Health Care: The U.S. versus Europe

Jonathan Cohn of the New Republic says European single-payer systems provide better health care than the U.S. system:

What Jacques Chirac could teach us about health care, Comparative Advantage, by Jonathan Cohn, TNR Online: ...Michael Tanner, of the Cato Institute, wrote recently. "While one sympathizes with Elizabeth Edwards and wishes her well, it's important to note that the national health care system her husband has taken this opportunity to propose would be disastrous to thousands of Americans who suffer from cancer and other diseases." ...

[T]his argument--that countries with universal coverage ration care and limit investment in new medical technology ... has been around for a while. ... Harry Truman's opponents warned of European-style rationing when he proposed creating universal coverage in the 1940s; Bill Clinton's opponents did the same in the 1990s.

It's a potent argument politically. Americans certainly don't like the idea of losing their health insurance... But they're also spooked by the prospect that they might not be able to get the best, most advanced life-saving care if faced with a deadly disease. That's particularly true for more affluent Americans, for whom the threat of losing insurance coverage seems remote...

But is it actually true that universal coverage results in worse care? That's a very different story from the one that conservatives tell. Let's start with what we know for sure. Relative to other highly advanced countries, the United States lags well behind the leaders when it comes to infant mortality, overall life expectancy, and life expectancy at 65. ...

Critics argue that measuring infant mortality and life expectancy is too crude, since whether a newborn dies or how long somebody ends up living may have as much to do with outside conditions like poverty, environment, and lifestyle as they do with the quality of medical care. ... That's why the scholars ... prefer to look at some more finely tuned calculations: "potential years of life lost" or "disability adjusted life years." ... But, ... on these measures, too, the United States is decidedly mediocre compared to Japan and the more advanced countries in Europe.

Conservatives insist that even these, more finely adjusted measures still can't adequately account for outside influences like poverty or environment. As such, they say, ... you need to look at health care-specific factors--like the amount of high-tech technology here versus there. In universal health care systems, the government inevitably exercises more control over health care spending. This is a big reason why all the other systems cost less--and, if you believe the critics, why people in those other systems get less.

It sounds perfectly reasonable in theory. But the facts don't back it up. Look at Japan. It has universal health care. It also has more CT scanners and MRIs, per person, than the United States. It's true that the European countries tend to have less technology (although Germany and Switzerland appear to be comparable or at least very close.) But their citizens get more of something else...: Face time with doctors and time in hospitals. ...

Truth be told, if there's an objection to relying on this sort of data, it's that they measure inputs and not outputs. Who's to say that more technology--or more days in the hospital--really does amount to better medical care? A lot of experts would argue that sometimes the opposite is true. And they would have a point.

That leaves one place to look: The results of people who actually get sick. This is where the conservative argument about American superiority seems most persuasive--because, in a few cases, it actually has some merit. Cannon, Gratzer, Tanner, and others have all seized on the survival rates for cancers--particularly breast cancer and prostate cancer. In those two cases, Americans diagnosed with those diseases are significantly more likely to live than Europeans diagnosed with them.

But before leaping to the conclusion that this proves the overall superiority of American health care ... you have to consider a slew of caveats. ... It's possible that, even accounting for such [caveats], the United States still has better treatment for breast and prostate cancer. But, even if that were true, it's hard to read the data as indictment of universal health care when the U.S. survival rate on other ailments isn't so superior. The Swedes are more likely than Americans to survive a diagnosis of cervical, ovarian, or skin cancer; the French are more likely to survive stomach cancer, Hodgkins disease, and non-Hodgkins lymphoma. Aussies, Brits, and Canadians do better on liver and kidney transplants.

All of this comes with an important cautionary note: Measuring the outcomes of medical care is an imperfect science at best... It's difficult to make a ironclad case that any one system is better than another. But the fact that countries with universal health care routinely outperform the United States on many fronts--and that, overall, their citizens end up healthier--ought to be enough, at least, to discredit the argument that universal care leads to worse care.

And that, in turn, ought to tip the scales of debate, since not even conservatives dispute the one clear advantage other countries have over us: You don't see their citizens choosing between prescriptions and groceries, or declaring bankruptcy, because of medical bills. As John Edwards put it when he announced his health care plan, "It doesn't have to be that way."...

