Our health system is exceptional-unfortunately.
Exceptional ,yes. Exceptionally wrong. Which is connected with our misunderstanding of how our system works.
Almost alone in the "developed" world the US entrusts medical care-that is to the say our lives- to the Market. As Arnold Relman notes( July 2 New York Review) in 1963 the Nobel Prize winner Kenneth Arrow made the definitive argument why that doesn't work.
Quoting Relman ,quoting Arrow:
". medical care cannot conform to market laws because patients are not ordinary consumers and doctors are not ordinary vendors * ......patients must rely on physicians in ways fundamentally different from the price-driven relation between buyers and sellers in an ordinary market....contrary to the assumption of anti trust law, market competition..cannot ...lower medical prices. And since physicians influence decisions.far more than patients...health costs need to be controlled by forces other than the market "
(As they pretty much were when Arrow wrote at a time when professional standards,a still progressive tax system, and a non litagatory consensus meant we had reasonable health care, reasonably priced.)
How does it happen that we get this so wrong?
Remember Ann Richards comment that G.H.W.Bush was born on third base and thought he'd hit a triple ? Something like that applies to all of us..
We occupy a space-essentially a continent- so endowed with everything required for a prosperous country that it takes extraordinary efforts not to have a society in which everyone lives well. We've made those efforts(think Globilization and a non progressive tax system) and consequently a significant proportion of our population is- unnecessarily- poorly fed , poorly housed and unemployed.And scorned for their misery which is attributed to their personal failings rather than being seen as the result of the system we've put in place.
We understand ,dimly, that the Fed follows a policy intended to ensure that unemployment will not fall below 5% but nevertheless scold those included in that unfortunate 5% for not making the effort that would allow them to get a job at the expense of someone else who would instead join that 5%.
Even more wrong headed we-or at least intelligent conservatives (forget Limbaugh,Coulter and Co,-think Friedman , Kristal, Brooks and Bernanke)- perversely misidentify these failures of our system as causes of the residual benefits of our fortunate location their philosophy has not yet blighted..
We've had greatness thrust upon us . And we ducked.
*Kenneth J. Arrow " Uncertainty and the Welfare Economics of Medical Care" The American Economic Review December 1963
Excellent, Flavius. What the US has done is take
1. the powerful idea that market-based allocation of resources can be more efficient in maximizing social welfare than centralized approaches,
and turn this into the dogmatic belief that
2. market-based allocation of resources is always and everywhere more efficient in maximizing social welfare
and then turn this into the further dogmatic belief that
3. market-based allocation of resources is BY DEFINITION the maximal social welfare outcome.
Hence the idea that if some poor person dies of a treatable disease, well he deserves it. For if the market allocates health care resources elsewhere, it has by definition more value there, and if it allocates none for the poor, well, by golly it has no value there.
Just Econ 101, baby. Or rather, Friedman's little green book. Just read and repeat, every night before you go to bed boys and girls...
August 1, 2009 2:37 PM | Reply | Permalink
Exactly right.
August 3, 2009 9:10 PM | Reply | Permalink
1.Americans have better survival rates than Europeans for common cancers.
2.Americans have lower cancer mortality rates than Canadians.
3.Americans have better access to treatment for chronic diseases than patients in other developed countries.
4.Americans have better access to preventive cancer screening than Canadians.
5.Lower-income Americans are in better health than comparable Canadians.
6.Americans spend less time waiting for care than patients in Canada and the United Kingdom.
7.People in countries with more government control of health care are highly dissatisfied and believe reform is needed.
8.Americans are more satisfied with the care they receive than Canadians.
9.Americans have better access to important new technologies such as medical imaging than do patients in Canada or Britain.
10.Americans are responsible for the vast majority of all health care innovations.
http://www.hoover.org/publications/digest/49525427.html
August 1, 2009 4:05 PM | Reply | Permalink
Scott W. Atlas makes a compelling argument until you start looking for verification of his claims. I was interested in what he was saying, so I took the time to google most of his claims, and found his article for the Hoover Institute to be mostly a lot of cherry picking, and other claims that I was not able to verify in the time I want to spend on this topic. Here's what I found. I've not included links due to the complexity of doing so in a comment here at TPM.
