I'm a practicing physician in Reno, Nevada and have been a physician for 30 years. I've worked in three different health systems in three different countries. I've been a part of U.S. Health Care for the past 15 years and watched health care change from the pinnacle of success for a developed nation to becoming a murky, expensive fight amongst corporate entities for middle America’s dollars. Where did we go wrong? This is my attempt to try and unravel how we went from nightingale floors and charge nurses with clipboards who rounded with physicians to EMRs, data entry, denials of care and bloated co-pays.

This is Part One of a Four Part series looking at American Health Care. Part One looks at defining the problem; the problem in a nutshell is we pay too much and get too little. In Part Two I will look at who are the players. Part Three will show how costs are driven up. Finally, in Part Four I will offer potential solutions.

The following is a clickable guide to show this graphically so you can see the source of the chart or graphic.

If U.S. Health Care was a country, it would be the 5th largest country in the world, bigger than the Gross Domestic Products (GDPs) of over 188 countries!

Health Care is big business. It makes a lot of stakeholders a lot of money, but the money has to come from somewhere. We seem to have excellent quality of care and good access yet fundamentally the system appears broken.

We spend a lot on healthcare:





As a percentage of GDP, we are also the highest. Bear in mind we have the highest GDP in the world at $US21.41 trillion which is bigger than China, four times that of Germany, ten times that of Canada and more than China and Japan combined. Given this it’s still shocking that we spend so much on healthcare:

Combining Health Care spending per capita and GDP per capita, we are an outlier:

To get an idea of what spend on Health Care, U.S. health care spending grew 3.9 percent in 2017, reaching $3.5 trillion or $10,739 per person. As a share of the nation's Gross Domestic Product, health spending accounted for 17.9 percent.

Finally, when we look at Total Federal Government spending, Medicare and Health comprises 27% of all spending in 2015, more than total military spending. This amount does not include private sector spending.

What does all this tell us? It tells us that the most prosperous country in the world spends an inordinate amount on healthcare whatever way you cut it and that amount is increasing. U.S. Health Care has become as much an industry as motion pictures, defense or technology.

What do we get for this spending? Not as good as we think.

Despite all the money we lag on many basic metrics of Health Care. We have great nurses and physicians, cutting edge research, access, the latest technologies yet for the cost of delivery it is not translating into better outcomes any way we cut it, and guess what: it's getting worse:

Middle America is paying for this spending with increase in premiums and deductibles:

Despite all we the hospitals, urgent cares, mid-levels, clinics, pharmacies and technologies, for many it’s getting too expensive:

Is it because we the customers use too much? Expense is a function of price and volume. If things are being used too many times, or if things are too expensive, cost goes up. Interestingly in the US patients often spend less time in hospital than in other countries:

Patients in America see their doctors less often:

but, if they have surgery, generally it costs more:

and if they get prescriptions, they cost more:

Every week now, we see stories of Americans with insurance being sent exorbitant bills:

So, despite less doctor visits, if patients need surgery or prescriptions in the US, it costs more. There lies the rub. The problem is one of value, we are getting less for what we pay for and we pay a lot.

This brings me back to what is probably my favorite YouTube video which encapsulates the myth we've been living in for the last few decades please take a few minutes to watch and digest it. It's a good metaphor for where we are:

It would be naive to think we don't have a problem. It's not our doctors or our nurses. It's not the techs or the medical assistants. It's not the physical, occupational or respiratory therapists. It's not the dedication and passion and blood and sweat of the frontline workers in Health Care. It's not our trauma system. It's not the care we get in hospital. It's not the access to imaging. It's not our research. It's not the quality of care in general.

It's cost.

Next: Part 2- U.S. Health Care Gone Wrong: Who Are The Players?