How do we fix the scandal that is American health care?

It’s not just that life expectancy in Mississippi (71.9) now appears to be a hair shorter than in Bangladesh (72.4). Nor that an infant is some 70% more likely to die in the United States than in other wealthy countries.

Nor even that for the first time in probably a century, the likelihood that an American child will live to the age of 20 has dropped.

All that is tragic and infuriating, but to me the most heart-rending symbol of America’s failure in health care is the avoidable amputations that result from poorly managed diabetes.

A medical setting cannot hide the violence of a saw cutting through a leg or muffle the grating noise it makes as it hacks through the tibia or disguise the distinctive charred odor of cauterized blood vessels. That noise of a saw on bone is a rebuke to an American health care system that, as Walter Cronkite reportedly observed, is neither healthy, caring nor a system.

Dr. Raymond Girnys, a surgeon who has amputated countless limbs here in the Mississippi Delta, one of the poorest and least healthy parts of America, told me that he has nightmares of “being chased by amputated legs and toes.”

“It starts from the bottom up,” Girnys said, explaining how patients arrive with diabetic wounds on the foot that refuse to heal in part because of diminished circulation when blood sugar is not meticulously managed in a person with diabetes. Girnys initially tries to clean and treat the lesions, but they grow deeper, until he has to remove a toe.

When more wounds develop, he takes off the foot in the hope of saving the rest of the leg. New wounds can force him to amputate the leg below the knee and perhaps, finally, above the knee. After that, Girnys said, the patient is likely to die within five years.

A toe, foot or leg is cut off by a doctor about 150,000 times a year in America, making the United States a world leader of these amputations.

I’ll be blunt: America’s dismal health care outcomes are a disgrace. They shame us. Partly because of diabetes and other preventable conditions, Americans suffer unnecessarily and often die young. It is unconscionable that newborns in India, Rwanda and Venezuela have a longer life expectancy than Native Americans newborns (65) in the United States. And Native American males have a life expectancy of just 61.5 years — shorter than the overall life expectancy in Haiti.

But there are fixes, and three in particular would make a huge difference: expanding access to medical care; more aggressively addressing behaviors like smoking, overeating and drug abuse; and making larger society-wide steps to boost education and reduce child poverty. One reason to believe that we can do better on health care outcomes is that much of the rest of the world already does.

This is the third essay in my series about how we can better help the millions of Americans left behind. We in journalism mostly cover problems: We typically write about planes that crash, not planes that land. But this series aims to offer solutions to challenges our nation faces.

A superpower where many citizens die young

A starting point is to avoid the myopia of Russia when it experienced a drop in life expectancy beginning in the 1980s and a rise in “deaths of despair.” Leaders took comfort in Russia’s status as a military superpower and a standout in the sciences and performing arts; they blamed individuals’ lack of personal responsibility for the deaths. They didn’t understand that when so many people are sick and struggling, the ailment is deeper than individual weakness.

Americans sometimes blithely boast of the best medical care in the world, and there is some truth to that. I have a friend who is alive today because of the success of immunotherapy to fight stage IV cancer.

Our health technology and cutting-edge medicine is superb. Yet whatever the quantity and quality of our bone saws, the tragedy is that they are so often needed.

America’s health crisis is most evident among low-education and low-income Americans, notably people of color and particularly men.

“The poorest men in the U.S. have life expectancies comparable to men in Sudan and Pakistan; the richest men in the U.S. live longer than the average man in any country,” researchers with the Opportunity Insights team at Harvard concluded. But while the gaps we focus on have to do with mortality, there are also enormous gaps in quality of life.

“It’s very rare that I’ve got somebody in that has just one health problem, or in for a wellness visit,” said Yvonne Tanner, a nurse practitioner in the Mississippi Delta town of Itta Bena, with a population that is largely poor and Black. “Everybody that I see is already very, very sick.” Most have multiple diagnoses, she said, of hypertension, diabetes, arthritis and more.

Type 2 diabetes, the kind that is linked to diet and inactivity, used to be called adult-onset diabetes but now affects children as well — and it encapsulates American ill health. It reflects the brilliance of soda companies and fast-food companies at marketing their products — in ways that are good for corporate profits but disastrous for American health. Type 2 diabetes often strikes the poor and marginalized who live chaotic lives without insurance, seek cheap calories in food deserts and struggle to manage budgets and insulin levels. The upshot is often dialysis, amputations and disability.

Statisticians have tried to calculate what they call “healthy life expectancy” in a population — the number of years an average person in a country can live a normal life, before amputations, dialysis, blindness or other setbacks. In the United States, that is just 66.1 years, shorter than in Turkey, Sri Lanka, Peru, Thailand and other countries that are much poorer. My dad was an Armenian refugee who fled Romania and was thrilled to settle in America; now Armenia and Romania both have longer healthy life expectancy than the United States.

One step forward: Expand access to care

Here’s a simple step to improve access to health care: Expand Medicaid.

Ten states, including Mississippi, still have not done so even though nearly all the funds would come from the federal government. Partly as a result, some hospitals are cutting back services in Mississippi and are at risk of closing.

A cartoon in Mississippi Today recently showed a patient asking a doctor, “How long do I have, doc?” The physician replies: “Longer than this hospital.”

Some 28 million Americans lack medical insurance. An even larger number of Americans — 77 million — lack dental coverage.

Cost is often the argument against expanding access to health care. But it’s hard to understand how just every other advanced country can afford universal care and the United States can’t. And consider that 94% of Americans with substance-use disorder do not get treatment, even though this pays for itself many times over. Our policy often seems driven less by cost considerations than by indifference, even cruelty.

Improving access to health care can also take other forms, such as improving outreach and increasing diversity in the ranks of health workers. Researchers have found, for example, that Black patients have better outcomes with Black doctors.