1. Breast cancer survival rates in the US are lower than Australia, Norway, Luxembourg, Greece, Sweden, Portugal, Finland Poland, Spain, Japan, and Korea.
2. Prostate cancer mortality rate in the US is greater than Spain, Luxembourg, Greece, Italy, and Korea.
3. Overall cancer survival rates in the US are exceeded by Australia, Norway, France, Austria, Sweden Finland, and the UK.
4. The percentage of women receiving mammography screening in the US is exceeded by Iceland, New Zealand, United Kingdom, Canada, France, Ireland, Netherlands, Sweden, Finland, and Norway.
5. Americans going without needed healthcare due to costs occurred at a higher frequency than in Australia, New Zealand, Germany, United Kingdom, Canada, and the Netherlands.
7. Atlas appears to be correct in that the US has the lowest wait times for non-life threatening surgery. There is a concept of ‘optimal wait time’ with regard to specific surgeries. The fact that the US leads in this area does not necessarily correlate to better health outcomes.
8. Correlations between patient satisfaction with healthcare and actual health outcomes is unclear. Having a national database of information will help establish a connection if it does correlate. The most used measurement of health outcomes is Average lifespan. The US life expectancy at birth is exceeded by Greece, UK, New Zealand, Luxembourg, Germany, Netherlands, Finland, Austria, Belgium, Canada, Norway, Iceland, Australia, Italy, Sweden, Spain, France, Switzerland, and Japan.
9. MRI units per population unit in the US are exceeded by Italy, Finland, Austria, Switzerland, Iceland, and Japan. CT units per population unit in the US , (which is below the average OECD nation), are exceeded by Finland Denmark, Germany, Sweden, Greece, Switzerland, Iceland, Italy, Luxembourg, Austria, Belgium, Korea, and Japan.
10. The number of clinical trials conducted in the US has little to do with meaningful technical innovation. I would refer you to Marcia Angell’s article in the New York Review of Books, entitled ‘Drug Companies & Doctors: A Story of Corruption’.
Atlas's assertions don't make much sense in regard to establishing a national healthcare option or program, (or not). He appears to have just cherry picked a few statistics to make a case for maintaining the status quo.
August 1, 2009 7:32 PM | Reply | Permalink
Bad proofreading on my part. #s 1,2, &3 should read that the outcomes in the US are worse than the countries listed.
August 1, 2009 7:58 PM | Reply | Permalink
Here's a link you might like, miguel. What's killing the public option worth to the insurance industry? For 3 (Aetna, Cigna, UHG) it can be estimated at 30 billion.
http://baselinescenario.com/2009/07/31/the-value-of-not-having-the-public-plan/
This is what we're up against. It's wrath-of-god money...
August 1, 2009 8:34 PM | Reply | Permalink
Thanks for that pugsley. People kill for sooo much less than that, it puts what's at stake here in perspective. There's so much disinformation flying around right now, it's hard to keep the debate focused, but all you really need to reach the appropriate conclusion is to follow the money.
August 1, 2009 8:43 PM | Reply | Permalink
Hmm. If they just gave the government that money instead of lobbyists, we'd barely have to raise taxes on the rich.
August 1, 2009 11:19 PM | Reply | Permalink
Impressive, Miguel. Thanks - and bookmarked.
August 1, 2009 7:59 PM | Reply | Permalink
Good ones! You don't contradict his facts, just add additional ones.
And the emerging picture is so far from the paradise that Fred describes, you can only make make a "compelling" argument for copying them if you relay on the broadest and most average statistics.
It's a 50-50 at best, and I can't see how it justifies a trillion bucks.
:-)
August 1, 2009 8:02 PM | Reply | Permalink
Wow. I guess I made a mistake trying to engage sensibly with you on the health issue, Lalo. You throw up a list of headlines like that from the Hoover folks, headlines which turn out to hardly even be backed up by the statements which follow - and then you refer to them as "facts?"
From now on, I'm gonna assume that when it comes to health care discussions, you don't actually give a shit, but are just looking for some additional anti-government flak, doesn't much matter what it is or where it's from.
In short, you're talking out your ass, and taking up people's time.
August 1, 2009 10:37 PM | Reply | Permalink
As my son would say, "WORD."
