Greg Mankiw writes:
The next time you hear someone cavalierly point to international comparisons in life expectancy as evidence against the U.S. healthcare system, you should be ready to explain how schlocky that argument really is.
He points to the following claim by Gary Becker:
National differences in life expectancies are a highly imperfect indicator of the effectiveness of health delivery systems.for example, life styles are important contributors to health, and the US fares poorly on many life style indicators, such as incidence of overweight and obese men, women, and teenagers. To get around such problems, some analysts compare not life expectancies but survival rates from different diseases. The US health system tends to look pretty good on these comparisons.
Becker cites a study that finds that the U.S. does better than Europe in cancer survival rates and in the availability of hip and knee replacements and cataract surgery.
It makes a lot of sense to think of health as multidimensional, so that some countries can do better in life expectancy while others do better in hip replacements and cancer survival.
But I disagree with Mankiw's claim that it's "schlocky" to compare life expectancy. If the U.S. really is spending lots more per person on health care and really getting less in life expectancy compared to other countries . . . that seems like relevant information.
To put it in statistical terms: much of our quantitative analyses are essentially comparisons. And, once you're comparing, it makes sense to consider other factors (for example, Americans are less likely than Europeans to smoke, and more likely to be obese). But the overall outcome is important in its own right. Becker mentions cancer survival rates, and, cancer survival is definitely important--more important than all the research I've ever done, that's for sure--but a large change in cancer survival rate does not necessarily correspond to a big increase in life expectancy. And the same can be said for joint replacements and cataract surgery. What's missing in Mankiw's discussion is the connection between the huge cost differences between the U.S. and other countries, and the very specific cases where our system works better.
The funny thing is, I think my former co-blogger Robin Hanson would probably agree that government-funded healthcare is a bad thing--but for an opposite reason from Mankiw's! Hanson would oppose government health care, I think, because he would fear that it would lead to political pressure to spend even more on healthcare that, as he sees it, doesn't actually do much of anything to improve net health outcomes. In contrast, I think Mankiw is opposing a government system because he fears it would lead to cost-cutting and a move to a European-style system with lower cancer survival rates, fewer hip replacements, etc.
In summary, I am sympathetic to Mankiw's frustration with people who draw sweeping conclusions from raw comparisons. If policymakers are interested in moving the U.S. to a medical system more like France's, or Taiwan's, or whatever, they ultimately should be looking not at static comparisons but at how health and cost outcomes might change here under different proposed policies.
That said, life expectancy is important. If you're going to make a raw comparison, I'd rather compare countries on life expectancy than on cancer survival rates or the availability of hip replacements and cataract surgery. Or, to put it another way, if health care doesn't matter, if the main driver of life expectancies in America is the way we eat and live, then maybe it would make sense to spend 50% less on our health care system.
100 comments
First?!
Anyway, Nate, you should know that Greg Mankiw's grandmother does not appreciate you talking about him in your blog.
I agree that life expectancy is important, but I think you're missing the point of Mankiw's post. Imagine two countries with identical health care systems. If one country, demographically, has more people of low income, then looking at life expectancy per se doesn't make any sense. You need to control for these things before you can draw any good conclusions on effectiveness. If you don't, and make a raw comparison, you probably end up learning more about the socioeconomic makeup of a country than its health care system.
I usually agree with nate.
But, here he misses the point.
I agree with Dan S, I am very disappointed that Nate is so uninformed here. This is usually the kind of thing he can dissect.
Nice job, Andrew.
Life expectancy is the average number of years that people in a country live. It is affected by all kinds of things including their own (un)healthy behavior, accidents, wars, epidenics, famines, the environment, and public health and medical care.
You are right to close on the ovious logical flaw in Mankiw's argument. Maybe we ought to divert some of the money that's wasted on our health care system to addressing those other sources of loss of life.
Mankiw here, as in some of his other work, is just throwing up flak instead of really addressing how we should best compare the payoff from health/medical care spending.
Technical note: life expectancy, as it's usually represented, is subject to certain kinds of measurement error, including age exaggeration and underreporting of deaths. So we should be a little cautious about accepting the reported figures.
But it's still a pretty good indicator of the overall physical quality of life of a population -- much better than reported infant mortality rates, which are subject to even more measurement error including different definitions of "live birth" used in different countries -- as well as underreporting of deathts.
Chris?
airhawk86?
Did you notice that the byline reads "by Andrew Gelman @ 9:29 PM"?
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
I love it when economists start talking with authority about what constitutes quality in healthcare. Perhaps you should pay more attention to my thoughts about regulation of the derivative market then.
Given Mankiw's background, it's not surprising that he would point out that we do better in terms of hip replacement surgery, but what that has to do with the overall quality of the US healthcare system is beyond me. Infant mortality is a much better indicator, and we lag behind Slovenia and Cuba.
Yes, yes, yes, making simple comparisons can lead you to erroneous conclusions, but a cheap equivalency between hip arthroplasty and childhood immunization ("we're just good at other things") is worse than simplistic, it's frankly immoral. Particularly from someone who should know better.
"Nate is so uninformed here"
oh the irony
What is lacking from this discussion is a reasonable alternative for comparing the success of relative health care systems. One of the things economists claim they do well is count things. I haven't read the definitive paper on measuring aggregate returns on healthcare expenditure.
I have friends doing work in healthcare research and his reading of the existing literature is that it is embarassingly lacking in good empirical economics.
So the fact that we are fatter, sicker, and die younger than other countries is now being used as evidence that we DON'T need a better health care system?
All jesting aside, wouldn't a measure like infant mortality rates remove some of the lifestyle choice variables from a cross-country comparison? (admittedly, many socioeconomic differences would still be at play).
I actually just took a class on this very subject, and one of the things we talked about fairly often in the class was how do you compare two health care systems of countries. Life expectancy is generally not used since it is not entirely dependent on health care alone, it is one of the many factors, but it is not the only one. Therefore it is much more difficult to control for.
One of the mot common comparisons drawn is the success rate of surgeries and medical procedures. Yes, we do better with things like cancer survival rates, hip replacement, cataract surgeries. However, we do much worse in any number of things.
Statistically speaking, when countries are compared side by side in any kind of medical aspect no country comes out ahead in everything. There are generally individual things that countries are better at, and ones they are worse at.
However, the U.S. spends twice the OECD average on health care per capita. The only country that even came close was Japan, I believe, which was roughly two thirds of our per capita cost. The size and cost of our health care system has not provided a reasonable increase in benefit-to-cost ratio.
However, there are any number of reasons that could explain this, it's very difficult to jut say "We're spending more money without being a noticeable leader in health care" without looking at a huge number of potential factors and reasoning.
I believe that disparities in mortality rates is better explained by levels of income inequality than health system quality. For more on this, see Richard Wilkinson's work: http://www.bmj.com/cgi/content/extract/314/7080/591 as a starting point.
Like Mankiw, I think it's better to focus on specific desired outputs when evaluating the cost/quality/access levels among health systems. If you want to use mortality, try looking at infant mortality first. That is more indicative of health system failures (especially public health system failures) than overall mortality.
Regards,
@ Marielle,
"Statistically speaking, when countries are compared side by side in any kind of medical aspect no country comes out ahead in everything. There are generally individual things that countries are better at, and ones they are worse at."
Exactly.
The US fares worse than Canada and Europe on a number of measures, including success rates of organ transplants, obstetric care in general (MMR, or maternal mortality rate, is as disproportionately high in the US as infant mortality is ), general surgical mortality, and specific types of cancer (such as stomach cancer and non-Hodgkin's lymphoma, I believe). I used to have the links, I'll post them once I dig up.
