that's not just an idiosyncratic remark from sullivan, it's downright stupid. the population of the United Kingdom is north of 60M, and somehow sully knows they believe suffering is an important part of life?

two can play at the anecdote game: my family lived in london in the 1970s. i never met a soul who believed suffering was an important part of life; ergo, none do.

what i think is a possible formulation is that gay tory catholic brits can't imagine that suffering isn't a core aspect of british life....

"In the case of ill health, they're actually in much better health than their American counterparts, though that's a function of lifestyle more than hospital choice."

1. Given the last clause, what's your point?

2. Averages are funny. They frequently disguise all sorts of interesting things.

This is Extreme Libertarianism vs. Extreme Utilitarianism -- and I'm running out of sympathy for either.

I don't think Andrew was ever really sick in the British system, so his objections aren't even anecdotal - just ideological. I've been sick in both systems, and there's nothing in my experience that reflects Andrew's vehemence on the subject. I do, however, think my experience aligns with all the data I've seen on the two systems.

ostap, ezra's point is clear: in addition to advantages from lifestyle, brits actually have a better health-care experience with their "hospital choice" than americans do without sully feeling compelled to draw conclusions about americans love of suffering.

as for averages, yes, you're right: so what? how do "averages" come into play in this discussion?

meanwhile, thinking more about sully, what turned the UK against the period of labor domination from 1964 - 1979 was the massive power of the unions within the nationalized industries: certainly this affected sully.

and in the UK, once you turned against labour, you turned against the whole set of programs and policies associated with labour, including the NHS. the rest, for sully, is all self-dramatizing ex post facto rationalization.

Building on the last (3rd) point, don't assume that because you have lots date and andrew uses none, you'll be the most convincing.

Consequentialism is known for developing a fetish for data that hides a more debatable assumption.

You're assumption here was, I think, expressed before, below -- "and don't say priceless" -- is at least debatable.

http://www.prospect.org/csnc/blogs/ezraklein_archive?month=12&year=2008&base_name=what_is_life_worth

Good on you, Ezra. Puncturing Sullivan's ideological fallacies is perhaps not the most important thing you can do to advance the cause of universal health care in this country but it is certainly satisfying to watch.

For Sullivan, still, "the left" = Stalinists with a positive loathing for human freedom. And it's hilarious to listen to him -- who's long flirted with the 'pain caucus' school of economic thinking -- decry the Brits for (allegedly) believing that suffering is virtuous.

Sullivan's bottom line for everything is: He's been economically successful, and that proves he's virtuous, and his reward for being virtuous should be not having to share with anybody.

Andrew is right in his point that Brits are willing to put up with a great deal more aggravation than Americans are. The fact that this doesn't translate to poorer health is probably a result of many factors, not least preventative health care.

The truth is, if you have a chronic illness, like asthma, you're better off in Britain. If you need cutting edge drugs, however, you won't get them in England (though you possibly might in Scotland or Wales).

Of all the Western health care schemes, Britain has the worst, in my opinion, because of Nice--their drug approval board. If they were willing to spend more money on new drugs, we wouldn't be having this conversation. But refusing to give Alzheimer's drugs to AD patients or cancer drugs to cancer patients is unconscionable.

Me, I'd say don't look to imitate a system that gets you into the same political shit we get into here.

http://www.youtube.com/watch?v=kL6KfGlztmQ

1:20 in particular

Call me a hopeless imperialist, but I'd like us to be able to flex some military muscle, or at least throw an olympics, without worrying about the total breakdown of our health system.

Oh, and before anybody starts a comment with "Well, if the VA is any..." -- look, whatever else Ezra comes up with, the only reason the VA does as well as it does is because politically, we put no real price too high to give medical attention to a wounded soldier.

Good focus on the quality of healthcare provided. But we also need to look at the breadth of healthcare provided--the degree to which we fail to cover Americans.

The Reaction has a story about insurance companies insuring the gaps in insurance companies.

The idea that even if you're insured, you have such a fear that your insurance company will fall through on you that you need to buy another set of insurance is what is most horrifying about our system.

Also:

http://www.medpagetoday.com/PublicHealthPolicy/PublicHealth/7895?pfc=101&spc=235

notes that the amenable deathrate has fallen more in countries like France, Japan, and Australia--if we had fallen at a similar rate we might have prevented an additional 101,000 deaths.

Oh, and before anybody starts a comment with "Well, if the VA is any..." -- look, whatever else Ezra comes up with, the only reason the VA does as well as it does is because politically, we put no real price too high to give medical attention to a wounded soldier.

You do understand that the V is VA stands for veterans. They don't do much business with wounded veterans, or at least not the recently wounded. That's a different system.

In addition, the stories coming out of Walter Reed and other armed forces medical facilities over the last eight years make that "no price too high" idea hard to believe.

Finally, the VA system's successes have nothing to do with unlimited budgets. Per-patient spending is actually lower than average for the US, especially considering the demographics involved.

I would offer as a verifiable indicator the incidence of cesarean sections. "The World Health Organization estimates the rate of Caesarean sections at between 10% and 15% of all births in developed countries. In 2004, the Caesarean rate was about 20% in the United Kingdom, while the Canadian rate was 22.5% in 2001-2002. In the United States the Caesarean rate has risen 46% since 1996,[24] reaching a level of 30.2% in 2005." If Sullivan were right, you'd expect fewer Cesareans in Britain.

On another note, I remember how my (American) dentist's assistant couldn't believe it when I refused anesthesia for a routine tooth filling. German dentists always ask the patient whether they prefer anesthesia. I judge the injection to be less tolerable than feeling a bit of pain.

you've just got to stop citing that study about amenable mortality, usually your bs detector is much more finely attuned: http://www.coyoteblog.com/coyote_blog/2008/01/uncovering-some.html

KathyF: Andrew is right in his point that Brits are willing to put up with a great deal more aggravation than Americans are.

Care to offer *any* sort of evidence to that? My impression is that Americans are dealing with an amazing level of aggravation and mostly without complaining (ever noticed the almost total absence of strikes, protests etc. in the US as compared to other advanced countries? And no, it is not likely that Americans have less reason to complain than others) but that may be difficult to quantify.

I don't think Andrew was ever really sick in the British system, so his objections aren't even anecdotal - just ideological.

More to the point, I don't think Andrew was ever really poor in either system. The US system works great for people at the top and sucks for pretty much everyone else, whereas the inequality in the UK is lesser. (Even with the NHS, you can pay money to "go private" and you free yourself from the stifling Communism.)

The quality of care varies from place to place within the UK as well. At my local GP clinic in London, I could make an appointment between 13 and 17 days out (no sooner because they were booked up, no later because they wanted to avoid being booked up in the future) or sit all day and wait for an opening if it was urgent. In Oxford I could walk in in the morning, make an appointment in the afternoon, and go about my daily business in between. In either I could go to the Accident & Emergency department of a hospital if I needed to, and I didn't have to pay for any of them.

Sullivan is a silly ass and only fools read his drivel.
Brits are healthier than Americans

Wait a minute, did Ezra actually just cite that ridiculous study on "amenable deaths"? The one where they used deaths per 100,000 for a rather arbitrary list of conditions, and without even adjusting for incidence rates between countries? The one where they were not sure how to account for some deaths from heart disease being preventable and others not so they just cut them in half?

