is the father of two teenagers.He will turn 44 later this year. He’s almost 25 years younger than me, and even so, my HLE is longer than his. In fact, it’s very likely he won’t reach my current age.

Two key factors that greatly reduce both overall life expectancy and healthy life expectancy are poverty and lack of access to health care, both of which have increased since the Great Recession started in 2008. During this time, the standard of living for African-Americans has declined more precipitously than it has for other groups.

I prescribed medications to reduce Mr. S’s high blood sugar and antibiotics for his foot infection, and set up appointments with a vascular surgeon and a diabetes nurse specialist. He’s also going to see a social worker, who will help him get on Medi-Cal (California’s version of Medicaid).

But in reality, this all probably won’t make much difference for Mr. S. I suspect his lower right leg will have to be amputated; his left leg will likely soon follow. His kidneys are probably not working well (again, because of diabetes) and, if he doesn’t die of a heart attack or stroke (big risks for people with diabetes), he faces the prospect of tethering his life to a dialysis machine.

What chills me is that all of this could have been prevented. We hear it over and over again: The U.S. spends far more per person on health care than any other country, but we don’t get our money’s worth—and millions of Americans get virtually no care until they’re in perilous shape. The poorest health delivery system I have seen is the one proffered in the richest country in the world. It shouldn’t be this way.

I do have hope, however. I believe that the Affordable Care Act will improve matters and increase everybody’s healthy life expectancy. It may well be too little, too late for Mr. S, but it’s a sign that we’re heading in the right direction.