Where the US generally tends to do better are breast/prostate cancers and geriatric care.
Andrew here is doing his cause a disfavor by accepting the subtle frame of "the US fares worse on broad public health measures (i.e. life expectancy), but does better once you get down to the nitty-gritty of medical care". That's simply not true. On the nitty-gritty, it's a wash. From a public health standpoint, the US is a little bit behind. From a cost-effectiveness standpoint, the US is substantially behind.
Marielle said...
. . . the U.S. spends twice the OECD average on health care per capita. The only country that even came close was Japan, I believe, which was roughly two thirds of our per capita cost.
And even that comparison can be questioned.
It is fairly well documented that the majority of health care costs in a person's lifetime are those after age 65. The time period of least health care costs are those from age 15-64 years.
Japan's age distribution is:
0-14 years: 13.5%
15-64 years: 64.3%
65 years and over: 22.2%
By comparison, the age distribution in the US is:
0-14 years: 20.2%
15-64 years: 67%
65 years and over: 12.8%
Median age in Japan is 44.2 years, while in the US it is 36.7 years.
Japan's least costly age group is (as a percent of total population) slightly less than the US, and the most costly age group is approaching twice the US in per cent terms.
And even though Japan spends less on health care per capita, life expectancy at birth is 82.12 years, while in the US it is 78.11 years.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
A couple of points:
A Hidden Benefit to a government run system: The cheapest way to deal with healthcare is through primary prevention. This includes vaccinations, exercise, eating well, living an active life, having a psychologically healthy life, etc... If our government is paying for our healthcare, it will create an incentive for the government to promote healthy living. Perhaps once this happens health education in schools will be properly taught. Perhaps it will change the way the government subsidizes agriculture so that we can eat healthy food cheaper than unhealthy food (it's cheaper to buy a burger than a half pound of strawberries, guess which one is cheaper to produce and healthier sans subsidies?) The list goes on.
To all those who say that this is a multifaceted subject, you are correct. Looking at life expectancy is a phenomenally terrible parameter, for example- things like guns and violence and crime and life in prison decrease life expectancy, regardless of the healthcare system. Guess where America ranks on those things?
As to the cost-benefit of America's current healthcare system: a) we live in an expensive country, so everything costs more. b) we have a for-profit (in most places) hospital system paid for by a for-profit insurance system- that's a lot of palms to grease (and also for-profit ambulances, ever seen one of those bills?!). c) every doctor's office needs to hire sometimes dozens of assistants just to deal with insurance companies 24/7, who tell the doctors how they can or cannot treat their patients. These people dictating to your doctor, mind you, are NOT doctors. d) we have rampant (and often unwarranted) malpractice lawsuits that are uncapped in many places. Malpractice insurance, lawyers, and plaintiffs must all be paid. e) The FEAR OF LITIGATION FORCES many doctors to order wasteful tests and perform needless procedures. That's not to say all doctors would do the bare minimum without this fear, but it does significantly drive up the cost of healthcare.
the list goes on, but i believe i've elucidated my main points. All in all I was quite disappointed by this article.
And then there's the VERY important point that those who can't afford to receive anything but emergency health care simply aren't accounted for when things like cancer survivability, mortality rates (for medical procedures), are studied in the US whereas they are (at least mostly) in countries with universal health care.
I don't see how anyone can argue that this doesn't skew the results in favor of the US's flawed system, even if the skewed totals are still inferior. It simply brings the average up "artificially" in the US by excluding the level of health of anyone who can't afford care.
Another point of how to compare is innovation.
For instance, the corneal transplant was invented over 100 years ago in what is now the Czech Republic (then a part of the Austro-Hungarian Empire). The procedure was not adopted in the US until the 1950s.
In the 1990s, Dr. Gerrit Melles (The Netherlands) developed a newer technique for corneal transplant for those who didn't need a full, penetrating transplant. By ten years later, some doctors in the US were using Dr. Melles technique, and improving on it.
Recently, Dr. Melles has developed an even newer technique for the transplant. To date, only one doctor in the US is using this newest technique, although doctors in Europe are starting to use it in greater and greater numbers.
The Greeks and Romans were practicing cataract removal 2000 or more years ago. The major problem was when the natural lens was removed, eye sight was severely limted. When eye glasses were developed, the cataract removal was accompanied by a prescription of very heavy, very thick external lenses to allow the person to see to some extent. In the late 1940s, Sir Harold Ridley of Britain, started to develop the replacement IntraOcular Lens (IOL) now used in cataract surgeries, based on his observations of eye injuries pilots suffered during the Battle of Britain. Most of Europe started using IOLs by the mid to late 1960s, but the US medical community (and even more so the insurance companies) resisted the use of IOLs until the 1980s.
In the 1990s, a doctor in Brazil developed a surgical technique for treating certain types of heart disease - namely cutting out part of an enlarged heart that contained non-viable tissue (the main reason the heart was enlarged). Doctors in the US wanted to try the new technique, but insurance companies said "It's new. It's not proven. It's too expensive. We won't pay." Ten years later, and only after years of fighting the insurance companies, the surgical technique is used at some US medical institutions when appropriate. Even so, the usual practice even now is to have to fight the insurance company each time a medical institution determines the procedure is the best for the patient.
So who is to say that the US is THE leader in developing new medical techniques, and adopting them? From what I've seen, in many areas the US is years or even decades behind the rest of the world when it comes to certain techniques or procedures. And one of those reasons is because insurance companies, even so-called 'non-profits,' are more worried about their bottom line than caring about the patient.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
how much of health in america is due to poverty?
there is a direct correlation between being obese in america and poverty. the poorer you are the fatter you are.
not much is being said about dental coverage. last i heard poor dental health also equates to poor health. the poor get next to zero dental coverage.
i dont know why i bothered to post on this. the chance that america will actually improve the health care system is next to zero.
public health cant interfere with the almighty capitalistic dollar.
the health care debate is more showbiz from our politicians
Mankiw is doing what Giuliani did during the primaries last year -- cherry-picking where the US is better and pretending that this
"proves" that the present system is somehow better, or at least not worse than, government systems in other countries. I am astonished that Andrew gives this crap the time of day, let alone accepting its premises.
As for innovation, as long as Mankiw wants to cherry-pick, I'll mention the surgeon who performed a very difficult open heart operation on a good friend of mine who had learned it and trained for it in France, which has continued to refine the techniques beyond what is being done here. The only reason Americans believe we are more innovative than other countries with government-run systems is because the insurance companies and the AMA tell us so.
I remember being stunned to learn that the British Empire cost the people of Great Britain more to maintain than it gained the country in income. Why would a nation undertake this fantastic expense -- in blood and treasure -- for something that didn't enrich the country at all? Answer: the Britons who DID make money from the Empire were more politically powerful than those who lost it, and prevailed.
The American health system is exactly the same thing -- something which impoverishes the nation as a whole, but is forced upon us by those who profit from it, because they are politically powerful enough to do so.
tangoclose said...