And Ezra is someone who is supposed to have some credibility on health policy? Unbelievable. The scary part is that people who are uninformed on this issue come here for analysis, and might now be armed with this completely useless data.

Ezra... your data regarding amenable mortality is not complete. See, in Britain, everyone has immediate access to the health system, and so the numerator is "all Brits"...

In America, not everyone has immediate access care, so you probably should have two measures of amenable mortality... perhaps one for "insured Americans" and one for "uninsured Americans"...

I'd bet the results would be different. That's not arguing against universal care...it might even be an additional argument for it...

Does Andrew know anyone in America who is actually poor? I know that sounds a bit name-calling, but I do suspect that's part of Andrew's problem. He lives in Provincetown and rarely ventures out to the rural reality of this nation-- so he still thinks only British people have bad teeth (children who die in this nation from dental abscesses notwithstanding).

In the UK, almost everyone gets a similar level of care. In the US, the poor and uninsured get abysmal care. Andrew chooses not to see that side of the reality.

Actually JimG, those are not the correct measures at all. The appropriate way to measure this would use as the denominator the incidence of each disease, otherwise the differences could be solely due to varying incidence.

Think of it this way: the numbers he cites would be like comparing the total number of homes destroyed by fire between states. When California comes out the highest would you conclude that California firemen suck at their job? Or would you think maybe a few more homes in CA went ablaze because of wildfires? Without the correct denominators those numbers are completely meaningless, and Ezra should know better.

And once more, Andrew Sullivan relies upon the ignorance of his audience to mask that he last had extended use of the NHS as an undergraduate in the early 1980s.

Ezra gets to the meat of it, while Sullivan deals with the emotional superficies: Americans may well be more assertive in demanding X, Y and Z from their doctors, but it doesn't make them any better off as a whole.

"Going to the doctor is often viewed as a moral failure, a sign of weakness."

As opposed to here in America, where you will never hear a conservative say that the problem with our health care is that we have too much of it, and go to the doctor at the least excuse.

I'm an American. I've lived in London, and worked at one of the largest hospitals in the UK, for the past two years.

My experience with the British medical system is generally positive. Yes, cost is considered always and in everything; but the level of care, on a practical level, is quite good. You have to wait a lot, but I always had to wait similar periods when I was in the US (working at a similar-sized hospital). Not having to worry at all about the cost of care means that you get things treated when they need it rather than worrying about the cost.

The attitude of the British toward the system is, I think, basically realistic. There are lots of complaints: no one likes to wait, of course, and a cheap system often means an ugly one (paint costs money) and long wait-times. But I have only ever met one person who wanted to privatize the system. Everyone else seems to prefer the egalitarianism of the NHS and the fact that you never need to worry what your care will cost.

A very important point in comparing health system performance: the US underperforms in every area except one, cancer care.

This fact should make us wonder if there is something different about cancer care in the US compared with other types of care -- cardiac, pulmonary, GI, trauma, GU, etc.

The answer is that there is. Cancer care in the US is organized in a much more scientific way than other forms of practice. The National Cancer Institute oversees well designed scientific studies to measure the effectiveness of treatments and to make (strong) recommendations about what forms care should take, and to create scientific programs that patients can enroll in to test new treatments. Most cancer centers are affiliated with groups of other centers in their area of the country, often headed by major players such as Mayo, M.D. Anderson, etc., which exchange information and refer patients back and forth. Centers doing significant amounts of cancer care are required to have a tumor board consisting of oncologists, radiation oncologists, diagnostic radiologists, surgeons, pathologists, and others which meets regularly to discuss cases and make decisions on treatments.

This is a striking contrast to the "Lone Ranger" style of practice in most other fields, and comes very close to the idea of adoption of national standards for care.

If you believe that scientific practice standards are potentially useful, it is not surprising that cancer care is the only field in which the US consistantly outperforms the rest of the world, and you are left wondering why other fields don't seem to get it.

Also, in terms of comparitive health results data, the data is NOT just due to uninsured in the US. The top 20% of people in the US, most of whom have excellent access to health care, have worse health results than the bottem 20% in the UK. There is more to the US poor performance than access issues, important as they may be.

Also, the "fat, smoking, alcoholics" argument as an explaination of problems with US health care does not stand up, since measures of outcomes once people are in contact with the system and diagnosed are not consistant with that. If that were so, why would our cancer stats be better and our trauma stats worse, since cancer is impacted heavily by life style and trauma not nearly as much (remember, these are not results related to total trauma deaths, but to the trauma death rate once you hit the ER door.)

I don't know AB... Ezra is using the whole of "health care" (rather than specific health problems), and the right definition of "amenable", which considers only those deaths that are preventable by health professionals.

Even taking your "fires in CA" example... we wouldn't look at just fires, because certainly CA has more fires than FL. So we'd look at all disasters that require search and rescue and medical workers... fires, tornados, floods, earthquakes, and so on.

"Amenable deaths" are those for whom rescuers would be responsible and can actually save lives. So it would include such things as having the right assets, people with the right training, the right command, control, and communications and so on.

Perhaps we could consider something more than just "citizens" in the denominator.

But unless we think that England and U.S. have very different levels of all diseases and health problems, "all citizens" could be correct.

Actually JimG, those are not the correct measures at all. The appropriate way to measure this would use as the denominator the incidence of each disease, otherwise the differences could be solely due to varying incidence.

Think of it this way: the numbers he cites would be like comparing the total number of homes [per 100k homes] destroyed by fire between states. When California comes out the highest would you conclude that California firemen suck at their job? Or would you think maybe a few more homes in CA went ablaze because of wildfires? Without the correct denominators those numbers are completely meaningless, and Ezra should know better.

I see your point about incidence, but I think it's debatable whether that's necessarily the right number or not. Things like heart disease and diabetes are clearly affected by smoking, diet and exercise - but that doesn't mean we should view these factors as entirely separate from the "health care system". The UK's NHS, for example, has had quite a bit of success in recent years in encouraging its patients to improve their lifestyle habits. I think the VA system may have some successful programs along those lines too.

(Or, to use your fire example, it's true that the first measure would be a poor measure of "firefighter performance", strictly speaking, but it would be a perfectly good measure of a state's "fire fighting and prevention system". For example, large numbers of homes destroyed by wildfires probably indicate too many homes built in dangerous or inaccessible areas, and without adequate fireproofing and landscaping. But these are problems that can at least partially be addressed by state policy, and are therefore a valid basis for comparison.)

Also note that the linked article is discussing a trend in amenable death rate: countries with state health care systems have improved a lot, the US hasn't. Over the 5 or so year period studied, this disparity likely isn't due to dramatic, exogenous changes in lifestyle.

Also, the "fat, smoking, alcoholics" argument as an explaination of problems with US health care does not stand up, since measures of outcomes once people are in contact with the system and diagnosed are not consistant with that. If that were so, why would our cancer stats be better and our trauma stats worse, since cancer is impacted heavily by life style and trauma not nearly as much (remember, these are not results related to total trauma deaths, but to the trauma death rate once you hit the ER door.)

All true, but AFAICT this study IS simply measuring the death rate of certain diseases designated "amenable to treatment". A death from, say, tuberculosis would be counted - whether that person had ever had contact with the medical system or not.

