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DO AMERICANS RECEIVE BETTER HEALTH CARE?
Noah Pollack starts this post by saying "I am far from knowledgeable about health care," and then gets right down to the busy of proving it, using the oft-discredited prostate cancer stats to argue that "survival rates for many diseases are higher in America than in western countries with socialized health care systems."
We've been down this road before, of course. It's very hard to compare cancer mortality because you must somehow hold constant "cancer stage" and "risk of death at time of diagnosis." America is much more aggressive at testing for cancer and so we're much more effective at catching cancer -- including lots of non-lethal cancer. But it's not at all clear that we're better at treating cancer. That's why the linked data is so important. We have much higher "incidence," which is to say we diagnose much more of our population with prostate cancer. But as many doctors now agree, lots of prostate cancer shouldn't be treated, and early treatment can actually be harmful. Meanwhile, we have almost the exact same death rate as the UK. So if you're going to use the incidence data rather than the death rate data, you'd better have a good argument for why. I rather doubt Pollack has such a reason. Meanwhile, the same study that provides the cancer statistics also has an aggregate statistic tracking years of life lost due to all causes that health interventions could prevent. So rather than cherrypicking cancer, we can examine the average:
So in the aggregate, Americans lose more years of life due to bad medical care than residents of any other advanced country. It's not a shocking conclusion: 15 percent of our population has no regular access to the health system, and another 15% to 20% has insufficient insurance coverage. But don't take it from me. I'm some sort of liberal. Later today, I'll be at Cato, responding to a paper from Glen Whitman that examines cross-country health outcomes data. I'm there as the liberal opposition. Glen is there because Cato's director of health policy studies, Michael Cannon, likes his work. Glen concludes:
Given the general consistency over several studies, and the large number of patients involved, the higher survival rates in the US in comparison to Europe, Canada, and in some cases Australia and Japan, are likely reliable, and worthy of consideration. But they are not necessarily indicative of higher quality medical care, because these studies do not adjust for cancer stage and risk of death at the time of diagnosis. A particular concern is survivor time bias: those patients with cancers detected earlier are likely to have higher survival rates even if they receive the same quality of health care. Thus, these statistics may indicate that cancer care is better in the U.S., or simply that cancers tend to be diagnosed earlier in the U.S. In fact, there is significant evidence that Americans are more likely to undergo regular screening tests for cancer than are citizens of other countries.
Other health policy experts, such as Robert Ohsfeldt and John Schneider , and David Gratzer, have argued that survivor time bias is not a problem because earlier diagnosis offers more chance of cure anyway. It is true that many cancers have better outcomes if found at an earlier stage, but that only opens up another question. Are those Americans who are diagnosed earlier than their European and Canadian counterparts getting better treatment as a result? More data is necessary to answer that question. For now, the most reasonable conclusion is that it is unlikely for the U.S. to have any worse outcomes than any other country, but that the better survival in the U.S. may be due primarily to earlier diagnosis.
And in order to receive that ringing endorsement, Americans only pay $4,000 more per person, per year, than the British. Suck on that, England! Meanwhile, Whitman's paper concludes that Canada is probably better than America at treating heart disease, and chronic diseases like diabetes or kidney failure are dealt with better in Canada and Europe. Indeed, he says, there's "no clear evidence that US is number 1" in care outcomes, "but also no evidence that US is poor, certainly not 37th."
So despite paying twice as much per person as any other country on earth, it's not clear that we get the best care (and there's no evidence, anywhere, on any measure, that our care is twice as good). Canada seems better at treating heart attacks, and most universal systems are better at treating chronic diseases like diabetes and kidney failure. On the bright side, we're probably not 37th. And this is coming from a scholar being published by Cato.
Whenever I read posts like Pollack's, I'm reminded of something David Frum wrote in his book Comeback. "Who agreed that conservatives should defend the dysfunctional American health care system from all criticism?" He asked. "Who volunteered to take the bullet for every crummy HMO and overpriced surgeon in the country? Who decided that it was okay with us for tens of millions of Americans to lack health care coverage?" It's a good question. Noah Pollack should ask it of himself more often.
COMMENTS (16)
I am not very knowlejible about health care, but it is a proven fack that too much socialist type stuff in the national health care market gives you a form of incurable cooties, which cannot be cured.
