"every over-priced surgeon in the country" ????

Excuse me, is Frum fucking serious with that line??

Ezra - is this YOUR position as well??? Serious question.

But would you rather be the urban poor in London, who wait a year for a hip replacement, or the urban poor in America, who never get one?

This is exactly why progressives fail. The only relevant question to voters is how does a middle class Londoner compare to a middle class American. Urban poor be damned. At least when they risk raising our wait times.

Anyways how many of those countries aggressively encourage consumer spending on health care? None. But besides that Americans will still spend more on health care than a country that largely rations care. Unless the top 50% are forced not to they will continue spending outrageous amounts of their wealth on cost ineffective care. And why is this wrong? You can argue for more redistribution or less government distortion but if Americans (especially the rich) still want to waste 7000$ on health care even if it could theoretically be better used elsewhere that's fine. The choice isn't whether 7000$ helps some poor black kid it is between spending 7000$ on some rich guys drug research (i.e. health care) or spending it on a new yacht.

There is no defense for a system delivering such poor value.

Yes there is -- it's possibly the only way to deliver no care at all to people you don't like, or conversely, to only deliver care to you, and people you like.

That's not a medical good, or a tangible good, but that's not to say that for some people it isn't still a good, and one they'll pay for. And the value of the good is perhaps increased by its scarcity.

You keep tackling health care delivery as if it were a health care problem, a policy problem.

It isn't -- it's a morality play.

The difference between the US system and the UK system is even more stark that you realise. Nobody has to wait a year for a hip replacement on the NHS these days. Over 1/2 million patients are on the NHS waiting list at any one time. 50% of them get treatment within 4 weeks. After 8 weeks it's 80%, and after 6 months fewer than 100 people are still awaiting treatment.

Year long waiting lists for anything under the NHS is simply a myth these days. Sure, rationing the most expensive procedures and drugs will always be a problem, but it's a much less insidious problem than millions of people not being able to afford any treatment at all.

All the latest waiting list stats for the NHS are available here:

http://www.dh.gov.uk/en/Publicationsandstatistics/Statistics/Performancedataandstatistics/HospitalWaitingTimesandListStatistics/index.htm

The convergence between what I read at USS Mariner (my team-specific baseball blog of choice) and what I read here is getting eerie.

Ezra! Tell the people we're overpaying for outfielders with declining skill-sets! Tell them we'll never win a World Series if we continue to saddle ourselves with bloated contracts for back of the rotation starters!

I promise they'll understand even if you don't.

I read a blog about Knitting by a Canadian woman who periodically writes about their medical system. She makes her living as a writer and her husband is a self-employed recording guy. So they are a couple of artistic types with a unpredictable but sufficient income, living in Toronto (very expensive place) and raising 3 children. She talks about how she has never had to worry about healthcare in her life. She talks about how that freedom has allowed she and her husband to pursue their passions to make their livings. She says that Canadians consider their universal healthcare their highest achievement and they revere the politician that helped them achieve it. She also says that Canadians consider it a duty to live health-consciously so that they don't create unnecessary pressure on the system. See also The 10 Myths About Canadian Healthcare by Sara Robinson (http://www.alternet.org/healthwellness/76032).

As a small business owner with no healthcare I can't tell you how much I envy the Canadians. As a person who used to work in "outplacement" - helping people who had been laid off find new jobs, I can tell you that a lot of people are both held hostage by jobs because they offer healthcare, and are devasted when they lose it.

As is always the case with broad statistics, they don't convey individual suffering.

I believe that if MediCare was simply opened up to the rest of us and we could choose to "buy in" in some reasonably affordable way, and never be cancelled or refused care due to prexisting conditions, or have premiums rise outrageously, etc, you would find a very large portion of the public would opt in. And the private companies would have actually offer some value that would make it worth choosing them. And I can't imagine what it would be.

The US system has an additional cost that AFAIK isn't even calculated: the amount of time (not to mention stress) patients and their families have to spend -- are *expected* to spend -- fighting insurers and providers over bills.