The US fares worse than Canada and Europe on a number of measures, including [...] MMR, or maternal mortality rate, is as disproportionately high in the US as infant mortality is
Kind of tangential, but I wonder if this could in part be explained by the popularity of fertility clinics and IVF? To be crude, couples who cannot maintain a natural pregnancy are generally selected out of the gene pool; the woman is not quite healthy enough to carry a child, or there is something wrong with the sperm/egg, or the man is functionally infertile which is indicative of health issues, etc. But couples who want biological children badly enough can resort to fertility clinics to get around natural selection. So any couple that undergoes IVF/assisted pregnancy is *probably* more likely to be at risk. If more Americans go with IVF than ppl in other countries.... (Although, if more Americans "need" IVF because Americans are unhealthy becuase of [etc]--then again, if you can afford IVF then you probably have decent healthcare, y/n?)
Amother thing I wonder might be a factor is pro-lifers who refuse to terminate risky pregnancies--if there are significantly more of these in the US (since the US is kind of deranged about abortion, have you noticed?) than in other countries, that could contribute to the maternal/infant mortality rates in a way that's mostly not the fault of the US healthcare system.
mob said...
not much is being said about dental coverage. last i heard poor dental health also equates to poor health. the poor get next to zero dental coverage.
It is my impression that the US cares more about dental health than other countries? My sister has lived in SKorea, and I've lived in Japan (ok, I was on exchange so I didn't really engage the UHS, but my sister was properly employed and recieved health, dental, and vision care in Korea), and dental care is just not as big a deal there? On the other hand, US dentists may be overactive and providing inappropriate treatment--my sister's (US) orthodontist performed root canals on 6 of her permanent teeth "because her mouth is too small" when she was, like, 15. In retrospect, that somehow seems very wrong.
@ kali -- Do you mean "root canal" or "extraction"? I ask because an endodontist, not an orthodontist would perform a root canal. And an extraction rather than a root canal would be undertaken to relieve a crowded jaw. Indeed, a root canal's function is to leave a tooth in the mouth, not remove it, and it is not an orthodotic procedure to alleviate overcrowding.
If you're wrong about this pretty simple difference in procedures, how can you be trusted about your other opinions on more complex subjects?
The stats I heard on NPR's Morning Edition and BBC radio 4, that life expectancy in the UK exceeded that in the USA, had factored out the following: race, class, gender, socioeconomic status, lifestyle...(and then some).
All I know is that I, personally, haven't found one single European or Canadian who isn't appalled at our health insurance and medical costs. Not one. Yeah they might gripe about as much as I hear all the people I know gripe about their own doctors and such. That's it. No, "gosh, I wish I lived in the U.S. so I could be riddled with anxiety over how to pay for something if I get sick". I'm sorry, but in 12 years of discussing this with Europeans, if I can't find one who is wanting OUR healthcare, it tells me that nationalized medicine just isn't such a bad thing. That's all the "data" I need.
One basic problem with Mankiw's analysis: early detetection of cancer by definition increases 5 year survival rates, because the five years counts from the detection!
However, it doesn't always actually reduce the age at which people die from cancer, just maximizes their precieved need for cancer treatment. Prostate cancer is a good example - there is an effective test, but often people who test positive for prostate cancer could have lived their lives without knowing, and would have died of something else. The test actually lowers quality of life.
A study two years ago compared Canada and the US for the outcomes for 6 common procedures. Canadians fared better than Americans in 4 and tied in two. Yet our countries are culturally similar though Canada is a bit less wealthy and we spend per capita for health care only half of what the US spends.
All Canadians have a health card that we use to "pay" for health services. This covers virtually all Doctors and hospitals without question or limit. But the bill is covered by the socialist system. By the way Canadians also drive on socialist roads and highways.
I'm with Mankiw. "Life expectancy" (actually "life expectancy at birth) and is a blunt instrument and does not capture the quality of life. It is similar to comparing the average temperatures in various cities and using the data to argue about which city is a better place.
I deleted a couple of my previous comments not to be wanky, but because they didn't add anything particularly relevant to the discussion at hand. To translate my 1:53am post:
I think it's possible that the prevalence of fertility clinics and IVF as well as Americans' (extremely?) negative opinion of abortion could conceivably contribute to higher MMR in the US; if someone more knowledgable can demonstrate the statistical (in)significance of these factors on US MMR, please make a comment.
Also, it is my impression that the US cares more about dental health than other countries, (although this is) based on anecdotal experience. If someone more knowledgable has something to say about the relative state of dental care in other countries, please make a comment.
I was defensive and cranky in previous comments because I didn't appreciate 2:11am's unprovoked attack on my intelligence. But thank you for alerting me to the existence of endodontics, in any case. My cumulative knowledge has increased today, hurrah.
If Americans have more unhealthy lifestyles than people in other countries, why is this not a failure of the health care delivery system.
It seems to me that it demonstrates that the US system is NOT oriented towards prevention--and that is a damning indictment of the system.
If the incentives in the system were oriented towards prevention instead of performing services after the fact, it would be a better system.
The health habits of the population are not an externality; they are a measure of the quality of healthcare delivery
Let me second what deltaepsilon said. Some countries don't screen (or report) for cancers that might eventually become a problem if you live to 126. If a clinic or doctor has a profit motive, then a probably-benign lump in the breast may be taken out early, rather than monitored. Thus the cancer 5 year survival statistics can be biased.
You don't need life expectancy to know that the US isn't doing so well. Because there are so many dimensions for health outcomes, the WHO undertook the task of constructing a single consolidated rating for health systems, combining all the major factors like life expectancy, infant mortality, cancer survival, and so on. The US ended up ranking in the 30s. France is first; Italy is second. Japan, for that matter, is tenth.
Marielle, the number two spender in the world per capita is Luxembourg, which has by far the highest GDP per capita in the world. Per dollar of GDP, number two is Switzerland, and number three is Germany. Japan ranks below OECD average on both measures, I believe.
Nylund, Mankiw actually talked about infant mortality a while ago, saying that it reflects low birth weights, reflecting higher teen birth rates. However, he doesn't talk at all about why the US, or for that matter Britain, Canada, and Australia, whose infant mortality and teen pregnancy rates aren't much better, can't reduce teen pregnancy effectively. Canada has the excuse that the median Canadian has sex for the first time at age 14.3, but in the US and Britain the median age is 16-17, in line with most countries of Continental Europe. Could it be that in Continental Europe the health systems are better at distributing birth control to teenagers?
Did anyone else notice that the statistics where the US does best are also the ones that mostly affect the elderly? Hip replacements and cataracts are almost always covered by MediCare, a socialized payment system; not private insurance.
Which implies that the US should adopt John Conyers proposal. MediCare for all! HR 676 forever!
Is 'life expectancy' all? So old people are uniformly happy? Nope, most are fucking miserable gits- you need other measures! And someone said Britain didn't benefit from having an 'Empire' - I reckon without it Britain would be a backwater of the world like Poland or Romania with precious little racial diversity. Think also of the monuments, houses, gardens built with empire money, especially in London. Nope, this a country people of the world are happy to flock to and wise leaders like Obama pay homage to.
KIC said...
June 21, 2009 2:35 AM
I am from europe,the only thing I can say is:
affermative Sir,You are sooooooooo right.
bye.
@skeptical
To be perfectly fair, we don't practice any kind of preventative medicine because economically it doesn't make sense for insurance companies to do so. (Trust me, I still think this is a lousy reason.)
Insurance company x is only possibly going to cover you up to age 65, maybe not even that long because you might switch to another insurance before than. So they spend larger quantities of money on preventative medicine to not see any of the benefits, due to them being in the long term. You're most likely to see the benefits post-65 when people really begin to suffer from medical problems. Therefore insurance companies aren't having their overall costs reduced by using preventative medicine, they're reducing the government's costs. Simply because we have a free market competitive system set up followed by a socialized system after 65 makes us uniquely inefficient at providing preventative care.