Posted by: El Cid | December 5, 2008 9:47 AM
"Who volunteered to take the bullet for every crummy HMO and overpriced surgeon in the country? Who decided that it was okay with us for tens of millions of Americans to lack health care coverage?"
Answer: those things are what the invisible hand created. If you wish to defend the hand, you have to defend its handiwork.
Posted by: Josh Yelon | December 5, 2008 10:44 AM
A better answer to the question posed in the title of the post is: 1) Americans with employer sponsored health insurance receive better care than most (if not all) populations that operate under government run systems; 2) Americans who lack health insurance receive worse care than most (if not all) populations that operate under government run systems.
So, the idea that we could save $4,000 per person in health care costs assumes that people who currently have employer sponsored health insurance will be willing to consume less health care (or that prices go down by so much that they can consume the same amount but that it will cost $4,000 less). I don't think this is true.
Posted by: MBP | December 5, 2008 11:17 AM
Who agreed that conservatives should defend the dysfunctional health care system and HMOs? Um, "Frist's ties to for-profit hospital giant Columbia-HCA. Frist's brother Thomas took over as the firm's chief executive officer shortly after federal officials launched a massive investigation of alleged billing fraud; with more than $375 million in stock, Thomas Frist is also its largest shareholder. The senator owns a much smaller stake in the conglomerate." This sounds about right.
Oh, please remember, if we're paying $4,000 per person less for heath care, that's $4,000 less per person GOING to health care companies. The business of America is business.
Posted by: Jaycal | December 5, 2008 11:44 AM
"Americans with employer sponsored health insurance receive better care than most (if not all) populations that operate under government run systems"
That is not as evident as you think, if you include countries like Germany and France under "government run systems" (Germany is a mixed system, of course, but for the purposes of libertarian rhetoric, it is socialistic anyway). And more than likely, those Americans who do get top health care are paying more for it than those Germans who get top health care.
Posted by: piglet | December 5, 2008 12:13 PM
I'm guessing it would cost rather less than $4K a year for the UK to add the screening that would be required for earlier diagnosis.
Posted by: paul | December 5, 2008 2:54 PM
I make the same point above, in the discussion of the "stoic" brits, but here is good too:
Cancer care is better in the US, everything else is worse.
This makes it unlikely that the poor results of the US overall are due to lack of access, since that should have a bad effect on cancer results (and given the fact that the lowest quintile in the UK outperform the top quintile in the US overall -- no MBP, the insured in the US do not get better care than people in other systems.)
It makes it less likely that the difference is due to lifestyle, since lifestyle influences cancer incidence and outcomes.
My guess it is due almost completely to differnces in practice style between cancer care and other forms of medical care in the US. Because of the way cancer care is organized (again, see the comment under stoic brits,) cancer care in the US is far more uniform and far more scientific than the much more intuitive and ideosyncratic way other forms of medicine are practiced.
This is a strong argument for using cancer care as a model and creating agencies that will do for all of medicine what the NCI has done for cancer care. Practice standards WILL save money and save lives, and are a very important argument in favor of more centralization of the health care system.
Posted by: Patrick Schoenfelder | December 5, 2008 4:05 PM
"... Americans only pay $4,000 more per person, per year, than the British. Suck on that, England!"
The common confusion of the UK, Britain, and England matters here because Blair's government devolved health care to Wales, Scotland, and Northern Ireland. The basic design of the system is common, but if you are doing professional comparative work, watch out for the coverage in the statistics. Scottish health outcomes are markedly worse than English, but most put it down to booze, fags, grease and bad housing rather than medical care.
Posted by: James Wimberley | December 6, 2008 5:55 AM
What I don't understand is why all the emphasis on the English system...as you have said, it won't happen here. and as you have also written about, other systems are better than both ours and the U.K.'s. Why don't we discuss the French or German model....as I have done here. http://joshuetree.blogspot.com/2008/12/health-care-look-to-french.html
These models, specifically the French, combine the price reduction of England, disease prevention of England, with the disease treatment of America with the universal coverage of England and freedom to choose of America. Why aren't these being stressed?
Posted by: Tim | December 6, 2008 3:31 PM
Here is some data from the Commonwealth Fund that reinforces your point with updated data (and charts!).
http://www.commonwealthfund.org/publications/publications_show.htm?doc_id=640980
The US is 19th of 19 countries measured in 'mortality amenable to health care'(people who die from stuff that could be treated with medicine) in the most recent data.