I'd say I take accounts like Sullivan's and Mr. Cross (in the comments) more seriously than surveys of folks who've only lived with one system. It would be interesting to see a survey of expats in various countries and gauging how they rate each one relative to one another.

Of course, that's subject to some bias, too, as I imagine most expats are probably more well-off and therefore don't have to worry about insurance as much as non-expats. It would still be interesting data.

dankoba -- I have lived under both systems -- 30 years in the UK (including several surgeries) and 15 years in the USA. My basic conclusion is that American healthcare provides better treatment, but *only* if you are wealthy enough to afford it.

In other words, American health care is the best you can buy, but an increasing number of Americans can no longer afford it.

My parents, who are both nearly 80, are big fans of the British NHS. They are regulars at the doctor's surgery these days, for various reasons, and they have always experienced excellent and timely service except on one occasion when they opted to go private (always an option, even in the UK).

The biggest problem I see personally in the US is the number of my friends who are gambling their health and lives by not paying for health insurance. I don't blame them because there are times they just can't afford it, but being without good cover adds appreciably to their stress whenever they get sick with anything. In the UK, if in doubt, you go to the doctor, no bills to worry about. In the US, you always have to wonder if your next illness will bankrupt you.

That is the biggest difference I see.

Just to be crystal clear, unless you have lived in a country with a universal healthcare system, it's almost impossible to understand how great it is not to have to worry about escalating health insurance premiums or paying massive hospital bills at a time when you are at your most vulnerable.

Such stress is a massive hidden cost of the American healthcare system as it is today. Millions of Americans have be force into bankruptcy as a result.

Number of Brits? Zero.

Things like heart disease and diabetes are clearly affected by smoking, diet and exercise - but that doesn't mean we should view these factors as entirely separate from the "health care system".

In this context, yes we should. The point Ezra was making is about people who died because they did not receive adequate health care. But the study he is referencing is practically useless. All it gives us is measure of relative incidence of these illnesses, and says absolutely nothing about care.

Or, to use your fire example, it's true that the first measure would be a poor measure of "firefighter performance", strictly speaking, but it would be a perfectly good measure of a state's "fire fighting and prevention system". For example, large numbers of homes destroyed by wildfires probably indicate too many homes built in dangerous or inaccessible areas, and without adequate fireproofing and landscaping. But these are problems that can at least partially be addressed by state policy, and are therefore a valid basis for comparison.

But the problem with your analogy is that while yes, state policy could dictate that you cannot build a home in a fire prone area, state policy is not going to dictate that someone has to exercise and eat healthy. Lifestyle choices are always going to affect the relative health between countries, and unless you're proposing some pretty draconian laws about fitness and diet those lifestyle choices are going to continue increasing the number of deaths we experience from their list of illnesses, rendering their study as it was performed completely useless. For all we know even adjusting for incidence the US could still come out worse than the other countries, I am not arguing otherwise, but this study doesn't really give us any meaningful data. This is not an ideological debate, I'm not saying "USA! USA!", I'm just saying that if one is going to claim that we have worse outcomes then you'll need to provide some better analysis. This study ain't cuttin' it.

And this is not even addressing the other quite obvious methodological flaws in their research.

Sorry, AB, but this looks like nothing more than forcing the opposing side to do all the research, to avoid any burden of proof requirements. It doesn't work that way. If people want to claim that medicine in the U.S. is so good, it's incumbent upon them to post some sort of justification for that claim as well . . . and saying that any given study or statistic 'doesn't take X into account' definitely works both ways.

I was reminded of this as a typical right-wing tactic (not saying that you one of those) a couple of months ago when a similar situation occurred on McArdle's blog. Yes, it was conceded, yes outcomes were generally better . . . but only because Europeans have a healthier lifestyle. Oh really? Pull up the statistics for smoking on WHO's site, and you see that Americans on average actually smoke less than the citizens of many other countries with healthier outcomes. Same thing for drinking - those 'healthier' Europeans often had an alcohol use incidence that made it look as if little old ladies could drink any three USians under the table. Then came the objections concerning diet, exercise, obesity, etc. And after those, the objections to non-homogeneous populations.

In short, no matter what was addressed, there was still something else that 'hadn't been considered' - the God of the ever-shrinking, but ever-multiplying gaps as it were. How do you know the differing outcomes aren't because of this? Or this?

So it seems that burden of proof goes to you now. If you want to claim that there are confounding factors that completely invalidate the studies cited, you'd best produce your evidence. Merely repeating requests for more evidence in ever greater detail and depth just won't cut it.

The amenable death stat more than likely has far more to do with lifestyle than with health systems. The countries with the lowest amounts are Japan and France while the US and UK have relatively high rates. 3 out of 4 have universal(or pretty near universal) health coverage. The difference is lifestyle. Japan has about a tenth of the obesity that the US has. Maybe the diet in the UK is nearly as bad as ours.

People like Michael Moore point out things about the FRench diet with creamy sauces, but the portions are small. Better to have a little cream sauce than a supersized Big Mac meal deal and a half gallon of cola.

Some try to say that obesity and its related heart and diabetes problems should be considered as a failing of the health system. Yet Michigan has had a high obesity rate for some time and has a high degree of people with health insurance. Many have very good government and UAW sponsored plans.

The point is that the US does not trail only in death rates and not only in the AFAICT data. It trails in multiple studies, many not using the result of overall population death rates but rather death rates following admission or diagnosis for a particular health problem. People are not just dying because of the fat, smoking, alcoholic issue, and are not dying just because of lack of access.

People who have access to health care and insurance do less well in the US than in other countries. For example (and this is raw death rates) the bottom quintile in Britain does better than the top quintile in the US.

The fact that cancer care works better in the US than in other countries is also telling. Cancer care is effected by the same problems as any other disease state, but despite poor health habits in the US population and despite poor access by many people, cancer care works better here. Unless people are better off being neglected or people who are fat are actually protected from ill effects of cancer, this suggests that something is right about cancer care and/or wrong with other care in the US. My suggestion is that cancer is the one area where US health care behaves more as it should -- following scientifically proven treatment patterns or else structuring care so that scientific data can be extracted from the results. In most other areas, we are stuck in a pattern of heroic intervention in crisis situations, employing high tech solutions even when other treatments are proven better.

The US expends hundreds of billions of dollars on dramatic interventions, many of which are actually worse than more conservative approaches usually followed elsewhere. We are too in love with bells and whistles and not enough in love with evidence, and too in love with the notion of being "fixed" by a dramatic intervention rather than being treated over a long term with more conservative therapy.

Sorry, AB, but this looks like nothing more than forcing the opposing side to do all the research, to avoid any burden of proof requirements. It doesn't work that way. If people want to claim that medicine in the U.S. is so good, it's incumbent upon them to post some sort of justification for that claim as well

Huh? The burden of proof is on the people making the claim, i.e. the people saying the US has worse outcomes. I have not said the US is better or worse, only that the statistics cited so far do not provide any evidence that it is worse.

If you want to claim that there are confounding factors that completely invalidate the studies cited, you'd best produce your evidence. Merely repeating requests for more evidence in ever greater detail and depth just won't cut it.

I have produced evidence. The evidence is right there in their report. They did not use the proper denominator that would show if the health care system is the cause of the additional deaths rather than incidence rates. To use the fire analogy again, if you're going to claim that California has a poor fire control system compared to other states then you need to show the percentage of houses burning down out of the total that were on fire, not as a percentage of all houses.