August 1, 2009 11:48 PM | Reply | Permalink
"From now on, I'm gonna assume"
- Suit yourself Quinn.
If your idea of "engaging sensibly" simply means people agreeing with everything you say - then yes, you did make a mistake.
Secondly, I'd rather rely on what a Standford medical professor says about facts as they are today than on a 1963 theoretical paper from anyone else or a paid opinion from some conflicted economist.
The role of government is at the heart of the issue here, but you obviously like googled "facts" that agree with your point of view more than Hoover "facts" that they don't - and then throw a hissy fit that someone talks out of their ass??
I have more at stake here than you do, so if that's all you have to offer by way of "engaging sensibly", then yes I'd rather you assume whatever you're itching to assume and get on with it.
August 2, 2009 10:01 AM | Reply | Permalink
1. You're the one always proposing that markets can be made to work in health care, right? And Arrow's paper blows great big holes in that, thus helping to explain the otherwise surprising result - that markets have done a really poor job in this sector.
2. My Googled facts are from WHO and the OECD, as opposed to somebody from Stanford who makes wild-ass claims that don't even connect to the sentences that follow.
3. I've got lots of sibs, nieces, nephews and other relatives South of the border, so I've got plenty at stake, thanks. I wish you and yours excellent health, and I hope whatever comes out of this produces the best possible result for everyone.
August 2, 2009 12:22 PM | Reply | Permalink
What got me Q, was that that misdirection by Atlas got wide play in the press and blogosphere and I was not able to find a good rebuttal to it anywhere. I mean I'm just a guy who took an hour or so to do a cursory look at his claims, and I can pretty quickly see he's just cherry picking facts and stats to support his position. It's a bit scary that we've reached a point where we can all be Rush Limbaugh incarnate, and just make shit up, throw it out in an argument, and it takes on the patina of a valid thought or analysis, 'cause nobody's fact checking anything anymore. It's the culmination of Rovian political games and disinformation, and it's infected our culture. The appearance trumps reality. We have jumped the shark, and now the shark is tailing us looking for a bite to eat. Time to head for shore.
August 2, 2009 12:18 PM | Reply | Permalink
Maybe you're going to trust the BBC and UK Cancer research more than some guy from Stanford.
Fair enough.
"The US, Australia, Canada, France and Japan had the highest five-year survival rates, while Algeria had the worst, Lancet Oncology reported.
"The study showed the US had the highest five-year survival rates for breast cancer at 83.9% and prostate cancer at 91.9%. "
"There were also large regional variations within the UK, which were linked to differences in access to care and ability of patients to navigate the local health services. Both are directly linked to deprivation."
"The results closely mirrored the amount each country was spending on health during the period.
While the US led the way with more than 13% of gross domestic product spent on health, Canada, Australia and the best-performing European nations were all spending about 9% to 10%.
The UK was spending just over 7% but that figure has now been increased following record rises in the NHS budget to bring it much closer to the likes of France and Germany."
http://news.bbc.co.uk/2/hi/health/7510121.stm
August 2, 2009 12:48 PM | Reply | Permalink
Hard to evaluate a scientific study from a newspaper article, but I think the evidence it cites is not an argument for a free market system but rather for directed medical investment within whatever system you're utulizing. BTW, most of the sources I used for checking Atlas's 'facts' were OECD documents.
August 2, 2009 1:10 PM | Reply | Permalink
No, you simply cherry-picked your version of "facts" versus his.
It's easy to play this hide-n-seek game with links and data. Once you start looking behind the big overall numbers that Fred likes, once you start looking at individual country statistics, the reporting methods, etc - then you realize that there is no evidence that overwhelmingly supports an assertion that counties with public insurance option have better health outcomes.
That argument can only be made when you use the broadest possible metric, ignoring everything else, such as overal life expectancy and infant mortality. It breaks apart when you look deeper into details.
The reason for that is because equating health outcomes with existence of public option is like comparing apples to oranges. It's a propaganda argument used to sell the ideological snake oil.
August 2, 2009 1:20 PM | Reply | Permalink
I always thought the argument for public health systems was more about cost containment than health outcomes. I'm leaving for a while, so you'll have to find someone else to continue the discussion. Have a good week!