One note. Two main arguments against universal care are that waiting lines are too long and that medical technology lags behind the U.S. The article rebuts the waiting time claim, and when you see a doctor in Europe, it sounds like they actually have time to listen to their patients rather than cutting costs by cutting you off when you try to talk.

On the other argument, that the use of technology lags behind the U.S., differences in technology may not be due to a superior U.S. system, but instead due to over-investment in technology caused by doctor's financial links to equipment makers. That is, even if we observe more equipment in the U.S., that does not mean the U.S. is more efficient or better, it could reflect a costly misallocation of health care resources in the U.S. with too much going to equipment and not enough flowing to other areas. This is the point that just looking at inputs does not tell us much about outcomes or efficiency. See "Drugs, Devices, and Doctors."

Ezra Klein comments on the reaction of the National Review's Jonah Goldberg to the article:

Throne-Kissers, by Ezra Klein: I've spent a bit of time this morning puzzling over the meaning of a pretty opaque Jonah Goldberg post. ... In it, he responds to Jon Cohn's smart article on the successes of the French health care system ... by trenchantly asserting that, "[m]aybe, just maybe, France and Denmark can handle the systems they have because they have long traditions of sucking-up to the state and throne. Marty Lipset wrote stacks of books on how Canadians and Americans have different forms of government because the Royalist, throne-kissing, swine left America for Canada during the Revolutionary War and that's why they don't mind big government, switched to the metric system when ordered and will wait on line like good little subjects....maybe, just maybe, the reason America doesn't have a sprawling European welfare state is that America isn't Europe. And, unlike some of our liberal friends, Americans don't want to be Europeans."

My first thought is that that's a very serious, thoughtful, argument which has never been made in such detail or with such care. I smell a book contract! My second thought was: Huh? I'm not sure exactly what Goldberg thinks he's responding to, but it isn't anything Cohn or I wrote. For instance, apply his argument to Cohn's point on health care systems and it falls apart. America has multiple health care systems, some government-run, some privately administered. In every case, Americans -- who presumably aren't the "throne-kissing swine" of Goldberg's fevered imagination --report higher levels of satisfaction in the public programs. ... Even the poor, who largely rely on Medicaid, free clinics, and the like are at 41 percent, higher than those of us in private care. Butwaitthere'smore!

The only truly socialized system in America is the Veteran's Health Administration. And surveys repeatedly and routinely find that they too are more satisfied with their care than those left in the private market. And anxious as I am to hear Jonah explain how our nation's veterans are just a bunch of toady throne-kissers, I'm not exactly holding my breath. So this one's back to you, Jonah: If America's culture renders us completely unsuitable for public health care systems, how come the vast numbers of Americans currently in public health systems seem so happy about it?

Update: Jason Furman of the Hamilton Project has a proposal I'm not all that excited about. He advocates having patients share more of the cost of medical care in order to reign in costs. It would be tied to income so that the wealthy would pay more than the poor with households paying up to 7.5% of their income before full coverage kicks in. See "A New Prescription to Curb Health-Care Spending, by Laura Meckler, WSJ Washington Wire."

Update 2: Ezra Klein adds:

Why Are We Here?, By Ezra Klein: A commenter takes issue with Jonah's historical  contention that Americans reject generous social welfare states because we're a country comprised of refugees from monarchies who hate expansive safety nets:

Does this kid know ANYTHING about American immigration patterns?

I find it especially laughable to think the potato famine Irish immigrants were fleeing a welfare state... Yeah, that's EXACTLY why starving Irish came to America--they took offense at the too-generous welfare policies of the English!

Likewise, I'm rolling at the suggestion that millions of African Americans chose America over Europe and Africa because they didn't want to be mollycoddled by a state that invested in their welfare.

And let's not forget the Eastern Europeans who flooded in during the late 1800's and early 1900's, terrified that they would be forced to live under the generous welfare policies of nations like Poland and tsarist Russia. ...

[W]hat an idiot. Yeah, that's the defining historical difference between Europe and the US--generous welfare states.

Update: See Henry at Crooked Timber for more on this and, to try to salvage something worthwhile, an intelligent discussion of the role of culture in politics.

