A comparison of the primary health care offered to citizens of 10 industrialized nations has found the United States sitting at the bottom.
Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health compared the nations on a variety of counts -- from public satisfaction with health care to infant mortality rate -- and found that only the former West Germany did as poorly overall as the United States. The Netherlands, Canada and Sweden ranked at the top.
Relying heavily on data from the 1980s, she found that primary health care in the United States was relatively inaccessible, there was widespread public dissatisfaction with the care, services were expensive, babies were born smaller and died more often and adults weremore likely to die from preventable illnesses.
Primary care is offered by family physicians, general practitioners, internists and pediatricians -- doctors trained to consider the whole body rather than particular organs or systems. They also decide whether a patient should see one or more specialists, then help the patient get appointments.
Dr. Starfield, whose analysis appears in today's Journal of the American Medical Association, said health care in the United States suffers partly because there are too many specialists and too few generalists -- forcing many people to hop from one specialist to another in search of answers to their health problems.
She said the poor showing of the United States also resulted from its status as the only industrialized nation besides South Africa that doesn't provide universal health coverage. About 38 million Americans lack either private insurance or public coverage such as Medicaid.
"The general conclusion is that we lack universal access, which is important, and we need to move away from high-tech specialty care," said Dr. Starfield, a professor of health policy.
Dr. James Todd, executive vice president of the American Medical Association, said the study failed to take into account the difficult social problems that make the United States unique among the nations with which it was compared:
"The leading cause of death of black males under the age of 20 is murder. We have more auto accidents than any other country in the world. We have more drugs. We have more violence."
He added: "On the other hand, you can't dismiss it [the study] out of hand."
For her analysis, Dr. Starfield compared Australia, Belgium, Canada, Denmark, Finland, West Germany, the Netherlands, Sweden, theUnited Kingdom and the United States.
Using existing data, she compared the countries on three levels -- the accessibility of primary care and the degree to which it served as an entry into the larger health care system; public satisfaction coupled with cost; and the health of the nation's people, taking such factors as infant mortality and life expectancy into account.
The United States ranked near the bottom in all three categories. The Netherlands, Canada and Sweden fared well across the board.
And while West Germany ranked near the middle in satisfaction and expense, it ranked near the bottom in the other two categories.
Dr. Starfield said she was not surprised by the poor showing of the United States, whose health care system is considered by many experts to have reached a crisis because of rising costs and poor access.
But she said West Germany's dismal performance surprised her because many U.S. experts have pointed to that country and Canada as nations whose health care systems are worth emulating.
"Both countries have universal access," she said. But Canada benefits by having government as the single insurer responsible not only for paying medical bills but also for monitoring the efficiency and performance of doctors, she said.
"Germany has many different insurers. . . . It's evidence of the fragmentation of a system."
Health care: cost and satisfaction
Dr. Barbara Starfield of the Johns Hopkins School of Hygiene and Public Health, using a poll of public satisfaction with the overall health care system, along with the cost of health care, ranked industrialized nations as follows. Data for Belgium, Denmark and Finland were not available.
* West Germany
* Australia and United Kingdom
* United States