As for accusations of "typical tactics", how about your tactic of citing a completely irrelevant source and then saying the burden is on me to disprove it?

Under a system with universal healthcare you don't have to worry whether a job has healthcare or not. So you can safely move to a low-paid or non-traditional job for a while. You don't have to be wealthy or paid by a big organization in order to do something risky like seeing whether blogging (painting, music, yoga, dog training, or Adrian Mole) would earn you a living.

Many people I know in the UK have done something like this, and I doubt that they would if they had to worry about the possibility of getting sick during the time they were between traditional jobs. In the US, a pre-existing condition is really bad news, since insurance companies can turn you down

Piglet: British people will tell you themselves that they aren't used to complaining, it just isn't their nature. You only have to be here a week or so to realize that when you complain about poor service, you are either ignored, or told to leave for causing a fuss. Seriously.

Just the other day I spent about 45 minutes trying to report an electricity outage. I had to call back to convince the person it wasn't an issue with my "customer box" (fusebox) but actually the people out working on the street who'd cut the lines. I had to use my scary American voice to get someone to transfer the call to someone who'd help me and not put me on hold again.

And yeah, Brits are very stoic when it comes to health issues. My classmate has a husband with Parkinsons, and she's constantly making jokes about him falling, whereas in my family, my father in law with PD is no joking matter. Of course, when she needs a nursing home for him it will be provided, whereas my father in law will have to deplete his life savings before the govt picks up the tab.

I could go on with more examples--for instance, did you know dentists here don't go to four year medical schools? In a lot of ways, comparing American to British health care is really comparing apples to oranges. We should compare ourselves to the French--we're much more like them temperamentally.

Isn't the French health care system even better and cheaper than the UK NHS? I'd love to hear more on the left discussing the French system as a model we should be studying, because I've heard much less criticism of it than the Canadian/UK models.

Yeah, you can't imagine "mustn't grumble" being part of the American vocabulary of cliché. But clichés aren't all-encompassing, and they take a degree of understanding in context.

The obvious rebuttal to Sullivan, though, is that American healthcare is viewed in Calvinistic terms, as Sara Robinson (among others) has noted:

The virtuous Elect can be discerned by their svelte figures and low cholesterol numbers. From here, it's a short leap to the conviction that those who suffer from chronic conditions are victims of their own weaknesses, and simply getting what they deserve. Part of their punishment is being forced to pay for the expensive, heavily marketed pharmaceuticals needed to alleviate these avoidable illnesses. They can't complain. It was their own damned fault; and it's not our responsibility to pay for their sins. In fact, it's recently been suggested that they be shunned, lest they lead the virtuous into sin.

You hear that bullshit conflation of sickness and irresponsibility in these threads from the usual suspects. So when Sullivan claims that "success is morally problematic" the counter-argument is that Americans simply believe -- or at least, American healthcare systematises the belief -- that if you are bankrupted by illness, or fucked over by your insurer, you were a moral failure and deserved it.

I find that reprehensible.

As a liberal reader of Sullivan for many years, I am a bit disturbed about the nature of the personal attacks on him (as opposed to his viewpoint) a bit disturbing. He may infuriate me at times, I have also learned quite a bit from his blog and have learned to understand his view even when I don't agree with it.

Having said that, I do believe he has a blind spot when it comes to the "middle class"due to both his hard worked for success and certain aspects of his conservative ideology. To me, middle class is $50,000 a year or so; to him it's $150,000. I also think it has been so long since he has had to struggle financially he has become out of touch with the working class. However I also think that is true for every CEO and congress member.

...And by the way Sullivan lives in Washington DC. He summers in Provincetown.

The US spends twice (twice!) as much on health care than UK.

A huge portion of americans have no access to health care whereas all Brits have access to care.

The health of americans is no better than brits.

What's the point of this discussion again?

Another thing, if the American system is so dangerous to the health of its citizens, then Japanese Americans should have life expectancies similar to those of your average white America but it is very similar to those of Japan.

Also, Mormons in the US live longer lives than Japanese who live in Japan, so lifestyle can't be dismissed. People in Utah, according to a recent analysis, lead very healthy lives.

If the British system is so swell, lets set up a system like it for every government employee, medicare and medicaid beneficiary and union worker currently covered by a health plan. That is an enormous part of the population. I highly doubt the teachers unions (who are both goverment and labor) would give up their Cadillac plans for the supposedly superior British version.

Sorry, AB, but this looks like nothing more than forcing the opposing side to do all the research, to avoid any burden of proof requirements. It doesn't work that way. If people want to claim that medicine in the U.S. is so good, it's incumbent upon them to post some sort of justification for that claim as well

Huh? The burden of proof is on the people making the claim, i.e. the people saying the US has worse outcomes. I have not said the US is better or worse, only that the statistics cited so far do not provide any evidence that it is worse.

Uh, no, AB. The original claim was that American-Style medical care was too expensive and that not enough people were being covered. Well, it's pretty indisputable that on that basis, the U.S. doesn't do so well. So the assertion was then made - by people on your side - that the reason medical care is so expensive in the U.S. is because the care it top-notch, the best, A-1 Joe.

That's the claim Ezra is addressing now. The claim that originally came from your side (I think it's obvious by now that it's completely fair to say this.) Since the claim came from your side, it's up to you to prove it. This game of making up stuff with no support, challenging people to disprove it, and then claiming that 'you're not satisfied' with the evidence just won't cut it.

So where is your evidence for this claim?

I LOVE this conversation. I have learned a lot. More of these between bloggers, please.

Civil debate. YES.

This is actually quite an easy decision tree. Question 1- do you want to have to worry about having to pay for health care or not? If you don't want to worry then somebody has to ration the service or else the system goes broke. In the United States we have made a decision not to give up power to some third person even if that means lower outcomes higher costs and large numbers of people without adequate health care.

"Isn't the French health care system even better and cheaper than the UK NHS? I'd love to hear more on the left discussing the French system as a model we should be studying, because I've heard much less criticism of it than the Canadian/UK models."

Posted by: Existenz | December 6, 2008 3:23 AM

Yes, French health care does better than the British system in many measures of health outcomes and in the famous 2003 WHO study.

No, it is not cheaper than the British system. It is quite a bit more expensive. The British system costs a little more than half the US as a fraction of GDP, while the French model costs around 65% as much.

The French system has been discussed in detail by Ezra in earlier posts. Briefly, because it is still based on insurance which is nominally private, although subject to very intense govenment controls in terms of price, coverage, and so on, and because it was introduces in pieces over a period of almost 50 years before reaching full universal coverage in the 90's, it is often seen as a potential model for the US.

In terms of costs, only Asian countries spend less on health care as a percentage of GDP than Britain.

A point that AS seems blissfully unaware of, and not addressed really in the posts above, is simply access to insurance at an affordable price even for those willing to pay for it. Insurance companies effectively redline -- choosing the healthiest (actuarily speaking) risks to cover -- and refusing others. This is of course well documented, and results in millions not being covered -- and at risk of financial disaster should they be unfortunate enough to incur a high-cost illness/accident/disease.