This is why I find attitudes like Andrew Sullivan's baffling. Hasn't he ever had to fight an insurer, to question bills and call up and nag and complain? And that's not even counting the resources doctors and hospitals have to put into fighting insurers -- at least that part is done by people who are paid to do it.

The solution to the problem of conservatives reflexively defending the shortcomings of our health care system is simple: institute universal health care.

Overnight, they will flip to criticizing it as wasteful, burdensome on taxpayers, another example of government supporting inefficiency. EVEN if we have almost no changes to the delivery of care or how care is paid for, as in a Massachussets-like system.

On a more positive note, conservatives are more likely to be allies at that point on the hard reforms on perverse incentives that are needed to really keep costs in line.

The shift in conservative attitude is why serious delivery system reforms have proven possible before universal health care, but will come quickly after it.

Shoot, I meant to say "have proven impossible before universal healthcare..."

So, how long does a middle-class Londoner have to wait for a hip-replacement?

I guess the argument is that wealth is largely a matter of chance and so it's unfair for it to determine someone's health. But in that case why not just spend the money on vaccinating kids or building water-treatment systems in the third world, where it will do more good? Why should being born in a rich country morally entitle you to get better health care any more than being born into a rich family does?

She also says that Canadians consider it a duty to live health-consciously so that they don't create unnecessary pressure on the system.

There's nothing wrong with this exactly but anyone who is a serious individualist (i.e., conservatives) is justified in wanting to avoid a system that allows the entire country to (figuratively speaking) stick their nose into your business and disapprove of your unhealthy personal habits. Also for better or worse I think Americans would just not think this way, at least not for a long time--I think it's just antithetical to this country's culture.

Also for better or worse I think Americans would just not think this way, at least not for a long time--I think it's just antithetical to this country's culture.

Indeed. I mean, it's not as if you get a clipboard shoved in your face the moment you enter any American medical establishment. Oh.

It seems to me that if the UK were willing to spend as much as France, they'd then be able to provide cutting edge drugs to treat cancer and Alzheimers that currently are denied to patients.

So yeah, a little more spending is in order in the case of the UK.

Why keep obsessing about the UK and Canada? Obama will be president, and his platform was very clearly to introduce the German/Austrian/Swiss system not the British, Canadian, or Swedish: regulated heritage occupational schemes plus a new public backup scheme. The Germans are pretty happy with Bismarck's invention, just as the Brits, French, and Swedes are with their different models. There are several routes to universal care. Just do it.

James is right folks.

David Frum's Comeback quote: "Who agreed that conservatives should defend the dysfunctional American health care system from all criticism?...It's a good question.

No it's not. Like with most bad policy moves by conservatives, the answer is "Bill Kristol."

There's nothing wrong with this exactly but anyone who is a serious individualist (i.e., conservatives) is justified in wanting to avoid a system that allows the entire country to (figuratively speaking) stick their nose into your business and disapprove of your unhealthy personal habits.

I'm gobsmacked. As a 'serious individualist' (and who decides who's a serious individualist and who isn't?) in a land of 'serious individualists', I see people disapproving of other peoples personal habits all the time. Right now. You were somehow unaware of this?

I can answer Mr. Frum's question: conservatives.

The definition of conservatism is to oppose change.

P.S. Any talk of rationing is pure FUD. Every metric indicates that the outcomes of health care in the UK, Germany, Canada, etc. are better than in the US.

James: because, as Ezra says, the "Anglo" examples are easier for Americans to talk about, and because whatever gets introduced, it has to be spun as a Natural-Born American Innovation, to get past the stupid reactionary stuff.

You're right that it's a discussion that's designed to bog things down. But there's a real political need to overcome the exceptionalist Not Like Those Foreigners knee-jerkery when it comes to healthcare reform, and that requires a surreptitious import of the models you cite, while branding them with the Stars and Stripes.

The evidence seems to be that systems that spend $2,500 and systems that spend $7,000 give fairly similar results.