One of the things that should be mentioned about the statistical difference between Europe and the US in health care is that while the US might lag behind Europe, it really isn't by much. 78 years vs. 80 years is not a gigantic gap. The differences within a country (based on gender, SES or region) probably greatly outweigh the relatively small differences between countries.
I've noticed that the stereotypical cultural and political differences between the US and Western Europe in general don't pan out very much when the actual numbers are ran. In general, many of the stereotypes are true statistically (The US spends more per capita on the military and has a lower maximum tax rate than most European countries), but not in the dramatic way that many on the left and right think they do.
SantaTurdo, Britain was richer than Poland and Romania long before it had an empire. If you want a better comparison, look at Britain versus Sweden, or Britain versus the Netherlands. Stockholm and Amsterdam are less cosmopolitan than London, but they're a lot less poor; if you compare them to Birmingham and Manchester, Britain looks even worse.
Let's get over this and just move to single payer in one move, and do it now.
Talk to grandma about medicare, i bet she loves it.
American life expectancy is strongly influenced by infant mortality. we fail miserably at delivering medical care to expectant mothers and newborns. All those zeros have a huge effect on the average. Its tragic - but it can be isolated. if you look at expectancy of say people who lived to 30 or 40, then you can measure other aspects of health care deivery.
@Deltaepsilon and Mitchell,
You are right that early detection can create the illusion of increased cancer survival rates. However, most credible studies have taken this into account, but some others haven't. This is why these data just like data about life expectancy is not straightforward. However, you are wrong that assuming this is the only reason America has high cancer survival rates. The American medical system actually does an incredible job with cancer. We undertake more cancer research than anywhere else in the world and we are very good at treating it. Additionally, early cancer detection not only increases the illusion of cancer survival, but it also DIRECTLY INCREASES cancer survival rate due to faster initial treatment of cancer. Cancer is an exponential beast, and cutting it off when it begins is sometimes the only way to treat it. Moreover, because of the downside of our system- being very topheavy, if you have insurance or medicare or medicaid you can see a doctor about cancer quicker than other countries.
@maryfromknox
you're totally right about the infant mortality rate. However, obstetric care in America is very good- those doctors (mostly women) work very hard and do an incredible job. This is another measure more of health disparities and wealth disparities, not as much to do with prenatal care.
@ everyone,
I, like it sound like most of you all, believe that healthcare is a basic human right, not a privilege. I believe a universal healthcare system would be extraordinarily better than what we have. That said, we need to demand of our politicans not just a healthcare system that works, but one that makes sense and is designed with care.
I think that one of the main takeaways from this, which is lost in the discussion - is that life expectancy is important but (as Mankiw mentions) is not really what we are buying with our health-care dollars. So Mankiw is right that tying life expectancy comparisons into the discussion is somewhat schlocky.
However, if life expectancy is what we care about ... and many people do ... then we should focus on how to improve that. If we spent $1 trillion over the next 10 years on programs to encourage lifestyle changes - exercising more, eating less, smoking less, etc - I'd venture to bet that we could improve life expectancies by more than we could spending $1 trillion improving on reforming the health insurance system.
Does anyone know where to find country by country data on disease incidence and mortality by age?
For example, to compare death rate from prostate cancer in 65 year old men (i.e., deaths of 65 year old men due to prostate cancer per 10,000 65 year old men) in the US versus the UK?
I believe Canadians are even more obese on average than Americans, yet their life expectancy, infant mortality, and maternal mortality are measurably lower. That may not be only because of their guaranteed provincial insurance plans, but it's pretty clear to me that's part of it, and I don't think it's illegitimate to use those statistics as part of the argument in favor of Canadian-style plans for the U.S.
I meant that their life expectancy is longer and those mortality stats are lower.
It amazes me how often the distinction between government-run health care and government subsidized health insurance is ignored or blurred in posts like these.
Since no one in America outside of a mental institution is advocating government-run health care I don't understand why it is being discussed here. At best it is a distraction, at worst it plays into the hands of the health insurance industry spin-doctors who are desperately trying to turn the debate over government option/single payer into their most cherished hobgoblin-bogeyman government-run health care.
C'mon guys. Let's first get clear on what the parameters of the discussion ought to be, then stick within them. Any straying from the topic at hand will unnecessarily enlarge the current national debate until it so enormous and unwieldy sheer inertia will prevent--yet again--anything being done.
Those of you bleating about infant mortality being an indictment of the US health care system are missing two key points. One of these was pointed out by Juris above, that reporting standards vary significantly and that the numbers aren't directly comparable.
The other key point is genetics. The US publishes data by race, and it shows that black infant mortality is more than double the national average. Hispanic infant mortality is below the national average, and asian is far below the national average.
So, any comparison between countries must adjust for race mix as well. The US would be right near the top of the list under that standard -- possibly a good project for someone like Andrew.
Here are the 2003 numbers (latest I could find quickly) for US infant mortality per 1000, broken down by race:
[b]Average: 6.9[/b]
Black 14.0
Amer. Indian 7.8
Hispanic 5.8
White 5.7
Asian 3.8
Seriously, does anyone REALLY believe Cuba or any other second-or third-world country has a superior health care system? If so, that's just willful ignorance.
Why we look at mortality
Mortality is an indispensible indicator of success or failure of a given medical health improvement measure, and its near-relative life expectancy is an indispensible indicator of the success or failure of the sum total of all health meausures over the lifetime, because it is the one parameter that avoids selection and reporting bias. At the end of the observation period the patient is either dead or not dead. The difference is unambiguous, and generally not missed. The same cannot be said for any other parameter of success or failure you might choose.
With cancer survival, for example, two countries would have to detect and diagnose cancer at the same rates, and at the same stage in cancer developement, for any comparison of the length of time that people so diagnosed survive to be a good measure of the effectiveness of their systems of medical intervention. Yes, a country without universal care might tend to detect cancer late, therefore have shorter intervals until death from cancer, and therefore have to work against this inherent bias that makes them look worse at treating cancer (when it's really "just" universal early detection it's lousy at) when you tote up its overall cancer survival rate. But, on the other hand, cancer, especially the worst of it, could escape detection even after it results in death, since a country like the US does a strikingly lousy job at getting autopsies, which aren't especially likely to find something not clinically suspected anyway, and have a really tough time discovering anything in dead people who were never patients and therefore have no clinical history. But the most likely source of bias that might make us look like we're doing a good job of treating cancer when we're not, is that we make an enormous effort in this country to find prostate cancer early, and prostate cancer is a type of cancer you are much more likely to die with than of. This especially true of prostate cancer as detected by PSA, as opposed to that found clinically, on a rectal exam or after symptoms present. If a disproportionate share of the detected and reported cancer burden in the US is this PSA-detected prostate cancer that mostly doesn't kill, that introduces a huge bias that makes us look better than we really are at treating cancer that actually needs to be treated.
You want something schlocky, that would be looking at different countries' cancer survival rates as indicators of the effectiveness of their system of medical interventions, when you should, at a minimum, look at individual cancers, and even then only make comparisons that are informed by a thorough understanding of their differences in every other aspect of health and health care. And if you want one overall bottom line on health care effectiveness, it's irredeeemably schlocky to use anything but life expectancy.
The debate here has been over how to measure the outcomes in various nations, but I think that's a red herring. With the price the US pays, the system should be so much better that it's superiority is obvious and across the board.