AS is of course covered under insurance from The Atlantic or perhaps through his partner as part of a group; ergo, he has no worries about obtaining coverage. Should he be forced into the "free market", his experience I would venture to say would be dramactically different. Given his HIV, he ma indeed find himself uninsurable at any cost -- is that fair? Is that how we want healthcare delivered to those who need it in this country?

Until 2 years ago, I was covered under a generous employer sponsored plan. Then I elected to leave my employer, and had COBRA coverage thereafter for 18 mos (at a cost of 2X what I had contributed under my employer group). After that, I've now found myself uninsurable at any cost. My crime? Reasons cited for having coverage declined are these:

1. History of depression. I took anti-depressants for a period of one year in 1990-91 when I came "out" as gay and was dealing with the consequences of that.

2. Steel pins in ankle -- surgery for a broken ankle left me with 2 steel pins to help the bone heal. Surgery occurred in 1996.

3. History of High Blood Pressure. It's genetic, runs in my family, I've been on medicaion for it for 14 years and it's controlled.

4. Weight -- I'm 25# over what is considered desirable for my age/height -- however the tables do not take into consideration my build. My family genetics are we're built like wreslters -- strong, thick, big builds. I work out at the gym, am 215#, 5'10" and cannot conceive how I could ever get to 190#. I don't think it's in my genetics.

Other than the above, I'm in excellent health, no current issues. But I have been turned down for insurance repeatedly.

Repeat that scenario a million times or more. And although I'm fairly well off, a medical "disaster" could cripple me financially.

Lastly, if you are uninsured, consider how hospital's price services the uninsured "purchase" -- they get charged full "rack rate" --- often prices that are exhorbitant when comapred to the "negotiated rates" fixed with insurance companies and group plans for the same exact services that the hospitals provide to insured paients. So, uninsured individuals who are in the most dire circumstances have foisted on them the absolute full-cost, highest rates that hospitals charge for their services and have virtually zero negotiating leverage to bargain with them (well, absent a threat of personal bankruptcy).

We're killing the citizens of the US in more ways than one on the issue of healthcare.

A point that AS seems blissfully unaware of, and not addressed really in the posts above, is simply access to insurance at an affordable price even for those willing to pay for it. Insurance companies effectively redline -- choosing the healthiest (actuarily speaking) risks to cover -- and refusing others. This is of course well documented, and results in millions not being covered -- and at risk of financial disaster should they be unfortunate enough to incur a high-cost illness/accident/disease.

Yes. This is the initial concern. Not the U.S. health care is better or worse than in other countries, but that it is increasingly unaffordable to larger and larger numbers of people. The whole idea that our system is superior because of superior outcomes was introduced to justify what to many is a non-optimal scenario. Ezra is merely saying, 'Well, if this claim is true, how do you explain these statistics?' _That's_ what has to be addressed in this context. Not caterwauling from invested parties that they're 'not convinced' by the evidence.

I work in the health care industry in the US. Much of my main function is dealing with insurance. I dont understand why Americans have this fear that a Govt. run healthcare system would be worse for people overall.
You pay LOADS of money for insurance. You expect to be able to get care. Any kind of care. Truth is, that is not a guarantee.
There is continuous debate as to why this wont work, and why this is bad, but honestly people...The system here is BROKEN. " THEY'LL TAX YOU A HUGE % OF YOUR WAGES" Thats an argument outside of quality I hear all the time. I make 3000 a month, and I pay nearly $250 a month for my insurance that will tap out at a million dollar LIFETIME maximum. If I keep that policy for the next 10 years, and use a good portion of that million, even though I paid more than a 1/4 of that amount in preimiums alone, not including 2500 a year deductibles and whatever percentage of my own healthcare costs the ins. co. feels is "fair", Ill be older and more of a liability and therefore much harder to insure once my main policy runs out. Does that make sense to anyone. I would take free healthcare any day over having to line the pockets of rich beaureaucarats. Thats what our "system" does right now. Our system does not prevent you from being financially ruied even if youre insured. What kind of "care" is that exactly. Aside from the financial aspects, we have less and less Dr.s accepting Insurance these days, we have fewer new doctors and so many estblished Dr.s are simply closing shop. Quality care is becoming a myth here, and if you dont have the money to pay for it, you go to a hospital and you are left in the hall for hours to die. It happens more often here.

Which system is better? This one isnt cutting it, I can only say that for sure.

As a liberal reader of Sullivan for many years, I am a bit disturbed about the nature of the personal attacks on him (as opposed to his viewpoint) a bit disturbing.

I think that you have to make allowances here. Sullivan's writing style demands a degree of ad hominem, because the style he's crafted for his blog entails foregrounding his subjectivity and writing from his gut.

It's Sullivan who came up with the ridiculous line that "[u]ntil you have lived under socialism, [the NHS] sounds like a great idea." He's the one making the sweeping generalisations about the British regarding medical treatment as a "moral failure" and making the crack about dentistry, which is cheap cant designed to tickle his American readers.

As has been said repeatedly, this isn't an either/or choice, with only two options on the table. Still, no industrialised nation, regardless of the political leanings of its government, regards the US as a model of emulation.

That suggests the opposite conclusion to Sullivan's spiel about 'freedom' in healthcare (which is basically the freedom to be screwed by private insurers). Give universal healthcare to a nation, and while people might grumble about its implementation, they won't want to give it up.

Uh, no, AB. The original claim was that American-Style medical care was too expensive and that not enough people were being covered.

No it wasn't. The original claim in the original post was:

In concert with Andrew's thesis, Britain does indeed have a high rate of amenable deaths. Just not higher than ours. in 2002-2003, Britain suffered 102.81 amenable deaths per 100,000 citizens. America suffered 109.65.

Those "amenable death" numbers are hogwash, and if you or Ezra is going to cite them as evidence of the inferiority of American health care the burden of proof is on you to show that they are a meaningful and accurate comparison. I've shown why they are not.

the assertion was then made - by people on your side - that the reason medical care is so expensive in the U.S. is because the care it top-notch, the best, A-1 Joe.

My "side"? What is my "side" exactly? Is this a binary situation, there are exactly two "sides" and every one has to pick one? Something as complex as a discussion on a national health care delivery system has two "sides"? And what is more, if you're going to hold me responsible for someone making that claim (which I've never said nor do I think that) then I'll also hold you accountable for any ridiculous ideas presented by those on your "side".

Talk about straw men. I haven't defended the US system or said that it is superior, so please refrain from saying I need to defend anyone who has. I think you need to go back and read what I've actually said instead of acting as if I'm responsible for the ideas of anyone who has said things in defense of the US system. Seriously, go read my 5-6 comments in this thread and then tell me again how I've said US care is superior, top-notch, and show me where I've played this "game of making up stuff with no support". You are the one citing as evidence numbers that have been shown to be quite problematic in the way they were calculated, the burden is on YOU to show why they are not. So I'll ask again, how does the number of deaths from a given list of conditions as a percent of total population without taking into account total incidence give us meaningful information about the quality of a national health care system?

No, AB, you know quite well that the conversation goes well beyond what was the topic of this post. You also know that the original objections were to cost and access. Finally, you also know that the defense for the relative high cost and lack of access was that the care was superior.

You're just ducking the burden of proof. But hey, I'm willing to be proven wrong: why don't you show us those studies that reach the conclusion that it is 'lifestyle differences' rather than health care practices that are the significant factor to amenable mortality?

