The Silent Health Care Epidemic

Published April 1, 2004

A silent epidemic threatens the health of millions of people living in the United States; has no regard for age, race, education, or income level; is estimated to cost billions of dollars a year; is immune to preventative care and can’t be detected with a physical exam, blood test, or any high-tech diagnostic procedures.

According to physicians, volunteer health associations, universities, and health care companies, the epidemic is health care illiteracy. Forty million U.S. residents are reading at or below the fourth-grade level, with another 50 million residents reading at the eighth-grade level or lower. It is estimated by the National Work Group on Literacy and Health that approximately 66 percent of adults age 65 and older have low health literacy skills. These are the very people who use medical care the most.

Not a New Issue

In 1995, the Joint Committee on National Health Education Standards first used the term “health literacy”–the capacity of an individual to read, interpret, and understand basic health information and services. This includes the ability to comprehend instructions on prescription drug bottles, appointment slips, medical education brochures, and doctor’s directions and consent forms, and the ability to properly complete forms for government programs like Medicare and Medicaid.

In general, medical professionals agree health illiteracy is a risk factor for poor health outcomes. Without literacy skills, an individual may find it difficult to manage personal health, which often results in disease complications and health traumas.

Research suggests that people with low health literacy skills:

  • Make more medication errors.
  • Are less able to follow treatment directions.
  • Do not understand medical forms and procedures.
  • Are at a higher risk for hospitalization than people with adequate literacy skills.

The costs associated with low health literacy were calculated at more than $73 billion in a 1998 study by the National Academy on an Aging Society. The Centers for Medicare and Medicaid Services estimates Medicare pays out about $10 billion in additional medical care costs related to poor literacy skills. This does not include additional out-of-pocket costs, estimated at $11 billion, incurred by patients.


Medical information is becoming increasingly complex and, all too frequently, physicians do not explain things in layperson’s terms–or at least at the reading and comprehension level their patients function at. Physicians are under increasing time pressure in clinical settings and, even more important, they may not know when patients do not understand medical information or instructions.

Many patients, because they are embarrassed or intimidated by the powerful dynamic of the medical experience, do not ask health care providers to explain difficult or complicated information. If patients do not understand medication and self-care instructions, a crucial part of quality medical care is missing. All too often, adverse medical events are described as medical errors, when they really were failures in communication.

Health care illiteracy also can be attributed to the increasing failure of the U.S. education system to teach reading and comprehension skills. (See, for example, “NAEP Reading Scores Tell a Grim Tale,” School Reform News, June 2001.)

Call to Action

Clear communication should be considered the foundation of our health care delivery system, affecting everything from prevention and screening, to history-taking and explaining diagnosis and treatment. Tools and interventions to improve understanding of health information for all patients must be integrated into written and oral communications between caregivers and patients.

The Joint Commission on Accreditation of Healthcare Organizations suggests information for patient use should be written at fifth- to eighth-grade reading levels. The National Work Group on Literacy and Health recommends a fifth-grade reading level. The American Academy of Family Physicians’ Health Education Program recommends a seventh-grade or lower reading level. The University of Utah’s Health Sciences Center points out that the average adult typically reads one to two grade levels below their last grade completed.

Until modern medicine finds a way to increase the reading and comprehension level of some senior citizens–and poorly educated adults of any age, for that matter–it must find a way to communicate at the literacy level of patients.

Conrad F. Meier is managing editor of Health Care News. His email address is [email protected].