Bottom line for me is that we spend roughly double what similar countries spend for a healthcare system that delivers results that are not double the quality.
If I were a cardealer and I put a Ferrarri Enzo pricetag on a Ford Fiesta's windshield, would you buy it? The Ford Fiesta is an okay car, but not worth the cost of a Ferrari.
OTOH, nations like Canada, Britain and Australia pay a Ford Fiesta price, and get a Ford Crown Vic.
http://www.kff.org/insurance/snapshot/chcm010307oth.cfm
@jonderry:
Well, I am sure that if someone wanted to go to the effort of researching things, those statistics could be found. But see, once you do that, you can't make sweeping generalizations about how either A) Americans live in a classist society with widespread poverty and disease or B) Europeans don't have access to good medicine because socialism stifles innovation and no one wants to be a doctor.
Please, once you inject boring boring statistics, all of the fun leaves!
It is interesting that cancer surgery and hip replacement is brought up as American "successes". The cancer may be notable, but quickness in replacing hips is not a good thing. Replacement hips typically have a life-span of 15 years, and are difficult to do more than once. So quality health care will encourage patients to delay such surgery as long as possible. (See the discussion here, e.g.)
But this is a place where market incentives diverge from best-practices.
That the US has the best "availability" of hip replacment may in fact be a sign that they are done sooner than sound practice would suggest.
Michael said...
I believe Canadians are even more obese on average than Americans, yet their life expectancy, infant mortality, and maternal mortality are measurably lower.
WHO estimates for obesity rates in 2005 places Canada at 17th for men and 56th for women; the USA is at 7th for men and 13th for women. So... no. XD (Obesity is defined by BMI, which some people find debateable but for the most part probably fine when you're talking about obesity rather than simply being overweight--there simply are't enough bodybuilders to skew the numbers so much when obesity is defined at BMI>=30. And I assume US/Canada have similar enough populations that it is ok to define obesity the same way--unlike in Japan, where because of when obesity-related cormorbidities kick in, obesity is defined as BMI>=25.)
Countries that are more obese than America are places like Nauru, Tonga, Micronesia... Egyptian women also squeak in just ahead of the USA, for some reason. But for the most part, tiny island nations.
(I can't figure out where you can get your very own giant excel file of global obesity data anymore ("WHO_Global_InfoBase_BMI_Estimates_2005_2015.xls"), but I can upload it somewhere if someone really wants it.,)
@jonderry
Here is a place to start? It's where I got my Very Big Excel File Of Global Obesity Data a couple years ago.
Agree with this wholeheartedly: "If I were a cardealer and I put a Ferrarri Enzo pricetag on a Ford Fiesta's windshield, would you buy it? The Ford Fiesta is an okay car, but not worth the cost of a Ferrari.
OTOH, nations like Canada, Britain and Australia pay a Ford Fiesta price, and get a Ford Crown Vic."
But I would add (while keeping with the metaphor): For the person who can't afford or doesn't need any kind of personal car, let there be a public option."
Additionally, early cancer detection not only increases the illusion of cancer survival, but it also DIRECTLY INCREASES cancer survival rate due to faster initial treatment of cancer.
Pardon my lanuguage, but bullshit on faster treatment of cancer. In an HMO you routinely wait upwards of a month for a mammogram. Even with a "rush" on it, the wait is two weeks. Then if something is found you can't even make an appointment for a biopsy until you get the approval for it (one week), and then you wait another 3 weeks for the appointment. So we are at 6 weeks from finding a lump until diagnosis. Then a week to see the surgeon, but wait you still need to wait 2 more weeks for an MRI, ordered stat, mind you. Then you wait another week for the results, and a week for the appointment with the surgeon, and your pea sized lump ends up being stage 4 cancer, and then you have to see the oncologist, luckily getting started on chemo (including the insertion of a chemotherapy port) only took two weeks. I have spoken with many in chemotherapy who share my story of long waits. Two and a half months is the average from suspicion to treatment, except for those who have Medicare, Medical, and PPO. However, for PPO, since chemo drugs are so expensive (and the suppoting drugs) and they have to pay 10% they are going broke since half the time they are not able to work on chemo. The only people who are not going broke or waiting far too long are people who have public healthcare already.
The health care system is irretrievably broken. The HMO has all the characteristics that the right fears a public option will have, but since there is a profit being made it is all okay.
@Jen, I really REALLY hope you posted that story to the White House site asking for stories.
The argument boils down to "we're actually better at treating people than other countries, even though we have lots of uninsured and ER treatment; we just live shorter lives because we get that much sicker than others". Which, if true, moves the indictment from our health care system to our entire way of life. An interesting defense.
Not entirely without plausibility: we smoke less, but are more obese and get less exercise. We may breastfeed less, not sure. And we probably get more chronic stress: longer work hours, shorter vacations, not enough sleep, more worries about losing a job... and whether we'll be able to afford getting sick. (And send our kids to school, and keep the home, and...) AIUI chronic stress is a big and underrated killer; I've wondered how much a universal health system helps people simply by existing and assuring people they'll be taken care of. Population-wide placebo effect.
But, again, this tells us to not just fix the health care system, but to increase vacation time and income security, reduce wealth inequality (being of low status seems to kill, even controlling for actual expenditures), make our cities more pedestrian and bicycle oriented to increase natural exercise, pay for more education... why, it's a whole progressive agenda!
(Caveat: I'm not sure Japan passes for a low-stress society. We might have to look into influencing diet, too.)
How about we stop using precious time talking to morons like Greg Mankiw and Gary Becker, hmmm? That would be a good first step towards formulating health care policy -- leave the dodos out of the conversation. Neither of these "experts" has anything relevant to add to this policy discussion, so drop them already.
@Jen
(So how long is it from suspicion to treatment if you have Medicare, etc?)
Damien Sullivan said...
But, again, this tells us to not just fix the health care system, but to increase vacation time and income security, reduce wealth inequality, make our cities more pedestrian and bicycle oriented to increase natural exercise, pay for more education... why, it's a whole progressive agenda!
(Caveat: I'm not sure Japan passes for a low-stress society. We might have to look into influencing diet, too.)
That goes under "pay for more education", doesn't it? You're supposed to learn about nutrition in health class. Though if you disregard what you learn to go eat hamburgers everyday....
What many here are really making the case for is no health insurance. To truly control costs means either eliminating expensive procedures or paying providers so little that they refuse to do them.
As for the car analogy offered earlier, we pay Cadillac prices for Fiesta outcomes because those paying the bills also have to buy Cadillacs and Fiestas for all those who pay little or nothing for their care, and Porches for the lawyers who are looking over every doctor's shoulder and forcing them to spend extra money just in case their judgment might be erroneous.
Obama:
53% Approval Rasmussen
[34%-32% Disapprove/Approve]
57% Approval Gallup
56% Approval NBC
Obama's poll numbers are falling fast, any insight Nate?!
Perhaps it is because the Stimulus isn't working and didn't stop the unemployment rate from going past 9%??????
@Jen,
you didn't refute my point that you quoted whatsoever. My point still stands: Had the cancer been detected 6 months later there would be a much worse prognosis.
@Darian -- you wrote "How about we stop using precious time talking to morons like Greg Mankiw and Gary Becker, hmmm? That would be a good first step towards formulating health care policy -- leave the dodos out of the conversation."
Hear, hear. As I wrote earlier, Mankiw is just sending up flak, trying to prevent effective reform of any kind.
(So how long is it from suspicion to treatment if you have Medicare, etc?)