Because we all know that you wouldn't ever keep on demanding more and more evidence, rejecting each successive cite as 'not good enough', right?

Or you could explain just why we should keep a system that costs so much and offers so little. That shouldn't be difficult, right?

I think it's time you showed your colors.

There you go again, assuming that I am this caricature you have in your head of a right-wing ideologue.

Please answer me this question, at what point have I ever said anything to suggest "we should keep a system that costs so much and offers so little"? Since you keep accusing me of it it ought to be quite easy for you to show me where I've suggested that.

No, AB, you know quite well that the conversation goes well beyond what was the topic of this post. You also know that the original objections were to cost and access.

No, Ezra's post made this basic point: The UK has superior health care outcomes, as proven by this study that showed a higher number of "amenable deaths". Anyone with a rudimentary understanding of statistics will see that the methodology in the study he cites is pretty flawed, enough to render it practically useless for the intended purpose. Since he (and you, by defending it) is the one making the claim, the burden of proof is on him (and you) to show why those numbers have any relevance. Are you suggesting that the US and UK have identical incidence rates of the selected diseases, which would justify the use of total population as the denominator? Is that your stance?

I've already said that it's quite possible that the outcomes in the US are in fact worse, but this particular study does not give us any meaningful insight.

Because we all know that you wouldn't ever keep on demanding more and more evidence, rejecting each successive cite as 'not good enough', right?
Or you could explain just why we should keep a system that costs so much and offers so little. That shouldn't be difficult, right?

If you're just going to keep making ridiculous and incorrect assumptions about what I believe or how you think I would react I'll stop wasting my time.

I think it's time you showed your colors.

Why don't you stop acting like a petulant child and try to discuss real issues based on what someone has actually said, not by creating a bogeyman in your head of who you think they are.

I really don't believe AB when he claims that it's the reformers who are claiming the U.S. has poor health outcomes, and so the burden of proof is on them, and here's why:

Yet President Bush maintains an opposing view, saying on numerous occasions in his weekly radio addresses and other speeches that Americans "have the best health care system in the world." Presidential candidate Rudy Giuliani, on the campaign stump, echoed this sentiment last week with his claim that Americans have the "best medical care in the world."

For many years, could blithely proclaim that the U.S. had the best health care system in the world, but as it's major shortcomings become more visible, Americans are finding it harder to accept this assertion.

Many Americans are under the delusion that we have “the best health care system in the world,” as President Bush sees it, or provide the “best medical care in the world,” as Rudolph Giuliani declared last week. That may be true at many top medical centers. But the disturbing truth is that this country lags well behind other advanced nations in delivering timely and effective care.

This is where you start getting the requisite genuflection to the United States' having "the best health care in the world." One problem: a spate of new research shows the United States well behind other developed countries on measures from cancer survival to diabetes care that cannot entirely be blamed on the rich-poor or insured-uninsured gulf. None of this implies a specific fix for the U.S. health-care system. It does, however, say that "the best in the world" is a myth that should not be an impediment to reform.

How widespread is the "best in the world" view? In a survey of 1,026 U.S. adults, the Harvard School of Public Health and Harris Interactive reported last week, 55 percent said they thought the United States has the best quality care of any country.

US health care no longer "best in the world"

A fundamental change has occurred in the way US citizens view their health service, writes one bioethicist. The public has finally accepted that health care in the US is no longer "the best in the world," and politicians, journalists, or anyone else who repeats that now historical phrase is more likely to be laughed at than applauded for their patriotism.

John McCain's often-repeated claim that the United States has "the best healthcare in the world."

Frankly, to pretend that Ezra & company just made the assertion out of the blue that the U.S. does not have the best health care, that what's being challenged is the claim that 'America has the best care system in the world' rather than the reverse, is either woeful ignorance or complete rank dishonesty employed to avoid any heavy lifting. You know, sort of like those Creationists who claim that Evolution 'hasn't been proven' because there are 'more gaps in the fossil record now than when the theory was first proposed.'

Maybe I'm being unfair to AB. But if so, he should explain just what it is he thinks he's doing.

You're wasting you're time right now AB because no one is buying your act. If you want to people to believe you're operating on good faith, you will acknowledge that 'America has the best health care in the world' is meme that has been pushed for years by politicians and insurance companies alike. You will also at least make some sort of effort to cite a study that shows that these discrepancies are all about 'life-styles'.

But I'm guessing that you don't like the fact that the burden of proof falls squarely upon your shoulders; no one else's. And you were counting on the differential of being able to say 'I'm not convinced this study is valid'.

Now, which way are you going to jump? I'm willing to start from the top, if you are. But you are going to have to acknowledge some facts on the ground, as well as explain what you think Americans are buying with their pricey health care . . . if they can afford it. If you can't do that, than I don't see how I can do anything except categorize you as some sort of a troll.

That's being honest and that's being fair. Your call.

Does anybody in the United States understand that if you want to and can afford to, you can easily get Private Health Care in Britain? Approximately 10% of the population hold private insurance, either through their employer or otherwise; many more than that divert other savings to private treatment if they think it's important.

It is NOT either/or.

The NHS is the bottom line. And as a bottom line it's a damn good one.

If you don't like it, and you can afford to, you can go to a private hospital just like in America. The difference is that the bottom line is good enough that only the rich and strange are usually bothered.

So I'm supposed to defend a "meme" that I have never said myself? I'm supposed to stand up for GWB and Giuliani? I don't know how you get these ridiculous ideas in your head.

Let me break out the handpuppets for you:

Ezra claimed the US has worse health outcomes, and offered one piece of evidence: the flawed study on "amenable deaths". I pointed out the flaws in this study and said if he or anyone else is going to make that assertion they need more than one practically meaningless statistic produced in a flawed study. Somehow you've twisted that into me being responsible for defending every inaccurate belief any right-winger has about health care.

If Ezra claimed that the NY Giants were the best team in football because they had the best punter, I'd call him on it and say that that is not the appropriate way to evaluate the teams. That would not mean that I think they are the worst team in football, nor that I am totally convinced that they are not the best team, it would only mean that the evidence as presented did not prove it. It really is as simple as that.

no one is buying your act

You know what, just piss off. You've repeatedly ignored every point I've made (every one of which I stand behind), dodged my questions, placed the blame on me for other people's beliefs, falsely claimed that I want to maintain the broken status quo, completely refused to address the flaws in your supposed "evidence", and rather than address the point at hand and the points I've made you've tried to paint me as the right-wing health care bogeyman, despite the fact that not one thing I've said suggests that is the case. When you're ready to discuss things like a rational adult the rest of us will be waiting.

If you don't like it, and you can afford to, you can go to a private hospital just like in America.

And receive treatment, for the most part, from specialists who spend half the week with NHS patients.

At the first post on gay tory catholic brits:

That. was. hilarious.

Patrick, your comments about how the US underperforms all over the place EXCEPT for cancer treatment are very interesting; thanks.

Ah, you wondered when the stupidity defense was going to come up.

So I'm supposed to defend a "meme" that I have never said myself? I'm supposed to stand up for GWB and Giuliani? I don't know how you get these ridiculous ideas in your head.

First, putz, this post was written to refute the claim that America has the best health care system in the world. It was not just put up out of the blue. I know you know this, just like I know that you know that this is been a heavily pushed meme for several decades. And since it was written to refute that claim, the burden is on you to reply to it, not the other way around.