This is great news! The government already controls a large portion of the health care budget in this country, via Medicare and Medicaid. So why not cut the Medicaid budget by half right now! Then, when the good results are proven, you will have both the money and the support to provide health care to all!

Is this a plan you'd favor? If not, why not? This is a serious question. If government has the ability to cut costs and improve efficiency, why not start right now with Medicare?

What a shock Ezra dishonestly framing an argument.

"But would you rather be the urban poor in London, who wait a year for a hip replacement, or the urban poor in America, who never get one?"

If they are Urban poor in America they are entitled to Medicaid or SCHIP at little to no charge. It's not a question of them not GETTING healthcare it's all about them not WANTING it. Do you now propse we force people by threat of jail to receive he care they need?The vast majority of the uninsured are ither already entitled to free care or make enough to buy it themselves. The uninsured are such by choice. THe question americans need to ask is do we want to spend billions of dollars to insure people that already have access to insurance and choose to not take it.

Activly choosing to not take free insurance and minimal waits for care is far different then being forced to wait a year.

Why should 300 million americans see their wait times almost triple so a couple million people that choose to not partake in the current system can be forced to?

Lets also throw your hackish oversight of utilization on the taple.

"Value: Who has better outcomes is like Camry vs. Accord. Some things are better on one car, some things are worse. But if you paid 15,000 for your Camry, and I paid $22,000 for my Accord, then in fact the Camry is MUCH better. "

$6,714 of US Healthcare does not equal $2,760 of Healthcare in the UK. You would have to have a complete ignorance of economics and numbers to even make this comparison. Per capita Rx usage in UK is 20% lower then that of the US. We have more office visits and run more test. We are more expensive becuase we use more of it. Further our supposed poor are the fattest of any OCED nation utilizing even more free care then if we stopped feeding them so much.

My care is incredible, my care is affordable, and besides the actual treatment usually pleasant. That's becuase I take responsibility for myself, make sure I have insurance even when I rather have the extra cash to blow on the strip, and take the time to educate myself. If some idiot offered free care paid by my tax dollars is to stupid to take it and thus can't get treatment when he needs it or has an unpleasant experience F him for being stupid thats his problem.

Lets wrap up by explaining why you side note doesn't apply to education?

"Sidenote: The evidence seems to be that systems that spend $2,500 and systems that spend $7,000 give fairly similar results. More health care dollars does not bring you more health care results, and this is true across nations, but also across states (Minnesota v. Florida). Health care does not seem like a good place to overspend. We should probably err on the side of spending less, not more. Instead, we err on the side of spending much more."

Sounds like the DC school system to me but that doesn't stop your ilk from always demanding more money for schools.

Why should 300 million americans see their wait times almost triple so a couple million people that choose to not partake in the current system can be forced to?

Non sequitur from the blood-for-profit parasite.

So glad to see that Nate("every man for himself and screw the rest") is back in fine form.

As for me, like the knitting Torontonian, I am ecstatically glad to be living in Canada (also in TO, as we call it). Were I to live in the States, due to hereditary health conditions, I would be totally uninsurable. As it is, I am self-employed, receive excellent medical care and thus can continue to be a productive, tax-paying member of society.

We have more office visits and run more test.

Including, of course, the tests that aren't actually useful but get done because doing extra tests is how doctors make money.

Including, of course, the tests that aren't actually useful but get done because doing extra tests is how doctors make money.

I hear this accusation made a lot, but from my (admittedly limited) observation, its unusual that the doctor who orders the test makes any money at all from it.

Maybe you could offer some examples? (not saying you're wrong, just curious)

A Medical Student: Even when doctors aren't directly paid for ordering tests or prescribing treatment, they are indirectly paid, such as by drug company reps who invite them to all-expenses paid conferences in Hawaii if the doctors order lots of the company's tests/prescribe lots of the company's drugs.

And there's the Illinois case of statewide MRI kickbacks, which is mirrored by more isolated investigations into doctors sending people off to the Magic MRI in exchange for bennies.

I think the example of doctors being prosecuted for receiving money for MRI referrals indirectly answers my question: when doctors did receive money for MRI referrals, it was both illegal and sufficiently outside the norm to attract the attention of state prosecutors.