August 2, 2009 1:26 PM | Reply | Permalink
"the argument for public health systems was more about cost containment than health outcomes"
- Maybe we're in the wrong post then. Have a great week.
August 2, 2009 1:30 PM | Reply | Permalink
Regarding cherry picking, I only listed all countries whose health outcomes exceeded the US. Atlas on the other hand focused on a couple of countries with public health systems and picked the results from specific areas which 'appear' to support his argument. I never presented the facts I gathered as an argument for or against anything other than to expose the narrow scope, and consequent meaninglessness of Mr. Atlas's research.
August 5, 2009 5:32 PM | Reply | Permalink
The United States spends at least twice as much per capita compared with any other advanced country to get health care outcomes that are never more than a few percentages better than its "socialist" competitors, and are often worse. At the most charitable, Americans are being double-billed for a product that whatever it is, is certainly not double the worth or efficacy of that available elsewhere.
August 2, 2009 4:44 AM | Reply | Permalink
Just a personal note: My mammograms were no longer covered by my insurance as of 10 years ago because they were "diagnostic" rather than "preventive."
Now, why was that? Because I had breast cancer.
Yes, you heard it right. Once I had breast cancer, my mammograms were not covered by my insurance. (Even though only one boob was involved!)
August 1, 2009 11:43 PM | Reply | Permalink
I suppose in order to survive cancer, one must actually be treated for cancer.
However, our healthcare industry has long since shed the habit of treating cancer patients if it can get away with not treating them.
So far they've gotten away with it because nobody with any authority has said, "No. BAD. BAAADDDD!" There oughta be a law, but there isn't. It's perfectly legal in the land of the free and the home of the brave to deny medical care to cancer patients.
Studies conducted on cancer survival rates in the US would only include those who had received treatment. Those who had been unceremoniously dumped from their insurance plans or who had otherwise been denied treatment by their insurance providers would necessarily have been precluded from any published study. I believe we can all agree on that.
Let us examine the facts, Lalo:
From the National Institutes of Health:
"The SEER Cancer Statistics Review (CSR), a report of the most recent cancer incidence, mortality, survival, prevalence, and lifetime risk statistics, is published annually by the Cancer Statistics Branch of the NCI [National Cancer Institute]. The scope and purpose of this work are consistent with a report to the Senate Appropriations Committee (Breslow, 1988) which recommended that a broad profile of cancer be presented to the American public on a routine basis. This edition includes statistics from 1975 through 2006, the most recent year for which data are available."
Report from the National Cancer Institute:
"Age-Adjusted SEER Incidence and U.S. Death Rates and 5-Year Relative Survival Rates By Primary Cancer Site, Sex and Time Period [for] All Races"
See: http://seer.cancer.gov/csr/1975_2006/browse_csr.php?section=1&page=sect_01_table.04.html
Cancer survival rates by country published in the UK Telegraph in 2007 cite cancer rates through 2002.
See: http://www.telegraph.co.uk/news/uknews/1560849/UK-cancer-survival-rate-lowest-in-Europe.html
[cross-posted from previous blog which happened to disappear on the day of the spam deluge]
Lalo: You're either inventing statistics or you're quoting people who are inventing statistics. For shame.
August 2, 2009 12:02 AM | Reply | Permalink
Then why do Canadians have a higher average life expectancy than Americans?
You pay twice as much per capita, but it doesn't buy you a longer life. Scammed, much?
August 2, 2009 5:24 AM | Reply | Permalink
I think you're wrong about waiting time in the UK. That was certainly the case under Maggie.
The current statistics are easily available on the Web and they don't show long waits. And of course there , as will be the case here, you can eliminate any wait by becoming a private patient.
Not an accident. If you read Michael Foot's biography of Nye Bevan you'll see that he and the medical establishment jointly designed the system which worked well until Thatcher.
My daugher who's lived in the UK for most of the last 20 years simply didn't think about possible delays-if she thought she needed attention she went to her medical practice.
August 3, 2009 9:17 PM | Reply | Permalink
Government run health care is exceptional in this country. It is not perfect, but our VA system, or Medicare, while they have problems, are really quite a bit more successful than the contemptible private sector counterparts.