@ .kali, most of the oldr patients (at least with breast cancer) said about 4 to 6 weeks, including the wait for surgery. I think having the option of providers (though most mammogram facilities tend to have a wait for non-urgent mammograms of at least two weeks) and not going through an approval process makes it shorter? My IPA (who administers my HMO) has a doctor who determines medical necessity. However, he only works 3 days a week 8 AM to 12 AM.
Yeah, Rudy, you make a strong argument for the health system working.
I think the reason for our "better" health care in some regards is because we attract people from everywhere to come here, study, and often stay here. We attract doctors-in-training from across the world here and it creates a diverse pool of talents.
It's (legal) immigration that made this country great, not capitalism.
@Rudy
"As for the car analogy offered earlier, we pay Cadillac prices for Fiesta outcomes because those paying the bills also have to buy Cadillacs and Fiestas for all those who pay little or nothing for their care, and Porches for the lawyers who are looking over every doctor's shoulder and forcing them to spend extra money just in case their judgment might be erroneous."
I agree with you completely. Uninsured people cost a lot of money to have in a society. They don't get regular checkups, so minor problems turn into major emergencies, and the ECU gets clogged up with pts who really should be cared for by a PCP.
I will take issue with one part of your post... very few people actually ever get a Cadillac out of their insurance company. You can have the best insurance anywhere, but try actually getting sick with a major illness like diabetes, cancer or hep and submitting claims. Then you find out how good or bad your insurance is. The companies say they offer great coverage, but actually don't. And don't even try changing jobs or being sick so long that you lose your job! The pre-existing condition will either bankrupt you to pay for new private insurance, or put you on a public plan.
Red Herring Alert: As for the lawyers, that's why I support a national clearinghouse that would analyze health treatments and outcomes, then make recommendations on best practices. This way if a pt presents with a small, red bump on their arm, and the MD follows all the best practices as laid out by the clearinghouse and dignoses it as just a mosquito bite, but it later coincidentally turns into skin cancer, the doctor has a built in defense. Conservative talking heads very loudly opposed this sort of board saying it would be putting itself between the patient and the doctor.
Also, lawsuits will have much smaller pricetags once patients who are injured are not footing the medical bill to pay for mistakes that are made. Let's say a pharmacy misreads a doctor's handwriting and gives a pt a med that kills their kidneys. The pt won't be paying for the dialysis and associated treatment, so that won't be part of the lawsuit.
Plus, factcheck.org has said that savings made by limiting lawsuits would be minimal...
http://www.factcheck.org/article133.html
If Greg Mankiw thinks it's 'schlocky' to compare health care systems by life expectancies that I would like to know what metric he would propose using. Maybe I'm being horribly naive but I thought that the reason for doctors, medicine and helth care was to improve the quality of life and extend our years on earth. Mankiw points to hip replacement and cataract surgery as signs that the US has a good health care system. But isn't that like saying my baseball team always outscores in the second and fifth innings but loses the games from its play in the other innings or my football team has a highranking Defensive Line but has never made the playoffs. And what if you have an illness other than needing a hip replacement or cataracts then are you SOL? Why should we Americans who take such pride in being number 1 want to settle for being good at one or two parts of the whole?
Mankiw's argument is further irrational by saying that you can't compare life expectancies because in the US the population tends to be more obesse. The last I looked matters of weight and living a healthy lifestyle (exceept according to the fitness Guru Rush Limbaugh) go hand in hand. Again I would have to ask if you can't use life expectancies as a metric to compare health systems then what can you use?
In addition, Mankiw points to the fact that America excels in hip replacement and cataract surgery. Hmmm, most people who are having hip replacement and cataract surgery are for the most part elderly who are on Medicare. At the same time he talks about obessity, particulary in teens, who are on Medicare. You would think that if Mankiw's argument against public run health care then the things that the current US health care system excels in would be spread more evenly across the ages.
Has anyone bothered to read the Cancer study that Becker was refering to? You can find it here:
http://v1.theglobeandmail.com
/v5/content/pdf/CONCORD.pdf
What caught my eye was that while the US does do very well in age adjusted cancer survival rates there was one nation that beat the US in 6 out of the 8 gender/cancer type categories analysed: Cuba.
Given that not only does Cuba spend considerably less on healthcare than the US and that it has universal healthcare but that it is Communist as well should have made Becker (given his political inclinations) pause when he decided to cite this study.
I guess he didn't expect anyone to actually bother to read it.
You bet it's schlocky to compare different countries on life expectancies. It's mawkish, bathetic, kitschy and low-culture. They ought to fire the writers who came up with the discrepancy in the first place. I love america and therefore believe it should be built on lies.
Nate is absolutely right that you can control for a lot in statistics and ultimately should be able to design a model that will predict if socialized care is a positive or negative contributor to domestic health care and societal well-being, longevity being one indicia.
I think to ask the question is to answer it and that we should proceed with a great deal of caution especially at this time when we are nearly broke and our credit rating as a nation is under assault and the number of unemployed is climbing and looking to remain steadily so as we collectively march into the Obama era of slow but “correct” growth economics. Who can say where his “command and control” will lead us? What are lists scientific underpinnings?
Some debate is in order here.
Obama’s promise of slow, measured safe growth will grow stale and sound discordant to a working class populace that is insecure about its work.
The Promise of Slow Growth” There's an election slogan, but I digress.
Mr. Big Ideas Obama is not content with trying to fix the existing broken entitlement programs, be wants to create a few more. Adding trillions to the budget like it were no big deal.
Medicaid and Medicare are seriously underfunded and while cited (esp MCare) as successful socialized medicine, they depend on private sector subsidization and not just from extensive tax revenues but from market dislocations that shift costs on the non-government patient, which is most of us.
There's populism for you!
The real scandal of course is that Medicare reimbursement is so low that the private system is called upon to subsidized it and the even worse funded Medicaid. The problem with the cost of healthcare today is not the uninsured, but the cost of the Federally insured. Eventually the private systems will collapse as unable to compete against the poor paying government plans (who will also losing many willing providers, those who practices cannot afford them to take the loss on the federal patients).
Fewer and fewer patients will be able to find providers will to accept their business.
The private insurance companies will be forced into the business of offering supplementary coverage (for that which the government will not pay). It will be a booming business!
The outcome it seems is that we wind up on some sort of Medicaid style universal coverage where there is theoretical coverage for all conditions/disease states, but the range of choice and the availability of providers is limited.
For the 2/3rds of Americans who are satisfied with their coverage today (including many of the uninsured) along with the tens of millions who work or invest in the medical industry, we have a lot at stake and hope the government gets it right.
Please report, so we can decide.
petekent01 (on twitter)
From the perspective of a patient, no rational person would select the current US health care system over a single payer public system.
Comprehensive health care for all citizens should be considered a basic right in a modern democracy.
No objective analysis of the myriad metrics, of health outcomes, of longevity, of infant mortality, of financial ruin, or of pain and suffering - not one metric supports the current US system.
From the perspective of a strong financial model - profit for health insurers, medical clinics and many doctors - the current fee for service system has no equal!
The simple question, does America wish to reverse this financial model and place the patient at the center of heath care focus? To do so will both reduce cost and increase health outcomes.
I've been doing a little research. The US spent about $7500 on healthcare per person in 2008. Cuba spent about $570 per person in PPP terms. And yet by Becker's metric (higher cancer survival rates) they have a better healthcare system. Perhaps the solution to our current economic crisis is dramatic health care reform using Cuba as a model.