Comments

[kharris]

Ignoring the Goldberg segment, what we seem to have is an argument that confuses means and ends. The goal is not technology for technology's sake, but rather good health. This is hinted at in the snipe at doctors with investment links to medical technology firms.

The argument that the number of MRI or CT scan machines is the important issue simply misses the point. What matters is just the figures that critics of the US system have so long pointed to. Infant mortality, life-span and the like. Use the fancy, Phd-adjusted versions of those measures if you prefer, but the point still holds. If a necklace of feathers and a bucket of leeches did the job, we wouldn't need MRIs. If more MRIs don't improve outcomes, then the number of MRIs is the wrong measure to judge between health care systems.

By the way, has anybody looked to see whether the old-fashioned child-mortality and life-span measures correlate well across countries with the PhD-approved measures?

[anne]

Increasingly I understand just how awful these Hamilton Project-eers are. Jason Furman was last seen slashing away at Social Security with Andrew Samwick, while pretending to be about no such slashing. Now, the idea is to make sure health care reform is truly impossible by setting off class against where there need be no classes in the extending of health insurance.

[James Killus]

There have been several studies recently (including one reported in The Economist, I believe) that suggest that the reason why Americans seem to have better outcomes for diagnosed cancer is that there are a lot of cancers that don't result in mortality, and those are being picked up by a much higher use of diagnostics (as opposed to better treatments).

The similar debate for prostate cancer has been around for a long time. It turns out that there are two general catagories of prostate cancer: fast and slow growing. The former tends to strike at an earlier age, and is much more deadly. The latter grows so slowly that older patients often die before it seriously affects them. When the blood test for prostate cancer came out, incidence rates went way up, but mortality remained constant, so what appeared to be a sudden epidemic was actually just an artifact of testing.

There is currently a similar debate going on for mammograms and MRI testing for breast cancer, where the number of false positives overwhelms the real positives for many women. "Cure" a bunch of false positives or tumors that were growing so slowly that the body's immune system could handle them, and the system looks much better than it is.

[Mark Thoma]

Thanks James. To support what you said, I edited this out of the original (perhaps unwisely):One possibility is that aggressive screening in the United States turns up a lot of slow-growing tumors--cancers that would not have ultimately killed people had they been allowed to grow. This seems particularly plausible in the case of prostate cancer. Simply put, the U.S. cure rate may look better than the rest of the world's because we're curing a lot of cancers that don't need to be cured.

[Bill Jefferys]

To expand a little on what James Killus said, there are two important statistical problems that can make it appear that early diagnosis of cancers is a good thing. One, which he mentions, is the fact that increasingly sophisticated technology, while it might discover cancers at an earlier stage, will also discover cancers that never develop into a life-threatening stage (there's a technical term for these which I can't recall at the moment). Thus, if these lesions are treated it will give a false impression that the mortality rate has been improved.

The second effect, which he didn't mention, is that cancers may be discovered at an earlier stage, but treatment does not actually improve mortality. One may discover a tumor at an earlier stage, and improves the "five-year survival rate" because the patient lives on average longer after diagnosis; but the age at which the patient succumbs may not be any later than if the tumor were discovered later (because the tumor is of an aggressive type or because treatment just isn't very effective). All that has happened in this scenario is that the patient lives for a longer time in the knowledge that he or she has a tumor, but the average age of death may not be affected significantly even though the "five-year survival rate" may spuriously improve.

All of which goes to show that careful statistical analysis that is aware of these and other effects is mandatory.

[Bill Jefferys]

I now recall the term for these slow-growing cancers that would not have caused a problem if they had been left untreated: 'indolent'.

[save_the_rustbelt]

"...One possibility is that aggressive screening in the United States turns up a lot of slow-growing tumors--cancers that would not have ultimately killed people had they been allowed to grow. This seems particularly plausible in the case of prostate cancer. Simply put, the U.S. cure rate may look better than the rest of the world's because we're curing a lot of cancers that don't need to be cured...."

I doubt the author has ever had prostate cancer, which will kill you quickly, kill you slowly, or spread so your cause of death is ________ cancer. Duh.