The statement "doing extra tests is how doctors make money" made it seem as if this was a matter of usual practice.

AMS: point taken, though one problem with the "system" as it stands is that with money in the game, and doctors with fingers in different pies, it's a perfectly reasonable position for anybody given a referral for a costly test or procedure to be suspicious of the motivation.

And that's before you get to dealing with the insurance-bot's determination of medical necessity.

The big picture point is that its important for patients to know that if the physician that recommends a test, and the physician that actually performs and interprets it, are two different people, there is very little chance that the doctor who made the recommendation made any money by doing so. Otherwise, patients may forgo necessary tests because of a general suspicion of medicine, putting their own health at risk.

Of course, in an instance where the doctor recommending the test is the one who will perform it (a GI doc recommending a colonoscopy, or a cardiologist recommending an angiography) its reasonable for patients to seek a second opinion first.

I see you left out the inconvenient truth that cancer survival rates and major surgery survival rates are way the @#$%@# higher in America than in Europe.

In fact, in your little "liberal" or "humanist" medical utopias they ration those things so that when you need the services you are submitted to a creepy Orwellian process where some DMV committee determines whether you live or die.

Personally, that creeps me out and sickens me. No committee has any right to determine whether I should live or die. I have this strange belief that I have value as a human being unto myself, which is why I pretend to be a humanist, even though the word has been utterly desecrated by people advocating the precise inverse.

...the services you are submitted to a creepy Orwellian process where some DMV committee determines whether you live or die.

I'm much happier when the services are submitted to a creepy Orwellian proces where some CPA committee determines whether I live or die.

a creepy Orwellian proces where some CPA committee determines whether I live or die

Or when the decision on whether you'll be paying that $5,000 bill apparently depends on whether the insurance-bot on the end of the phone line got stuck in traffic that morning. Gotta love it. Obviously, Mick does.

scentofviolets: "I'm gobsmacked. As a 'serious individualist' (and who decides who's a serious individualist and who isn't?) in a land of 'serious individualists', I see people disapproving of other peoples personal habits all the time. Right now. You were somehow unaware of this?"

Part of this discyussion boils down to the embarassing caricature of an American making completely absurd, unsubstantiated by any evidence claims about how other countries are inferior to the US. Outsiders who know America usually can't recognize the rose-colored picture these people draw of their country. What strikes everybody with outside experience about America is the puritanism. After all, this is the only Western, "individualist" country that has tried to ban alcohol and that still criminalizes grownup people for drinking beer. Personal lifestyle is much more an issue of public approval or disapproval in this country than anywhere else I have ever lived. Anybody claiming that this ain't so is living in a fantasy land.

P.S. KathyF again fails to offer any evidence for her claims. Do you absolutely have to play that role of the ignorant American?

Hip replacement wait: from the time my hip was discovered to be bone-on-bone to the time the surgeon started to cut was well over a year. And I have some of the "best" coverage in an affluent high-tech American university town.

really good post, i know more knowledge here.

Some links:
http://econlog.econlib.org/archives/2008/12/health_care_edu.html

Health Care, Education, Spending, and Outcomes
Arnold Kling

I attended a Cato event at which Glen Whitman and Ezra Klein discussed health care spending. The main stylized fact is that those who spend more on health care do not necessarily get more. As Ezra puts it

The evidence seems to be that systems that spend $2,500 and systems that spend $7,000 give fairly similar results. More health care dollars does not bring you more health care results, and this is true across nations, but also across states (Minnesota v. Florida). Health care does not seem like a good place to overspend. We should probably err on the side of spending less, not more. Instead, we err on the side of spending much more.

In other words, we are all Hansonians now.