If it were up to me, I would choose to reform or perfect the systems we have in place now that work well for groups of American, our veterans, our congress, those over the age of 65--I would choose to work with what is working than to fix the hull of a sinking ship.
Lalo, the wind in the sails of your list of facts is really unmoving.
You're reaching and stretching but your boat is not moving very fast at all.
Insurance premiums outpace income eightfold. But you know what, instead of broadstroking this by comparing Canada to the US or Europe, I'm going to just go with what I know personally.
I am going to go with what I know about the health care situation firsthand, not just for me, but for my parents, my brothers and sisters, their kids, my friends, employed friends and unemployed friends.
I've never seen a disaster so up close and personal--I do not need broad comparisons of countries, or outcomes.
I see crisis in our health care system firsthand, Lalo.
There is only one way to judge the state of health care in this country. Ask yourself this:
Can you count on your health care in good times and bad? Will it be there in full measure when you need it? Will it be affordable when you need it? Is it of high caliber now? Will it be of a high caliber when you need it most? Can you take good care of yourself, can you stay healthy without the fear of going bankrupt and losing everything?
August 1, 2009 5:02 PM | Reply | Permalink
Every industrialized democracy surpasses us in covering more of its citizens at far lower cost and with better health outcomes as measured by the standard WHO criteria of life expectancy and infant mortality. All these other democracies utilize either a single payer system (the minority) or various public/private combinations. If our poor showing were only in comparison to one or two, it might be hard to interpret, but we rank at the bottom of a list of well over a dozen, and the burden of proof rests on anyone who claims our system is as good as the others.
Although we rank very poorly regarding overall mortality, our cancer data are only somewhat better. We are inferior to France, Sweden, Australia, and the UK in regard to cancer mortality rates, and on a par with New Zealand -
http://www.nationmaster.com/graph/hea_dea_fro_can-health-death-from-cancer
Numbers based not on mortality rates but on percent of diagnosed patients who survive are almost meaningless, because they are severely skewed by differences among nations in the extent of overdiagnosis. The most flagrant example involves prostate cancer. In the U.S., a large number of cases are diagnosed based on PSA screening, although the majority, if not diagnosed, would never have caused problems. A recent Scandinavian study showed a similar phenomenon involving mammography for breast cancer, although the overdiagnosis rate was not as severe. The study found that mammographically detected breast cancers not infrequently disappeared over time rather than progressed, and so mammography at too frequent an interval appeared to detect cancers that would not have harmed the individual if never diagnosed. The study did not attempt to refute the value of mammography, but merely to help physicians interpreet the results of screening.
August 1, 2009 6:19 PM | Reply | Permalink
I addressed many of the comments made earlier by Lalo, but forgot this one:
"10.Americans are responsible for the vast majority of all health care innovations."
On this one point, Lalo is absolutely correct. Almost all these innovations are due partly or completely to funding support from the National Institutes of Health (NIH), including drug development, which starts with NIH-funded discoveries and then is developed into patentable drugs by drug companies, often with some government subsidization.
It reflects an interesting American dichotomy. The American healthcare system, which for large segments of the population is exclusively private, ranks at the bottom among the developed democracies. In contrast, the NIH, which is a federal program administered by bureaucrats with the advice of scientific panels, and funded by income tax dollars, is one of the most spectacular successes in the history of modern civilization.
I hope I'm not interpreted as suggesting that private enterprises in the U.S. are inferior to tax-supported government programs in every case. There are certainly some exceptions.
August 1, 2009 6:45 PM | Reply | Permalink
but Fred, you're implying that the government has been responsible for many good things. National Institute For Health. Veteran's Administration.
Government, as I think you know, is only to be spoken about in public as "big and bad".
Fall in line, Fred:)
August 1, 2009 7:33 PM | Reply | Permalink
Glowing outcomes and statistics are irrelevant for those who can't afford treatment -- either because they don't have insurance or their insurance company finds a loophole in their policy to deny treatment.
Profit cannot ethically or morally be a component of health care. It just can't.
August 1, 2009 7:44 PM | Reply | Permalink
Conservatives argue, convincingly, that self interest is a powerful motivator. Which when harnassed results in far better community results than expecting people to work on behalf of a shared goal.Usually buttressed by referring to the Tragedy of the Commons- shared pasture land was never well cared for.