[dale]

Attempts to explain away health outcome differentials as due to poverty and environment strike me as exposing another weak link in the conservative armor. It is true that social-economic inequalities, status heirarchies, etc. do in fact make people ill and die younger. But is that a real defense of the US health care system? It's OK that we have worse outcomes because, of course, we have more poverty, etc.? What shallow and immoral thinking!

Of course, one way of reducing poverty and increasing equality is to institute universal health care. What a step towards social solidarity- towards recognizing the inherent worth and dignity of each person- would universal health care be. There will always be plenty of ways to achieve and display status differentials. But exclusion from health care should not be a legitimate means of social distinction.

[James Killus]

rustbelt:

"Prostate cancer develops in stages, becomes common in men as they age, and is often present in older men who die of other causes. Clinically apparent cancer is preceded by a sequence of multiple steps that are likely to unfold over many years (Cater et al. 1990). Some tumors, however, behave much more aggressively than others. Early stages of prostate cancer may go undetected for many years, complicating understanding of the natural history of the disease. Although autopsy studies of older men frequently identify prostate cancer as an incidental finding, a study in younger men reported a surprising incidence of prostate cancer (Sakr et al. 1993). In 152 men in California all less than 50 yrs old, who died of other causes, 34 percent of those 40-49 yrs old and 27% of those 30-39 yrs old had microscopic evidence of cancer in their prostate glands. Cellular changes (prostatic intraepithelial neoplasia) that may either progress to cancer or, alternatively, be evidence of susceptibility to cancer were detected in 9 percent of men 20-29 yrs old."

--"Prostate cancer," Ted Schettler, MD
Science Director
Science and Environmental Health Network
and Chair, Science Work Group, CHE

To repeat, 1/3 of men 40-49 years old show evidence of prostate cancer. Do 1/3 of us die of prostate cancer? No. Your comment is simply uninformed. You leave out several alternatives: that the body actually can destroy some tumors on its own, or that some tumors grow so slowly that they never present a risk of death.

This isn't some surprising new finding. It's been discussed for several decades.

[anne]

KHarris, what are you asking at the end of your interesting comment?

"By the way, has anybody looked to see whether the old-fashioned child-mortality and life-span measures correlate well across countries with the PhD-approved measures?"

Correlate in what reference frame?

[donna]

Having been through lots of "tests" myself lately looking for a cause for my anemia, I would rather see a doctor who can figure out what's actually wrong than have any more high-tech tests.

There's nothing wrong with my GI track, docs. Look for something else. Oh no, we have to do more GI tests...

Sigh.

[Bruce Wilder]

Mark Thoma: " when you see a doctor in Europe, it sounds like they actually have time to listen to their patients rather than cutting costs by cutting you off when you try to talk."

donna: "I would rather see a doctor who can figure out what's actually wrong than have any more high-tech tests."

If there is a single point of distortion in American medical care that stands out, it is that we have too few doctors, and try to pay them (individually) too much. Doctors see too many patients, and spend too little time with each case.

[James Killus]

I've never bought into the "mind over matter - attitude is everything" theory of disease; I've known too many people who had an optimistic attitude who died, and many people who had a sour attitude who lived. But having recently been through the mill, one notion did occur to me, and it's this: If you have a "good attitude" you will get more face time with your doctor and other health care professionals. They will take more of an interest in your outcome, and they will make a bit of an extra effort.

So, Donna, and I'm not being condescending here, smile, tell them some jokes, and maybe even suck up a little (or even a lot; it's amazing how high a tolerance most people have for flattery). You might save yourself some unnecessary tests and get them to listen to you more.

And god, do I wish this weren't useful advice.

[anne]

Oh dear; Public Radio is telling us Army physician researchers are finding that 18% of returning soldiers from Iraq have traumatic brain injuries. What have we done?

[bakho]

From CDC
The infant mortality rate, the rate at which babies less than one year of age die, has continued to steadily decline over the past several decades, from 26.0 per 1,000 live births in 1960 to 6.9 per 1,000 live births in 2000.

The United States ranked 28th in the world in infant mortality in 1998. This ranking is due in large part to disparities which continue to exist among various racial and ethnic groups in this country, particularly African Americans.