Let me break out the handpuppets for you:

Translation: Let me assert for the fifth or sixth time in an even louder voice my spin. Because talking in a louder voice always wins the day.

Ezra claimed the US has worse health outcomes, and offered one piece of evidence: the flawed study on "amenable deaths". I pointed out the flaws in this study and said if he or anyone else is going to make that assertion they need more than one practically meaningless statistic produced in a flawed study. Somehow you've twisted that into me being responsible for defending every inaccurate belief any right-winger has about health care.

No. Again, Ezra is claiming that those who say that Americans have the best health care system in the world are wrong. Or at least have some splainin' to do.

If Ezra claimed that the NY Giants were the best team in football because they had the best punter, I'd call him on it and say that that is not the appropriate way to evaluate the teams. That would not mean that I think they are the worst team in football, nor that I am totally convinced that they are not the best team, it would only mean that the evidence as presented did not prove it. It really is as simple as that.

The problem is, Ezra is not claiming that. For your analogy to be valid, other people are claiming the NY Giants are the best because they have the best punter, and Ezra has offered up evidence that this is not true. Now, the other side can claim the evidence is flawed, but they have to prove it, not go through this slimey kabuki of claiming that 'they are not convinced'.

Again, I know you know this, and pretending that this is not what's happening is, well, rather contemptible. It really is as simple as that.

no one is buying your act

You know what, just piss off. You've repeatedly ignored every point I've made (every one of which I stand behind), dodged my questions, placed the blame on me for other people's beliefs, falsely claimed that I want to maintain the broken status quo, completely refused to address the flaws in your supposed "evidence", and rather than address the point at hand and the points I've made you've tried to paint me as the right-wing health care bogeyman, despite the fact that not one thing I've said suggests that is the case. When you're ready to discuss things like a rational adult the rest of us will be waiting.

Posted by: AB

Sigh. As is so often the case, I've got you pegged to a T, and you've got nothing, other than a lot of projection. We can see this because you're not naming specifics, only making vague innuendo. I, otoh, am being quite specific: I say that you are deliberately ignoring the fact that 'America has the best health care in the world' is a pervasive meme being aggressively pushed by the usual unsavory parties.

The fact that you won't - or can't - admit that speaks volumes about your real position. And your honesty. I don't believe at this point that you are arguing in good faith at all, and if you actually were, you'd be concerned about that fact. As is embarrassingly obvious, you don't. So go crawl back into whatever hole you came from, or change your psued or whatever it takes to get you out of here.

Sullivan neatly dismisses the suffering of children who might not have gotten in line with his cruel stereotypes. "Please sir, I don't need another. I'm English, see, and I love to suffer."

And all the more stupid from somebody interested in fighting stereotypes. I applaud him his stance on torture, but he's been eating too many petit scones. That's what happens living in a blogging cocoon.

Of course, he also calls Hillary Clinton a "monster" and regularly bows to the bloody altar of Reagan and Thatcher. Nuff said, Ezra.

this post was written to refute the claim that America has the best health care system in the world.

And right off the bat you show yourself to be either very foolish or a liar, because the post Ezra was responding didn't even say that, nor have I. No one in this discussion has made that argument, I didn't say it, Andrew didn't say it, and you continual harping on that just shows that you don't want to address the only thing I did say, which is that the numbers Ezra cited are hogwash. I could not possibly care less if someone somewhere said the US has the best health care, nor do I care if it is a pervasive meme, nor do I care what Bush or Giuliani have said about the issue, the only, THE ONLY THING I've said here is that the study that was cited was unbelievably flawed, and offers no evidence of the relative efficacy of the American and British health care systems. That is a fact, but you refuse to address it and instead just expect me to be accountable for arguments that other people have made.

The entire motivation for Ezra's post was to refute Andrew Sullivan's comparison of American health care and the NHS. Sullivan really is not very well-informed on the issue and should probably leave it to those who are, but even so, the evidence Ezra used to show he was incorrect was faulty, and I pointed out as much. Try as you might to pin the meme of "the US has the best health care" on me, it just won't work, because I never said it and it is completely nonsensical for you to keep accusing me of denying it. I haven't denied it, I've just told you that it's not my position, and is not even the point of this entire thread.

Take your ideological blinders off for 90 seconds and read Sullivan's post, then read Ezra's response. This is all about comparing the US to the UK, and making a judgment on which system performs better. The whole "US is #1" argument was never a part of this until you chose to bring it up rather than answer my questions.

I say that you are deliberately ignoring the fact that 'America has the best health care in the world' is a pervasive meme being aggressively pushed by the usual unsavory parties.

Yes, to the same extent that I'm ignoring the fact that "college football needs a playoff system" is a pervasive meme, because it's about as relevant to my point as that is.

For the 6th or 7th time: please explain why one should not use the incidence of a given disease as the denominator rather than total population if one wishes to evaluate the quality of two health care systems.

RE: totat population amenable deaths vs. incidence amenable deaths:

AB, what would be wrong with this statement:

Propenents of the view that the US has a relatively superlative health care system have not provided evidence of this claim. On the other hand, some research suggests that health care in other nations has better outcomes. More research needs to be done, but the consensus among experts is that US citizens pay more for health care and yet are not healthier.

You've made the case that more research needs to be done, but it still seems that population-based amenable deaths is a better proxy of outcomes than no data at all.

AB, let me put it this way. You have 2 possible arguments:

1) The know-nothing argument: Because comparative international health care research is incomplete and may be misleading, we should entirely ignore it.

This mode of inquiry would be radically at odds with scientific (social or physical) practice. Know-nothing would not be an over-the-top description.

2) The positive claim: You say that Ezra's link is wrong because you have evidence that US incidence of amenable disease is higher. You say that the assumption that heart disease, cancer, diabetes, liver and kidney diseases, etc... is equivalent across first world national populations is false.

You therefor are invited to provide this evidence, or correct my reasoning.

There is plenty of evidence out there. Just one example:

The US population in late middle age is less healthy than the equivalent British population for diabetes, hypertension, heart disease, myocardial infarction, stroke, lung disease, and cancer.
...
To illustrate, among those aged 55 to 64 years, diabetes prevalence is twice as high in the United States and only one fifth of this difference can be explained by a common set of risk factors.
http://jama.ama-assn.org/cgi/content/short/295/17/2037

And using the data from the amenable study the diabetes statistic would actually make the US look worse, because the rate of diabetes deaths is more than twice as high in the US, but this perfectly illustrates the importance and potential impact of varying incidence.

1) The know-nothing argument: Because comparative international health care research is incomplete and may be misleading, we should entirely ignore it.

No one ever said we should ignore evidence, except for this one very flawed study. The study Ezra cited is practically useless. One of the first principles of a study like this is to control for all of the variables. Not adjusting for incidence is laughable if one wants to use these numbers to compare health care systems. 60% of the deaths in the study are from heart disease, so all these numbers give us a proxy for are the relative incidence rates of heart disease, not the quality or availability of treatment. Anyone claiming the latter needs some basic education in statistics.

Another point to consider, no one has suggested that the US does not need reform, and most acknowledge that access to health care is a big part of the problem. But in a country where 15% of the population is uninsured, how is it that the amenable death rate (to use the numbers that everyone seems to be so enamored with) is only 6% higher than that of the UK? Would that not possibly be evidence of superior outcomes (for those with insurance obviously), and indicate that by increasing access we'd actually be better than the UK?

