The U.S. vs. Other Systems of Health Care

Jane Galt says:

I have a new bloggingheads up with Jonathan Chait, during which I complained about the general tendency for health care books to engage in "argument through anecdote", where the data plays a distant second fiddle to the heartrending stories about x person who didn't get good treatment. So single-payer advocates drag out some American woman who didn't get a breast exam until it was too late, and opponents counter with the Canadian guy who died on the waiting list to see an oncologist.

I'm sympathetic to the data-based versus anecdote point she is making, but in this case I wondered if her impression wasn't partly due to what she chooses to read. Ezra Klein comments along these lines, and he also gives some useful comparisons between the U.S. and single-payer systems - the main reason for the post:

Arguing Health Care, by Ezra Klein: Is Megan's problem with health care writing really that the literature is too narrative-driven? Yikes. She should read some issues of Health Affairs, or the Annals of Internal Medicine, or the New England Journal of Medicine. This is not a debate that lacks for data.

Meanwhile, Megan actually gets a few things wrong in her argument with Chait. She suggests that waiting lines are longer in Europe. That's, uh, untrue. France and Germany don't have waiting lists. Americans do, by the way, with around 40% of patients waiting one month or more for elective surgery. She then suggests that moving to a French or Canadian system would require walking back the medicine we actually provide, telling people they can't have MRIs anymore. That's similarly incorrect. Care utilization in France and Germany is as high -- and in France, higher -- than it is in America. But they pay less per unit of care. And the technology isn't radically different. Germany actually has more CT scanners per million than we do, while the French have three less. The French and the Germans both have more physicians per capita and more acute care beds. Oh, and the French and Germans pay less, and don't have 47 million uninsured.

All this information -- and more! -- can be found in various data-heavy books on the subject, like Thomas Bodenheimer and Kevin Grumbach's wonderful Understanding Health Policy. The thing is, they tend to point towards the same conclusions Jon Cohn's book does, albeit with fewer anecdotes. One reason I spend less time arguing health care with libertarians these days is that it doesn't seem productive. If you really don't want to believe that other system's in the world are better, you won't. If the costs, outcomes, access, and equity advantages offered by the French, German, Japanese, Scandinavian, or Veteran's Affairs systems don't convince you, you simply don't want to be convinced. There are issues, like card check, where I see how the counterargument could be convincing and understand it is, to some degree, a values judgment. Health care isn't one of those issues.

There's a bit more here.

Comments

[Bruce Wilder]

1.) Anecdotes are probably more easily justified, as part of a policy argument, where the policy involves insurance, than in other cases. Where insurance is concerned, it is the unusual event, which we are trying to adopt a policy to cover, not the main tendency. The main tendency is for houses NOT to burn down; and for people NOT to die before age 75.

I understand that there are political advantages to Republicans, if Medicare prescription benefit covers elderly people, who want their blood pressure medication and pain relievers covered, but if the same policy results in, say, the deaths of even a small handful of poor AIDS patients, who don't have a way to cover the "hole", that's something worth noting.

In business, it is fashionable to talk about the business opportunities inherent in the "long tail" -- how Amazon can make money selling not-the-bestsellers, but worst-sellers -- books that have a national market of only a few hundred or a few dozen copies a year.

Medicine and health has a wickedly long tail, and it is perfectly appropriate to use anecdote to illustrate the reality of the consequences of policy for the unusual. The whole point of health insurance is to cover the case of the unusual, even the catastrophically unusual.

2. Arguing with libertarians does get tiresome. They seem unable to remember anything, which doesn't fit their peculiar view of the world, so every exchange involves hammering home the same basic facts about the world. (And, don't even get me started on Reaganesque libertarian anecdotes!)

[anne]

Anecdote:

http://www.nytimes.com/2007/03/24/business/24vaccine.html

March 24, 2007

Pediatricians Voice Anger Over Costs of Vaccines
By ANDREW POLLACK

The nation’s pediatricians, the foot soldiers in the campaign to vaccinate America’s children, are starting to revolt.

The soaring cost and rising number of new vaccines, doctors say, make it increasingly difficult for them to buy the shots they give their patients. They also complain that insurers often do not reimburse them enough, so they can lose money on every dose they deliver.

As a result, some pediatricians are not offering the newest and most costly vaccines. And some public health experts say that if the situation worsens, it could lead to a breakdown in the nation’s immunization program, with a rise in otherwise preventable diseases....

[anne]

When we are discussing so vast a part of the economy, anecdote is going to be awfully important in allowing for knowing.

[bernard Yomtov]

One reason I spend less time arguing health care with libertarians these days is that it doesn't seem productive.

It is important to understand that for libertarians (as for Marxists) ideology trumps data.