I believe that the same stylize fact holds in education. That is, the U.S. spends more per capita than other countries on K-12 education, without better outcomes. School districts that spend more per capita do not necessarily get better outcomes. So I asked Ezra if that implies that we should err on the side of spending less on education. He demurred.

http://www.guardian.co.uk/society/2006/jan/21/health.politics

In Iraq, life expectancy is 67. Minutes from Glasgow city centre, it's 54

In deprived inner city area of Calton, the chance of surviving to old age is lowest in UKAudrey Gillan guardian.co.uk, Saturday January 21 2006 09.05 GMT Article historyThere are ghosts sitting in the Cottage bar in Glasgow's Calton area. The locals call them the missing generation, the men who died before their time. Sometimes the drinkers dip their heads or lift their pints to them. They may not see them but all the drinkers know they are there. Jimmy, Swifty, Davy and many more.

For here in this multi-deprived inner city area, the average life expectancy of a male is just 53.9 years. In Iraq, after 10 years of sanctions, a war and a continuing conflict, suicide bombs and insurgency, the average man has a good chance of making it into his 60s; the life expectancy of a male there is 67.49. In Iran it is 69.96, in North Korea, 71.37 and in the Gaza Strip it is 70.5.

Statistics recently revealed that the Calton ward has not just the lowest life expectancy in the United Kingdom and Europe but of many areas of the world. A child born in the Calton - locals always prefix a "the" to Calton - arrives into an environment saturated by drink, drugs, smoking and poor diet. A baby girl has more of a chance of survival - her life expectancy at birth is 74.8.

I believe that the same stylize fact holds in education. That is, the U.S. spends more per capita than other countries on K-12 education, without better outcomes. School districts that spend more per capita do not necessarily get better outcomes. So I asked Ezra if that implies that we should err on the side of spending less on education. He demurred.

Uh-huh. Probably because 1)You're conflating all educational costs, and 2)the spending per capita is not necessarily the same as what is spent on the typical student. Bill Gates walks into a bar yadda yadda[1].

Iow, Ezra's positions are perfectly consistent.

[1]That being said, I don't think the problem is with school spending. The problem with is American parents.

The one upside I see to the USA system is that smart people can optimize by avoiding excessive healthcare and by getting a high deductable insurance plan. Also the USA system seems better for providers.

One interesting thing to me was to see that healthcare in the socialized systems do not so much control costs by avoiding net-useless care but by squeezing providers. In the USA on the other hand we seem to have regulator capture whereby the providers increase their income.

You said:

"But would you rather be the urban poor in London, who wait a year for a hip replacement, or the urban poor in America, who never get one?"

In the UK private insurance companies sell health policies to avoid NHS waiting lists (and also partly to get better "hotel" accommodation in the private hospital) This insurance company lists waiting times by commercial television region.
http://www.norwichunion.com/health/private-health-insurance/nhs-hospital-waiting-guide.html
The average wait for a hip replacement in the London area is 106.88 days, not the year you suggest.

The worst area for a wait is the north of Scotland at about 200 days but the Scottish government has different criteria about waiting times to England.

Very much fuller statistics on waiting lists have been published to October 2008

http://www.dh.gov.uk/en/Publicationsandstatistics/Publications/PublicationsStatistics/DH_091059

As an American who has at different times found himself among the poor I can tell you that I don't envy the British or Canadian system at all. American health companies are far more accommodating then you seem to think they are. I have had problems paying for health care at times and have found it to be a struggle; however, I have always received the care I needed and never had to wait more than six days for any procedure aside from a root canal where the wait was determined by the time it took to reduce an infection. I have medical equipment in my home for current problems. Last summer I could no longer make payments for the equipment and called to make arrangements for its return. Instead of accepting return of the equipment they cleared my account and essentially wrote off 70% of the cost of the equipment while still continuing to provide support and part replacements. This is not an isolated event either. Most poor do have free care, there are in fact three free clinics in my small town in Tennessee, each with X-ray equipment and the options to use MRI and CT equipment at local hospitals. I don't know about New York or London, but I can tell you I'd rather be poor in a small community in America than England simply because of the availability of appropriate diagnostic equipment and the readiness of doctors to investigate a problem immediately and without regard to the patient's ability to pay.

good post, Happy New Year

Thanks , good alctied

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