Posted by: joejoejoe | December 6, 2008 5:08 PM
This chart is statistical cherry-picking. As Ezra pointed out in the comments on his earlier story that employed it, what we see here is explained by infant mortality rates. This paper explains the problems in using the Potential Years of Life Lost metric, and the main problem is that it overstates losses in earlier years of life.
OK, the US has a poor infant mortality rate. Pathetic. Unacceptable. But how closely is that metric connected to the overall health care system? Are we going to change our entire health care system to address this one issue? That's what Ezra wants to argue, apparently, since he knows why this chart looks like it does, and he knows that it doesn't represent a fair comparison between health care systems.
Posted by: Undertoad | December 6, 2008 5:55 PM
Undertoad wrote:
"OK, the US has a poor infant mortality rate. Pathetic. Unacceptable. But....... "
Seems conservatives have to use a lot of coordinating conjunctions nowadays in the face of the actual facts coming to light after almost 30 years of Republican policy doctrine.
Posted by: Brad | December 7, 2008 11:06 AM
Anyone know what the stats are when comparing Americans who do have decent health insurance to people in Canada, Britain, France, etc.? As Ezra noted, it's not surprising that our aggregate results are low when you consider that 15% of our population is uninsured and another 20% underinsured. For the other 65% of the population, though, the question is whether their health care would be better or worse under a more socialized system.
Posted by: Sean | December 7, 2008 11:14 AM
Josh (second post),
I haven't read through all the posts, but I felt obliged to counter what seems to be a common misunderstanding about "the invisible hand" you cited.
In the thousands of pages Smith wrote, the notion of "the invisible hand" appears only three times. And at no time is there any explanation of "the invisible hand" as it is commonly understood now - as a kind of omniscient presence, ensuring a better, richer world for faithful capitalists. As the conservative American writer P.J. O'Rourke and the more liberal James Buchan have made clear, Smith's invisible hand was merely a metaphor for the unintended consequences of market activity.
http://www.pimpmyadamsmith.com/ihand.html
I think O'Rourke and Buchan got that notion from Emma Rothschild, who's written quite a bit on Smith. (Also, I suspect they actually finished reading "An Inquiry into the Nature and Causes of The Wealth of Nations.")
Per Smith, the real wealth of a country rests in its consumable goods and the labor that produces those goods. Not so much the labor that produces services, such as the HMO's mentioned, (which, everyone knows, is abstracted from the labor that produces ACTUAL health care.)
Smith himself was an empathetic and very gentle man who notes within "W.o.N." his genuine concern for the poor. Maybe the best explanation of the unintended consequences of the invisible hand that Smith introduced came from a New Yorker cartoon by Barsotti, with the caption: "There it is again! The invisible hand of the marketplace giving us the finger."
Posted by: eva | December 7, 2008 1:10 PM
Is it because conservatives dont care about human life{unless its unborn}?Or that they care more about the huge profits hmos and for profit hospitals and drug companies get?And at the same time make american companies LESS competitive by having companies pick up the cost of health care{the only industrialized nation in the world to do so}.And why do people always compare the u.k. system which is one of the worst.When I lived in france we had doctors make house calls,instead of having to go to the emergency room{which is much more expensive ,no?}when was the last time you heard of a house call in the u.s.? My current doctor went to cuba{shes writing a paper on international access to healthcare}she was shocked and suprised to see the over whelming numbers of doctors {most cubans dont have to walk more than 2 blocks to see a doctor}and the variety,the have m.d.s,homeopaths,alternative medicine etc.I guess its just the priorities each society has that makes the difference.Our priority is to maximize profits which conflicts with getting a healthy population.Just remember the nixon tapes where he laughed when told of the hmo scheme they were working on to make money by denying care.Not so funny now is it.
Posted by: truthynesslover | December 7, 2008 2:57 PM
For the other 65% of the population, though, the question is whether their health care would be better or worse under a more socialized system.
Why exactly is that the question? I'm trying to come up with a reason that doesn't boil down to "fuck everyone else."
BTW, since there will always be some tiering in the US system, the answer is "better."
Posted by: nolaboyd | December 8, 2008 9:47 AM