Today, we welcome a guest post from Dr. Muriel R. Gillick, author of Old and Sick in America:  The Journey through the Health Care System.

Since the introduction of Medicare and Medicaid in 1965, the American health care system has steadily grown in size and complexity. Old and Sick in America takes readers on a narrative tour of American health care, incorporating the stories of older patients as they travel from the doctor’s office to the hospital to the skilled nursing facility, and examining the influence of forces as diverse as pharmaceutical corporations, device manufacturers, and health insurance companies on their experience.

Old and Sick in America is now available in both print and e-book editions.

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The Not-So-Secret Secret About American Health Care

If you read any of the voluminous newspaper coverage of the seemingly perpetual debate about the American health care system over the past few months, you would think that the U.S. had two problems: first, health insurance is too expensive and second, many people can’t get insurance, either because they don’t have jobs that provide coverage, they can’t afford it, or they have something invented by the insurance industry called a “pre-existing condition.” If you are right-leaning in your inclinations, you think the main problem is the former, because you believe coverage is a matter of free choice (if people worked hard enough or cared enough they could manage to obtain health), and if you have left-leaning tendencies, you think the problem is principally the latter, because you believe that health care insurance coverage is a right (if it costs too much, then government should subsidize it). What nobody seems to be talking about is the quality of American medical care—what you get if you do access treatment. And the dirty little secret of American health care is that the medical treatment that people get, even when cost and access are not issues, leaves a great deal to be desired.

That’s not to say that some aspects of American medicine, at least as provided in certain hospitals, in particular parts of the country, and by some physicians, aren’t spectacular. My son suffered significant trauma after colliding with another player during an ultimate Frisbee tournament. He sustained a concussion, an orbital fracture, a maxillary fracture, and various other injuries. He was whisked off to a nearby hospital and evaluated; within days, he had plastic surgery performed by an outstanding physician, and within a couple of months, he had recovered completely.  I have a friend who fainted while on vacation in San Francisco and was astutely diagnosed as having anemia due to babesiosis, a parasitic infection transmitted by tick bite (endemic on Cape Cod, 3000 miles east of California). I have no doubt that the diagnostic acumen and swift response of the medical team—he received the appropriate antibiotics and the requisite number of transfusions for his profound anemia within hours of his arrival in the emergency department—saved his life. This is American medicine at its best: carried out by extremely competent doctors with access to the latest technology and the most effective medications. But what is often forgotten in the drive to “fix” the health care system is just what it is that needs fixing: it’s not merely inadequate access and excessive cost; for large swaths of the public, the care itself is sub-optimal. For no group is that more true than the very frail and very old.

Contemporary American medicine focuses on single diseases—on treating cancer or heart failure or asthma—but sick, very elderly individuals tend to have multiple interacting problems and failure to consider their “co-morbidities” results in sometimes devastating side effects.  Medicine today is at its best when it applies the latest, most sophisticated technology—but the oldest old often fare better with low-tech, high-touch, home-based care, thus escaping, for instance, the complications and confusion that ICU medicine engenders in this group. And modern medicine relies heavily on subspecialists such as cardiologists, oncologists, and neurosurgeons to deliver care—but what frail elders need most is the coordinated, comprehensive care of a primary care physician.

The inadequacies of American medicine in other domains have been noted before. The Commonwealth Fund, in its report “Mirror, Mirror, on the Wall,” first published in 2010 and revised in 2014,  finds that the U.S. places last in its overall ranking of the health care system in eleven developed nations. Among the quality indicator it cites, the U.S. ranks 7th in safety, 6th in coordination of care, 4th in patient-centered care, and 3rd in effective care. In those cases where its performance is reasonably good, it is nonetheless highly variable: its excellent track record in some populations swamps its abysmal performance in others. From the exclusive focus on cost and access in the current debate, you’d never know there were quality issues. It’s a secret hidden in plain sight. But it’s time we reform medical care, not just health insurance.

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Muriel R. Gillick, M.D., is a member of the Division of Aging at the Brigham and Women’s Hospital and professor of population medicine at Harvard Medical School.  You can read her earlier UNC Press blog post here.  For more, visit her website.