Examples of Important Disparities
Infant mortality among African Americans in 2000 occurred at a rate of 14.1 deaths per 1,000 live births. This is more than twice the national average of 6.9 deaths per 1,000 live births. The leading causes of infant death include congenital abnormalities, pre-term/low birth weight, Sudden Infant Death Syndrome (SIDS), problems related to complications of pregnancy, and respiratory distress syndrome. (14.1/1000 is higher than the Costa Rica rate of 11.8/1000).

Along with increased mortality comes increased incidence of sublethal problems. Lack of prenatal care is one of the risk factors. Making people pay more of their health care bill is not going to fix increased costs due to lack of care.

Health care has different dynamic in different areas. End of life care dynamics are different from prenatal and infant care dynamics.

[wjd123]

"Marty Lipset wrote stacks of books on how Canadians and Americans have different forms of government because the Royalist, throne-kissing, swine left America for Canada during the Revolutionary War and that's why they don't mind big government...." Ezra Klein

I was searching the links suggested at the end of this article and found an obituary on Martin Lipset. According to it, his main claim to why Americans were less socialistic than Europeans is that white Americans had more upward social mobility. Black Americans being kept in their place for so long developed a fondness for the redistributive policies.

[GA]

I'm assuming that those who came up with the "throne kissing" idea haven't heard of the French revolution...

[evagrius]

It's amazing how the "conservatives" dismiss what are important as pects of health, namely socio-economic status, environment, and "life-styles", focusing only on the "end-product", that is, the "heroic" measures taken to make a sick person well.

It's a fascinating ilustration of the commodity thinking that pervades thinking on health care.

It's also a fascinating view of what could be called an economic form of Cartesian dualism, that is, health care, just as any other commodity, is taken as being a completely self-enclosed and independent product.

Such thinking is essentially erroneous and ultimately harmful.

[knzn]

I think Goldberg’s point (or at least the point he should have made) is not that Americans don’t like government health care programs but that they don’t respect government authority enough to accept the cost controls that have made such programs successful in other countries. Sure, Americans may like Medicare better than private insurance, but Medicare is deep into actuarial bankruptcy, whereas the system in Canada is more or less solvent. Private insurance is tougher than government programs because it is owned by private investors who insist on some semblance of profitability; naturally people don’t like being forced to live within their means, as compared to being given benefits their children can’t afford to pay for.

[knzn]

Now that I read my last comment, I like it so much I want to say it again. I think Klein (and possibly Goldberg as well) has misunderstood the arguments of the “American temperament unsuited to a public health care system” school. For the record, I do lean toward a single-payer system (mostly for reasons of social justice and personal security), but I am not optimistic about its ability to solve the problem of exploding costs.

[wjd123]

"It's amazing how the "conservatives" dismiss what are important as pects of health, namely socio-economic status, environment, and "life-styles", focusing only on the "end-product", that is, the "heroic" measures taken to make a sick person well." evagrius

evagrius,

Many people sign statements that no "heroic" measures will be taken to extend their lives. My wife has one I gave her. The money we have to provide for health care isn't unlimited. Choices have to be made.

Much of the money spent on health care is at the last few months of a persons life. This is an exaggeration, but who wants to lay around in a hospital bed, moaning, and eating up limited resources.

[anne]

"Sure, Americans may like Medicare better than private insurance, but Medicare is deep into actuarial bankruptcy...."

What rubbish, what complete rubbish, actuarial rubbish at that I suppose. I am not the least interested in such actuarial nonsense till I am told why we can so easily afford a $2 trillion and climbing war and occupation and be continually told the cost would be cheap at twice the price? Medicare is easily affordable and more along with Medicare.

[anne]

Worried about Medicare? Then, leave Iraq immediately and why not even allow Medicare to negotiate drug prices. Also, I suggest expanding Medicare coverage as John Edwards is suggesting. But, do not preach about Medicare bankruptcy and turn away from the $2 trillion insanity of Iraq. There is no problem with Medicare that a little tinkering as with drug price negotiation cannot easily resolve.

[dale]

"Much of the money spent on health care is at the last few months of a persons life."

Trouble is, in many cases we don't know if someone's in the last few months of their life until they die. That's why I'm a little suspect of talk about the expense of end of life care.

