U.S. Health Care Is (Still) Bad and Expensive

Last month the Institute of Medicine (IOM) released an exhaustive survey of U.S. Health Care in International Perspective, measuring the United States against sixteen peer countries (other high-income democracies) on a wide range of health outcomes. The results—summed up in the report’s subtitle, “Shorter Lives, Poorer Health”—are not pretty, but they aren’t surprising. The IOM’s Report is accompanied by an interactive graphic, ranking the United States on specific causes of death (from drowning to diabetes to dengue fever), on which the country persistently falls near the bottom of the pack.

The bigger tragedy, of course, is that while underperforming all of our peers we manage to spend more—indeed, a lot more—than any of them. The graphic below plots the IOM’s basic health metrics (deaths, deaths from communicable diseases, deaths from noncommunicable diseases, life expectancy at birth) against the most recent data from the OECD on health spending. The United States is in red, its sixteen peers are in blue (hover over the dots to identify individual countries), and the dotted black lines plot the basic trends. On each measure, the United States is a stark outlier—spending more and getting less in return than any of its peers.

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The relationship between spending and outcomes is complicated. Some of the spending differences reflect background differences in wealth: the United States spends more per capita on health because it is a rich country (it spends more per capita on cars and breakfast cereal too). And some of the outcome gaps (such as the high American rates of traffic accidents or gun violence) reflect factors other than the reach or effectiveness of the health care system. But even accounting for this, the gap between what we spend and what we get is jarring.

The sources of that gap are familiar. As a rule, we pay more than our peers for the same health care goods and services (especially drugs). Much “health spending” is wasted on administrative overhead, on marketing, and on the important business of figuring out who is insured and who isn’t. And that spending is starkly uneven, lavishing services on those with good insurance coverage and bypassing those without.

Most of these problems, unfortunately, will remain even when the Affordable Care Act (ACA) is fully implemented. In papering over some of the gaps in private coverage, the ACA’s mandates and subsidies are unlikely to do much to rein in costs. The recent IRS ruling, holding that the “affordability” test for job-based coverage would be based on individual rather than family coverage, is likely to leave many uninsured or underinsured. Expanded coverage, in turn, seems likely to be accompanied by a simultaneous decline in quality.

When we look at these same measures three or five years from now, it is unlikely that the United States will have moved any closer to the pack—on what we spend (or squander) and what we get (or don’t get) in return.



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The Kurds

[W]hen we refer to all Kurdish fighters synonymously, we simply blur the fact that they have very different politics. . . right now, yes, the people are facing the Islamic State threat, so it’s very important to have a unified focus. But the truth is, ideologically and politically these are very, very different systems. Actually almost opposite to each other. —Dilar Dirik, “Rojava vs. the World,” February 2015

The Kurds, who share ethnic and cultural similarities with Iranians and are mostly Muslim by religion (largely Sunni but with many minorities), have long struggled for self-determination. After World War I, their lands were divided up between Iraq, Iran, Syria, and Turkey. In Iran, though there have been small separatist movements, Kurds are mostly subjected to the same repressive treatment as everyone else (though they also face Persian and Shi’ite chauvinism, and a number of Kurdish political prisoners were recently executed). The situation is worse in Iraq, Syria, and Turkey, where the Kurds are a minority people subjected to ethnically targeted violations of human rights.  

Iraq: In 1986–89, Saddam Hussein conducted a genocidal campaign in which tens of thousands were murdered and thousands of Kurdish villages destroyed, including by bombing and chemical warfare. After the first Gulf War, the UN sought to establish a safe haven in parts of Kurdistan, and the United States and UK set up a no-fly zone. In 2003, the Kurdish peshmerga sided with the U.S.-led coalition against Saddam Hussein. In 2005, after a long struggle with Baghdad, the Iraqi Kurds won constitutional recognition of their autonomous region, and the Kurdistan Regional Government has since signed oil contracts with a number of Western oil companies as well as with Turkey. Iraqi Kurdistan has two main political parties, the Kurdistan Democratic Party (KDP) and the Patriotic Union of Kurdistan (PUK), both clan-based and patriarchal.

Turkey: For much of its modern history, Turkey has pursued a policy of forced assimilation towards its minority peoples; this policy is particularly stringent in the case of the Kurds—until recently referred to as the “mountain Turks”—who make up 20 percent of the total population. The policy has included forced population transfers; a ban on use of the Kurdish language, costume, music, festivals, and names; and extreme repression of any attempt at resistance. Large revolts were suppressed in 1925, 1930, and 1938, and the repression escalated with the formation of the PKK as a national liberation party, resulting in civil war in the Kurdish region from 1984 to 1999.

Syria: Kurds make up perhaps 15 percent of the population and live mostly in the northeastern part of Syria. In 1962, after Syria was declared an Arab republic, a large number of Kurds were stripped of their citizenship and declared aliens, which made it impossible for them to get an education, jobs, or any public benefits. Their land was given to Arabs. The PYD was founded in 2003 and immediately banned; its members were jailed and murdered, and a Kurdish uprising in Qamishli was met with severe military violence by the regime. When the uprising against Bashar al Assad began as part of the Arab Spring, Kurds participated, but after 2012, when they captured Kobani from the Syrian army, they withdrew most of their energy from the war against Assad in order to set up a liberated area. For this reason, some other parts of the Syrian resistance consider them Assad’s allies. The Kurds in turn cite examples of discrimination against them within the opposition.

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