[Lafayette]

Start here (http://www.who.int/whr/2000/en/index.html):

"The world health report 2000 - Health systems: improving performance

This report examines and compares aspects of health systems around the world. It provides conceptual insights into the complex factors that explain how health systems perform, and offers practical advice on how to assess performance and achieve improvements with available resources"

[Isabel]

Actually, I had thought answering to Stormy (I think) the other day, that was calling for a reasonable, data-driven comparison between health care systems (to which Lafayette answered with a good defense of the French system). There is no lack of careful analysis of the matter in the internets, if people really want to read. Angry Bear has an exellent series of posts from the point of view of the US system, costs and benfits, as compared with various other industrialized countries, and Ezra Klein did a series on 5 or 6 health care systems, explaining how they, variously, work (no "European and Canadian" garbage there). I think he's right, people don't want to hear about best practices from no damn furriners. And poster Anony-mouse at Jane Galt's has a good point:

"...the least level of language and cultural barrier is found between Great Britain and its heritage -- Australia, Canada (except for Quebec), and the US. Of the three examples closest to the US, Australia is too far away to notice, and Canada and Great Britain have two of the worst-designed social healthcare systems in the western world..."

It's no coincidence that the study that specifically compares performance on cancer, acute myocardial infarction and stroke, breast cancer and asthma compares Australia, Canada, New Zealand, England, and the United States. I understand the temptation to minimize language and cultural barriers. But that means ignoring the best practices of some of the best performers. Which happens to be very comforting.

[Lafayette]

From the above report's statistical annex. Data somewhat dated (1997):

Overall Health Performance (Rank)
France (1)
Italy (2)
Germany (25)
US (37)
Cuba (39)
Zimbabwe (155)

The above ranking were hotly contested when published - for obvious reasons. It must be remembered that the WHO gave a heavy weighting to "public access to health care", where the US showed very poorly.

[Lafayette]

In the above ranking, the UK is 18th.

[anne]

Isabel, please do set down any reference you suggest to Angry Bear on Health, if convenient.

Here is the reference to Ezra Klein on Health:

http://ezraklein.typepad.com/blog/health_of_nations/index.html

[anne]

France

http://ezraklein.typepad.com/blog/2005/04/health_care_fra.html

England

http://ezraklein.typepad.com/blog/2005/04/the_health_of_n.html

Canada

http://ezraklein.typepad.com/blog/2005/04/the_health_of_n_1.html

Germany

http://ezraklein.typepad.com/blog/2005/04/health_of_natio.html

Japan

http://ezraklein.typepad.com/blog/2005/04/health_of_natio_1.html

[Isabel]

Angry Bear I:

http://angrybear.blogspot.com/2005/04/real-crisis.html

[Isabel]

Angry Bear II:

http://angrybear.blogspot.com/2005/04/health-care-in-us-and-world-part-i-how.html

[Isabel]

Angry Bear III:

http://angrybear.blogspot.com/2005/04/performance-of-us-health-care-system.html

[Isabel]

Angry Bear IV:

http://angrybear.blogspot.com/2005/04/waiting-for-health-care.html

[Isabel]

Angry Bear V:

http://angrybear.blogspot.com/2005/04/health-care-in-us-and-world-part-ii.html

[Isabel]

Angry Bear VI:

http://angrybear.blogspot.com/2005/04/health-care-in-us-and-world-part-iii.html

[Isabel]

Angry Bear VII:

http://angrybear.blogspot.com/2005/04/health-care-intelligence-failure.html

Sorry, I had to do it this way because this machine told me in various languages that it thought I was a spammer when I tried to put all the links in the same comment.

[anne]

Ah, there we have a reference base and I will read and add all the Angry Bear essays to my sources.

There is nothing wrong with continually using anecdotes to show limits and problems in America's health care provision, because provision is such an extensive matter and endlessly complex in detail because we have "designed" so complex a system of provision.

[anne]

Also http://www.pkarchive.org/ has all of Paul Krugman's writings on health care but the Google site search must be used to call up the series.

Isabel also shows me, for the second or even third time, that Angry Bear has a convenient health care article index along the side of the site. I will try not to forget again.

says...

Ideology trumps facts. I could not have said it better or more eloquently.

None of those conservatives making the bucks want anything that may remotely rock the boat of their nice little world. They will reach for any argument to fend off the other side. Those making some of the biggest checks often have the best benefits, but the rest of us at the bottom "over consume" or 'live unhealthy lifestyles' by being obese or smoking or whatever. The drugs cost too much, the equipment costs too much (but the pricing is often based on marketing and what the market will bear, not on actual costs).

We euthanize dogs and cats, maybe they think we should start doing that with the uninsured?

[anne]

"So single-payer advocates drag out some American woman who didn't get a breast exam until it was too late, and opponents counter with the Canadian guy who died on the waiting list to see an oncologist."

Either anecdote would be important both of itself and to be generalize if possible. Then, which happens to be true and why, and if either is true and can be at all generalized how is the problem resolved?