The real issue, it seems to me with Mankiw's argument is to do with his logic. The real firebell that this rings with me is the right are about to come at healthcare with flawed logic. They will essentially go at the wheeny bits of argument from the left that maybe don't ascan, like Mankiw does here, and assume that knocks down the argument over healthcare. (Ie You are wrong that life expectancy is an important comparitive measure, therefore you are wrong about the need for healthcare.) IMHO the left as a whole needs to stay out of these arguments. Stick on the main issue- that its stupifyingly immoral that the richest nation in the world has no universal system of healthcare. To me thats the issue. That in the USA the current healthcare system works for the wealthy, but not the poor. I guess thats why life expectancy might be important in the issue, but to me its being forced down into the minutiae of details rather than the big picture, which is what is important in the healthcare debate.
Slow newsday . . . Iran in revolt . . . same film at 11 . . . .
News that's not news anymore:
Two American military die in Afghan rocket raid
http://tinyurl.com/lees94
Keith Olbermann was said to have no comment.
petekent01 (on twitter)
Isn't Mankiw's point analagous to the ceo of a company stating that his company's profit margins are below it industry competitors and its return on capital is far below its industry competitors but they are tops in managing their travel and entertainment expenses?
Mankiw was part of a team who policies gave us our present economic situation. They crashed the hedge fund. Even a broken clock is right twice a day, but I would not pay too much heed to this person's view. The policies they espouse didn't work. If you own an NFL team, do you hire Matt Millen as GM?
I apologize that I haven't read all 79 - or whatever - comments, so I may be plowing old ground here. But first, the infant mortality statistics, the favorite statistic of the America-does-everything-worse-than-everyone-else crowd, is 100% fraudulent. The only reason our infant mortality numbers are bad is that many babies born with potentially mortal defects are classified as live births in the U.S., and they try to save them; whereas in Europe and Canada many of those babies would be classified as stillborn. The correct statistic to use is stillbirths PLUS infant deaths. The last time I knew of the numbers (which was admittedly a bunch of years ago), the U.S. was the best in the world in that statistic.
Secondly, on the original topic, many commenters have done a much better job than either Nate or Mankiw (against whom Nate seems to have some kind of inexplicable personal grudge) of expressing the need for adjusting and normalizing the statistics for things like age and ethnicity (among other things)if we're going to use either life expectancy OR survival from various diseases as benchmarks to compare health systems.
Third - the person or people who keep braying that health care is a "right" really need to bow out of the discussion. No one who has the slightest clue what the word "right" means will ever utter such nonsense - and I exempt no one from that assertion.
Fourth and last, we are talking in circles when we jump from the issue of the quality of health care to the COST of health care and then back again - UNLESS we acknowledge the unpleasant necessity of placing dollar values on years of life saved, years of pain alleviated, etc. No one seems to be willing to do that because it seems so calloused. Despite the histrionic proclamations of some, however, NO ONE believes that a human life is more important than any number of dollars. If we truly believed that, then ALL of our economic resources would go toward health care, health research, and producing the basic necessities of life, like food and shelter. We wouldn't be spending any money on museums, parks, music, jewelry, or sports - not to mention sex and drugs.
Stan,
Actually I think this is pretty simple. If we choose a single metric, say performance per cost then we have two dueling criteria. Life expectancy per cost or cancer survival rate per cost (because presumably cancer survival rates affect life expectancy more than most other health treatments). By the life expectancy criteria, Japan takes the crown. By survival rate per cost criteria, Cuba takes the crown. Both of these healthcare systems are universal.
Well Stan, we are not discussing an intrinsic natural human right to health care, we are discussing a civil right. This is a right bestowed on citizens by the choice of the nation. Most modern democracies have made the decision to bestow the right to comprehensive affordable healthcare. The USA stands alone among the wealthy democracies for a refusal to take this step.
Ironically, despite the consequent suffering that many less fortunate American citizens will suffer, the cost to the country overall is much greater than the cost bourn by the countries who have concluded that a caring civilized society grants the right to health care to all of its' citizens.
It is also ironic that the first proponent of the civil right to health care was Thomas Jefferson.
People are conflating the overall health of people in a country with the effectiveness of the health CARE SYSTEM. an overweight populace that eats unhealthy diets, does not exercise, smokes, etc would need an extraordinary advantage in its health care system to compensate and end up with overall health metrics similar to a country going against less headwind. The debate is changes in the health care system, not in healthy lifestyles.
I would find greater focus on healthy behavior to be an exciting option if there were evidence that spending on education and health promotion worked. Does anyone know whether it does? I find it hard to believe there are people in the US who do not know that MacDonalds is not a place for healthy food, that they need daily exercise, that they should not smoke. Would spending massive amounts on educating the last 5 people who don't know this accomplish anything?
We should have health care for everyone. Whether the government should run the system is a separate question.
Here is a question. Let's say that under a new system you have better preventative care, and let's assume that it really works, people are healthier, get their cancer and heart disease later, fewer car crashes from drunk drivers, etc. Recall that most health care costs are consumed in the last 6 months of life. Recall that everyone dies eventually, and that there is no reason to think that preventative care will significantly reduce the number of people who get cancer, and if it reduced the number who got severe heart disease, then these people would continue to get fatal illnesses of some kind. So... you invest trillions in preventative care. Everyone still dies, and, with universal coverage, a larger proportion of them get expensive end of life care. After all that you have satisfied a moral imperative by providing care to everyone. But have you actually reduced costs?
The main problem with thinking the US can emulate one of these other health care systems is that they have all been effectively subsidized by the US for many years, both in technology and drugs.
Few new drugs or innovative technologies could have been developed over the last forty years if US reimbursement was similar to the price controls in any of these other countries.
US health policy tacitly has acknowledged that subsidization of medical progress for our citizens and the world. There is no one to subsidize the US.
Rudy said...
blah, blah, blah
Rudy?
Got any statistics or authoritative sites to back up those Lush Rimbaugh talking points?
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
I think there are some things that we can do to improve health care in this country without turning to a completely centralized national health care system-- namely, mandate (i.e., require) high-deductible health care insurance for all residents of the United States, and provide preventive care and certain routine procedures for free. It's a strong step in the direction of nationalized health care, maybe in a more American sense. I just blogged about this on my own site: www.approximatingpoliticaltruth.com. Check it out if you want to read a bit more about it--I don't want to take up a bunch of comment space here!
D. W. said...
. . . mandate (i.e., require) high-deductible health care insurance for all residents of the United States,
Ah yes. That is a formula that will work for
oh
maybe
about 25% to 50% of the population.
And that solution says to hell with the rest of the people. To hell with the young worker who has no savings. To hell to the wife now divorced because the husband wanted to chase the new young thing in the office. To hell to the young parents, who through no fault of their own, their baby was born premature, and needs hundreds of thousands in medical care to have any opportunity to live.
Is that actually your best idea, D.W.?
Do you know how much medical care costs for something as simple as an appendectomy? A broken bone? Both happen at a very disproportionate rate to pre-teen and teenagers.
Not to mention something as costly as cancer, or heart disease, or an auto accident?
I think you need to go back to the drawing board and rethink your entire philosophy.
Mike in Maryland
My Blogger ID is http://www.blogger.com/profile/02848893412251095965
D.W.
The US does not need to reinvent the wheel. Just copy a pretty good template, pick the system in one of half a dozen countries.