But a corollary is that self interest will cause a doctor, or even more a for profit insurance company to want to earn a profit-at the expense of the patient. Both in money and well being.
As is happens at the moment I am dealing with my insurance company which is trying to deny a claim
not because it's unjustified, they know it is, but simply to reduce their costs. Most of us have had that experience. Why expect that health insurance would be any different?
August 1, 2009 10:11 PM | Reply | Permalink
Above, I repeated my assertion that among the major industrialized democracies, the U.S. is at the bottom of the list for the standard health outcome criteria of life expectancy and infant mortality. For those interested in the 2009 rankings, the following information may be useful -
http://www.infoplease.com/world/statistics/infant-mortality-life-expectancy.html
August 1, 2009 9:06 PM | Reply | Permalink
Although not shown at that site, all the more than a dozen nations that surpass us spend far less than we do on health care - about half of our per capita spending, and a similar fraction of expenditures as a percent of GDP, where our current level is about 16 percent and most of the others are in the 8-11 percent range.
August 1, 2009 9:15 PM | Reply | Permalink
Ah, Fred, tirelessly peddling the law of averages and "grass is greener in other countries"...
"The age-adjusted death rate in 2006 declined to a record low. Life expectancy was 77.7 years, continuing a long-term increasing trend. Life expectancy increased for the total population, as well as for the black and white populations. Both males and females, overall and within the black and white populations, experienced an increase in life expectancy in 2006 compared with 2005. Age-adjusted death rates decreased significantly in 2006 from 2005 for 10 of the 15 leading causes of death, and increased for 2 of the 15 leading causes. Rates for the top three leading causes—heart disease, cancer, and stroke—continued a long-term decreasing trend. Significant increases occurred for unintentional injuries and kidney disease."
http://www.cdc.gov/nchs/data/nvsr/nvsr57/nvsr57_14.pdf
But, of course, Fred's point is that these things are not happening "fast enough" to get us to a ranking he'll be proud of.
August 2, 2009 11:35 AM | Reply | Permalink
With regard to infant mortality, the US law requires reporting of live birth if it shows any signs of life at all, regardless of weight, prematurity or size of the baby:
http://www.law.cornell.edu/uscode/uscode01/usc_sec_01_00000008----000-.html
Austria, Germany, Belgium, France, Switzerland, etc - all have different reporting requirements, such as weight (at least 500 grams) or size (12 inches) or term time (at least 26 weeks of pregnancy). They report lower rates than we do in part because they use different tracking system of infant mortality.
This is why OECD explicitly says in its report that direct comparison of infant mortality between countries in meaningless.
But the reason Fred is using these "low of average" meaningless statistics is because he's constantly suggesting that infant mortality in the US is high because of preventable medical conditions that our system of health care doesn't address. Anything to prove the need of the public option!
The truth is, as the CDC report linked above notes, the leading causes of infant mortality are congenital malformations, low birth weight, etc.
August 2, 2009 11:54 AM | Reply | Permalink
This is priceless:
So much for the meme of the "greatest nation." We have a lot to answer for.
August 1, 2009 11:56 PM | Reply | Permalink
Thanks for the compliment. I stole the line from a friend who used it about Nixon the day he resigned.
August 2, 2009 6:13 AM | Reply | Permalink
The thing that I find most exceptional about all of this is the fact that our congress and our government in general has so completely abandoned everything this country is about and what this country was founded upon.
Many of our elected officials and appointees as well as career bureaucrats in congress and the various branches are using government as a means to obtain undeserved wealth at the expense of the country. Our system has become corrupt beyond measure.
And we are stuck with this forever because the people who are running this are the ones who are corrupt. Government and the private sector have unmistakably merged into a seamless criminal enterprise that is extorting every citizen of this country every minute of every day. That we would witness such a blatant and complete usurpation of power isn't something I was ready for and really didn't think was even possible. Democracy is very fragile and is only as good as our leaders are honest. The crimes being committed against this nation, without a single public official voicing outrage and taking action that is commensurate with the crimes, is very informative. I see two choices. We can fix this or we can be a nation of criminals. We have a Constitution that tells us what to do. thepeoplechoose.
August 2, 2009 1:31 AM | Reply | Permalink