[James Killus]

I've had exchanges with JG. She uses statistics to bolster her already formed opinions, and when confronted with an analysis that differes from those opinions, she throws up the usual set of non-sequiteurs, then disappears.

It's very easy to be the smartest person in the room when you hang out with no one but conservatives. It's probably unfair to suggest this as a motivation for someone's being a conservative. Probably.

[James Killus]

Also, after some reflecting on Bruce Wilder's first post on this thread, I'm moved to ask the question: "What exactly is the difference between 'anecdote' and 'case study?'" If statistical data are all that are allowed in reasoned discourse, what is one to make of the overwhelming use of case studies in both business and medical schools?

[Sergey]

I would be interested in reading some notes on Israeli healthcare - and perhaps a general care/expense comparison between East Europe, West, and Asia. Does any one know any good resources?

[anne]

The question other than for Israel is too broad to be helpfully answered. Narrow the scope dramatically.

[reason]

Making something completely unaffordable for a large proportion of the population does wonders for waiting lists! And it doesn't even work! WOW!

My tuppence worth here, is the problem with the model. Health care is not like consumer electronics, we cannot treat everything that can bought as though it is in the same category. Some things have moral components, not just economic ones. Economics could look more carefully at distinguishing between needs and wants (I know at the margin they become substitutes). But there is a fundamental mismatch between a world view that considers all receipts must be earned and one that thinks of some receipts as being entitlements. Do we have duties to fellow citizens or not? Should handicapped or sick Libertarians be allowed to die?

[real person from the real world]

TALK ABOUT BUREACRACY IN A SINGLE PAYER SYSTEM AND THAT INSURANCE IS BETTER BECAUSE IT IS A BUSINESS

READ THIS

Aged, Frail and Denied Care by Their Insurers
....Mary Rose Derks was a 65-year-old widow in 1990, when she began preparing for the day she could no longer care for herself. Every month, out of her grocery fund, she scrimped together about $100 for an insurance policy that promised to pay eventually for a room in an assisted living home. On a May afternoon in 2002, after bouts of hypertension and diabetes had hospitalized her dozens of times, Mrs. Derks reluctantly agreed that it was time....But when she filed a claim with her insurer, Conseco, it said she had waited too long. Then it said Beehive Homes was not an approved facility, despite its state license. Eventually, Conseco argued that Mrs. Derks was not sufficiently infirm, despite her early-stage dementia and the 37 pills she takes each day.
After more than four years, Mrs. Derks, now 81, has yet to receive a penny from Conseco, while her family has paid about $70,000. Her daughter has sent Conseco dozens of bulky envelopes and spent hours on the phone. Each time the answer is the same: Denied.
....The New York Times and confidential depositions indicate that some long-term-care insurers have developed procedures that make it difficult — if not impossible — for policyholders to get paid. A review of more than 400 of the thousands of grievances and lawsuits filed in recent years shows elderly policyholders confronting unnecessary delays and overwhelming bureaucracies.
In California alone, nearly one in every four long-term-care claims was denied in 2005, according to the state. “The bottom line is that insurance companies make money when they don’t pay claims,” said Mary Beth Senkewicz, who resigned last year as a senior executive at the National Association of Insurance Commissioners. “They’ll do anything to avoid paying, because if they wait long enough, they know the policyholders will die.”
...In court filings, all three companies said the denials had been proper. They declined further comment on the cases, though Bankers Life and John Hancock eventually settled for unspecified amounts.
...“These companies have essentially turned their bureaucracies into profit centers,” said Glenn R. Kantor, a California lawyer who has represented policyholders.
....Yet these concerns have been ignored by state regulators, advocates say, and have gone unnoticed by federal lawmakers who recently passed incentives intended to promote purchases of long-term-care policies, in the hopes of forestalling a Medicare funding crisis.
....Inside the large Conseco headquarters in Carmel, Ind., scores of employees receive the flood of documents and calls that arrive each day. At times, according to depositions and interviews, that deluge became so overwhelming that documents were lost, calls went unreturned and mistakes occurred.
Some employees describe vast mailrooms where documents appear and disappear. One call-center representative said he was afforded an average of only four minutes to handle each policyholder’s call, no matter how complicated the questions. Employees said they were instructed not to say when the company was behind in processing paperwork, even when the backlog extended to 45 days. Workers were prohibited from contacting each other by phone, although such calls might have quickly resolved obstacles, according to depositions.
....Depositions of executives at Penn Treaty also point to questionable practices. In a 2005 lawsuit, a Penn Treaty senior vice president, Stephen Robert LaPierre, testified that the company rejected one claim without informing the policyholder why, asked for information that was not required to process a claim, gave incomplete information about a claim’s status and said the company was delaying payment because of an investigation while failing to take steps that might have resolved the inquiry.