I'm Canadian, I have a government issued health card - like a credit card with an unlimited balance, for which I do not get the bill. It is good for any doctor, clinic or hospital of my choice. There are no co-pays or deductibles. Very simple and stress free. It sounds insanely expensive, yet this socialized system on a per capita basis costs the Canadian taxpayer half of what Americans pay for their health care.
No Canadian families go bankrupt through health costs. No Canadian worries about loosing coverage if they loose their job or contemplate quitting to start up a business. Small businesses do not have to shoulder escalating premiums. Canadians don't go through the stress of bickering with an insurer for coverage or permission to seek treatment. Thats a whole mess of stress collectively lifted off our society.
The challenge for the USA is not to recognize what a good smooth running health care wheel looks like, the challenge is to stand up to the vested interests and put patient care above profits.
Complexity in all things. Socialized medicine encourages early intervention and preventative measures. People go to the doctor before they get deathly ill, which can help prevent some of the more serious illnesses for which survival rates are compared.
But also, governments which pay for socialized medicine engage in some social engineering practices to try to increase overall health. Canada provides tax credits for registering kids in sports programs. Employer-supplied bikes are a non-taxable benefit in the Netherlands.
End result...if survival rates are higher in the US, but life expectancy is lower, there must be a reason why disease incidence is so much higher. Some of these reasons do tie back to the lack of socialized medicine, so you need to factor that in when making the comparison.
+The health habits of the population are not an externality; they are a measure of the quality of healthcare delivery+
I agree, Skeptical1. Yet, will our healthcare system close down McDonalds, whether or not its universal coverage for insurance? Will anyone let "socialized medicine" take away our guns or the cars we drive two blocks to the store? How about restoring PE to our back-to-basics school curricula? Not even there can our healthcare system make any headway. So I don't blame it for that.
I've lived 13 years in the US and 18 years in Canada. I currently have terrific private US health insurance through my work (no copays, lots of choices in health coverage, even drugs are free). There is no doubt in my mind that if I could choose between the status quo in the US versus the status quo in Canada for health care it is a no brainer - sign me up for the Canadian system.
Tying health care coverage to an employer in our age of turnover and layoffs is beyond stupid. Having private individuals who make more profits from denying you coverage is far far scarier than any "government bureaucrat".
One reason I was skeptical about Obama in the democratic primaries instead of Edwards or Hillary is because I don't think he'll really deliver on some of these popular "liberal" positions. End the waste the multiple insurance paperwork causes and go single payer!
@Stan
I would argue that healthcare is more of a universal, natural right than most of the statutory rights we have in this country.
Let's posit Bob, he's of any culture you can find: Maori, Belgian, Apache, New England Yankee, Puelche, Maasai, Tuareg, Druze, Kazhak, Bonan, Tofolar, whatever. Now faced with several situations which one is he most likely to feel a deep, intuitive knowledge that he must help an individual. In other words, in which situation is Bob most likely to recognize a Natural Right.
1. A political dissident is arguing against a leader Bob strongly supports. The leader's supporters want to stifle the agitator. Bob has the opportunity to protect the agitator, who is calling for peaceful disruption of services and a complete change of government. Should he support the dissident's right to speak and allow the overthrow of his own group?
2. A guy is walking down the street carrying a loaded assault rifle. A police officer says, "put that gun away. It's dangerous." Bob has the opportunity to tell the cop to butt out. Should he assist the gunman?
3. Bob's nation has been invaded by a foreign power and has fallen into a state of near anarchy, with bombing raids and gun battles in the streets. A local barracks has been destroyed in the fighting and ten soldiers need a place to stay, but Bob is worried about the men being in the same house as his beautiful teenage daughters. Should he say no?
4. Bob's neighbor is suspected of producing child porn (aged 3-5) in his basement, but there's no real evidence, just strong suspicion and gossip. The police decide to search the house. Should Bob intercede and prevent the cops from doing so?
5. Bob's car is stolen and Bob absolutely knows in his gut who did it. The man is brought to trial, but found not guilty of car theft due to lack of real evidence. The prosecutor, a friend of Bob's, offers to arrange for a new trial, so they have another chance to convict the man. Maybe this time, they'll get lucky. Should Bob agree?
6. Bob is hiking in the countryside one day and sees a little girl by the side of the road. She has fallen off her bicycle and seriously scraped her knee. It's bleeding freely, beginning to swell, and the girl is having difficulty walking. Bob has a basic first aid kit in his backpack, and some very basic first aid training. (He learned from his new son-in-law, an army medic.) Should he stop to help her, or just figure that if she and her family didn't make preparations for such an eventuality it's their problem and continue hiking?
While the first five illustrate rights we currently have in this country under the Constitution, the last one is the most natural, intuitive right.
Many cultures are willing to stifle dissent, or use frontier justice or give civil authorities strong-arm powers, but does any society, anywhere, believe that refusing help to the sick, aged or injured who can be helped is a good thing? One of the ways anthropologists gauge the degree of "human-ness" among our early ancestors is by finding remains that show someone survived for years after having an injury or disease that caused disability. In some ways, it is taking care of the sick and injured that defines us as human.
Is there a more natural right?
Nice argument Nosimpleway,
Primatologists have observed plenty of examples of primates showing sympathy and caring so I don't think this behavior is uniquely human. Nevertheless, taking care of the sick and injured is certainly a good sign of a well balanced person or society.
But we are talking about moving from the feeling of empathy for another's suffering into responsibility to provide help. The codification of this obligation is the granting of a civil right.
Natural rights are those principally of liberty. It is the very agreement to cede many of our liberties that distinguish a moral and civil society from a brutish chaos.
The USA frequently struggles to find the balance between liberty and respect for moral peaceful civil rights. This discussion is really about the rights of insurers, pharmaceutical companies and health providers to generate as much profit as they freely wish, with an agreed moral responsibility to care for the sick and injured, and to do so in an affordable and comprehensive manner.
I would also argue that we humans have a collective responsibility to afford natural rights to animals, particularly when we are in danger of causing an extinction. Humans are currently racing towards responsibility for the greatest mass extinction since the dinosaurs were wiped out. It will notably be the first mass extinction on this planet propagated by a life form. That this life form is sentient and considers itself moral is a grand tragic irony.
My wife's a primary care physician. Time she spends working with patients on how to reduce obesity and other "life-style indicators" doesn't get reimbursed in our system. Procedures to treat the expensive consequences of obesity do, in a big way. So obesity is not a background condition, a given you need to take into account before assessing the efficacy of U.S. health care. Our system doesn't work effectively to fight obesity, or substance dependencies, lack of exercise, and so on, and so forth.
@SantoTurdo
I would appreciate your not labeling Poland a backwater. Kindly move your ignorance further to the East.
You are correct about racial diversity. Today. But Poland had substantial racial diversity, and then came along this little thing called the Holocaust...
@Jacob,
I hadn't noticed Santo Turdo's comment. Thanks. As one who is half Scottish (and consequently part Norman and Norwegian) and half Polish (and consequently part Lithuanian) it is something of an irony. Yes Poland was once a very diverse Republic (Poles, Jews, Germans, Lithuanians, Latvians, Estonians, Belarus, Ukrainians, Ruthenians, Maldovans, Gypsies etc. etc. etc.), almost as diverse as the British Empire, before the Nazis arrived. She is now much more homogeneous and has lost some of her character. But it wasn't really her fault.
I forgot about the Tarters. There was no slight intended. (What made me think about that was a film with Charles Bronson in it.) You see the Polish Republic was so diverse it was hard to keep track of all our minorities.
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