And one last point re: the cited study:

It is important to recognize that the development of any list of indicators of amenable mortality involves a degree of judgment, as a death from any cause is typically the final event in a complex chain of processes that include issues related to underlying social and economic factors, lifestyles, and preventive and curative health care. As a consequence, interpretation of findings requires an understanding of the natural history and scope for prevention and treatment of the condition in question. Thus, in the case of IHD, we find accumulating evidence that suggests that advances in health care have contributed to declining mortality from this condition in many countries, yet it is equally clear that large international differences in mortality predated the advent of effective health care, reflecting factors such as diet and rates of smoking and physical activity.16 To account for this variation, we included only half of the mortality from IHD, although, based on the available evidence, figures between, say, 25 percent and 70 percent would be equally justifiable.

One cannot possibly read that and still claim that the authors are qualified to present this type of analysis. That is unbelievably bad, they'd get an F in undergrad stats with analysis like that.

Thanks AB.

KathyF, I suggest you spare us your totally subjectrive anecdotes. I have offered some evidence (the rate of Cesarean) that is relevant to the discussion at hand. You have not offered any kind of verifiable evidence for the claims you are making. I have lived in five countries: Germany, Switzerland, the UK, Canada, and the US. Believe me I have learned to be suspicious of the kind of stereotypes you are promoting.

But if you wish, I could add another anecdote of my own. I have never been seriously ill while in the UK but I once went to see the doctor for a very minor thing. I went there without an appointment and was treated within an hour or so, for free of course, without as much as being asked for an ID. Here in the US I wouldn't consider seeing a doctor in that situation because of the money I'd have to pay out of pocket, and I'm one of those with good insurance. It is probably true that a sufficiently wealthy portion of the US population, undeterred by cost, seeks medical care for every minor condition, maybe more excessively than people in other countries, and maybe you, KathyF, are part of that population. But this can definitely not be generalized to the US as a whole. This is what you, KathyF, are not getting, you are making inadmissible generalizations.

37% of US respondents confirmed in the Commonwealth study that they had skipped medical care for cost reasons in the past year. And those people tend to accept the heartbreaking injustice of their health care system with little complaint. If "Brits are very stoic when it comes to health issues", how would you describe those 37% of Americans? Please answer that.

P.S. Andrew Sullivan is either shockingly ignorant or shockingly cynical, or both.

The entire motivation for Ezra's post was to refute Andrew Sullivan's comparison of American health care and the NHS. Sullivan really is not very well-informed on the issue and should probably leave it to those who are, but even so, the evidence Ezra used to show he was incorrect was faulty, and I pointed out as much. Try as you might to pin the meme of "the US has the best health care" on me, it just won't work, because I never said it and it is completely nonsensical for you to keep accusing me of denying it. I haven't denied it, I've just told you that it's not my position, and is not even the point of this entire thread.

Sigh. You're telling me you really, honestly don't see how this is part of the 'America is #1' meme? I find this really, really hard to believe.

But set that aside then, because the important point is this: you admit that this is a response, a reply, and not an initial assertion(well, that's progress of a sort.) That being the case, Ezra is under no obligation, nor anyone else, to show that this study is not flawed. Period.

It's up to the people who want to find a flaw in it to, you know, actually find the flaws. Period.

This is basic, _basic_ scholarship, and you're telling me you don't know this? That it's up to the person making the claim to defend it, not the other person to show that it's not so? If that's the case, just tell me that's what you really think up front, so I'll know to stop wasting time talking to you.

Take your ideological blinders off for 90 seconds and read Sullivan's post, then read Ezra's response.

You don't seem to get this at all, despite my multiple explanations. This is not about ideology at all. This is about burden of proof standards. Since projection seems to be rife with your kind, I'd say that you need to take off your ideological blinders and look at what I'm saying. It's not difficult, and it's not controversial.

For the 6th or 7th time: please explain why one should not use the incidence of a given disease as the denominator rather than total population if one wishes to evaluate the quality of two health care systems.

Posted by: AB

And at least for the seventh or eighth time, I already have. The short and somewhat misleading version of the answer is that using incidence alone in the denominator is really stupid. If, for example, one country has a public program of vaccinations against, say, measles, rubella, scarlet fever, etc., and it is compared to another country that doesn't, then of course it will have a lower incidence of those diseases because of the health care system. It could also be that the first country isn't so good with the intensive medical care for some nasty disease that can be inoculated against, but the second country excels at this sort of thing. So doing it your way would show the second country having better stats when in fact it would be worse.

Contrariwise, it could also be that one country screens much more aggressively for diseases that are associated with a lower mortality rate. Yes, country A finds three times as many cases of prostate cancer as country B. But most of those cancers will not be life-threatening. Again, the actual incidence doesn't have much to do with anything, so using that in the denominator is misleading.

Is that good enough for ya?

The longer reply is that this is nothing more than a way to place an excessive burden on the other side to produce research controlling for 'lifestyle choices', i.e., to produce something that is very hard to get in the first place. I've had literally dozens of conversations with right-wingers where they openly admit that this is their strategy.

Bottom line: nobody has to produce proof that this study is not flawed. The burden of proof is most definitely on those who claim it is.

AB, let me put it this way. You have 2 possible arguments:

1) The know-nothing argument: Because comparative international health care research is incomplete and may be misleading, we should entirely ignore it.

This mode of inquiry would be radically at odds with scientific (social or physical) practice. Know-nothing would not be an over-the-top description.

This is exactly the problem that seems to occur. Mention a study, someone will ask if they controlled for smoking, and you are able to reply that yes they did. They'll come back with another variable to control for, and another, and another, until you have to say, 'no, that wasn't controlled for'. At which point these types will crow that your cited study is 'worthless'. Here are a few samples of this type of dishonesty:

Do you have an analysis that controls for the differences between the countries in smoking, diet, BMI and every other lifestyle or environmental influence on "amenable mortality?" Of course not. There is no such analysis. As an indicator of the performance or effectiveness of different nations' health care systems, the study is meaningless, for the reasons coyote explains.

Here's another:

1. You cannot draw any meaningful conclusions about the quality or performance of different nations' health care systems from aggregate health indicators like average life expectancy or infant mortality rate. Any differences in those indicators attributable to differences in health care systems are swamped by other variables, such as patterns of diet and exercise, rates of smoking, alcohol and drug use, crime and accident rates, pollution standards, etc.

This too, has a few problems, though not nearly as egregious:

2) The positive claim: You say that Ezra's link is wrong because you have evidence that US incidence of amenable disease is higher. You say that the assumption that heart disease, cancer, diabetes, liver and kidney diseases, etc... is equivalent across first world national populations is false.

You therefor are invited to provide this evidence, or correct my reasoning.

Posted by: b9n10t

For example, according to WHO, the French have a higher rate of smoking than U.S. citizens. But their obesity is incidence is lower. I'm not saying you can't tease out differences in lifestyle choices, but I will note that it is harder than you'd think to make up for the variation.

really good post, thank you for sharing this information.

Andrew is right in his point that Brits are willing to put up with a great deal more aggravation than Americans are.

I'm not sure that's true. You're still putting up with Sullivan - we got rid of him decades ago.