[knzn]

anne: “There is no problem with Medicare that a little tinkering as with drug price negotiation cannot easily resolve.” That’s nonsense. Medicare was already actuarially bankrupt before they even added the drug benefit. Iraq is a big problem, too, but hopefully a temporary one. Medicare becomes a bigger problem the further you project into the future. Also, Iraq is funded out of general revenues, so in principle, it can be paid for by raising taxes (which will happen when the Bush cuts expire). Medicare is a separate trust fund, and under any widely accepted cost projection, the fund is going to run out unless there is a huge increase in the contributions and/or a huge cut in the benefits (and getting rid of the prescription benefit entirely would not be enough).

But that’s not even the point, anyhow. I’m comparing the US with other countries. Whether Medicare is bankrupt or not in an absolute sense is irrelevant. It is unambiguously in worse shape than the health systems of countries like France and Canada. If the US were to expand Medicare to cover the whole population, it would not be the sort of affordable health system that other countries have; it would be a still unaffordable system run by the government instead of the private sector.

[dale]

The point is not that Medicare is or isn't in financial crisis. The point is that the entire US health care system- private and public- is in financial and moral crisis. Medicare finances are just one expression of that larger US health care crisis.

[Gil]

Anne, the 2 trillion dollars spent in Iraq was over 4 years. The US spends 2 trillion dollars per year on health care alone (16% of GDP). As rich as the US is, the fact remains that there are limited health care resources. Who should decide their health care decisions? The patients with their doctor OR the government. The choice is clear. Do not forget that charity is indeed a viable way of paying for health care.

[evagrius]

Medicare is a separate trust fund, and under any widely accepted cost projection, the fund is going to run out unless there is a huge increase in the contributions and/or a huge cut in the benefits (and getting rid of the prescription benefit entirely would not be enough).

If you're employed....take a look at how much is deducted for Medicare.

[anne]

http://www.nytimes.com/2007/04/12/us/12mass.html?ex=1334030400&en=72e8400a4a2326e2&ei=5090&partner=rssuserland&emc=rss

April 12, 2007

Massachusetts Offers Details on Health Coverage
By PAM BELLUCK

BOSTON — Massachusetts is poised to become the first state to make it possible for 99 percent of its adults to be covered by health insurance, with an ambitious plan that sets limits for the premiums people would be expected to pay.

State officials said that under the plan, they expected that all but about 65,000 of the 328,000 adults who are currently uninsured would be able to get affordable coverage.

The proposal sets a sliding scale of affordability standards in which, for example, a single person earning $40,001 a year would be expected to pay no more than 9 percent of income, or about $300 a month, for health insurance; a single person earning $25,000 a year would be expected to pay a much smaller percentage, about 3.3 percent of income, or $70 a month.

The plan is expected to be approved by the Commonwealth Health Insurance Connector Authority on Thursday.

Jon Kingsdale, the executive director of the authority, the agency set up to administer the plan, said setting the affordability standards "was always the most difficult and innovative element" of the state's groundbreaking health care law, passed a year ago.

The law required all residents to get health insurance or face a fine or tax penalty. But from the beginning, there was concern that available health plans might be too expensive for some people, or, that some affordable plans might provide skimpy coverage. Last month, the authority voted to require all plans to have substantial coverage, including prescription drug benefits, which raised further questions about how expensive the insurance would be.

"To do this right means we're walking a tight rope," Mr. Kingsdale said. "We don't want to be too punitive, we don't want to put too high a standard of affordability, but we don't want to let too many people out of a universal requirement. We've been putting a lot of stakes in the ground, but this is the center pole that will allow us to put up the tent and get everybody covered."

The plan, if approved Thursday, would still need to be presented at public hearings across the state and face a final vote in June. The proposal would cost the state $13 million more than the $200 million it was planning to spend.

This proposal changes premiums and subsidy rates that were established earlier. It would allow about 52,000 more low-income people to qualify for free or cheaper coverage. A person earning up to $15,315, one and half times the federal poverty level, would not have to pay anything under this proposal.

Individuals earning $30,630 to $50,001 would not be eligible for state subsidies, but they would not be penalized if they could not find health insurance priced at $150 to $300 a month. People who earn more than $50,001 would not be given a cap on insurance costs.

People who claim they cannot afford coverage under the new system could apply for a waiver....

[Bill Jefferys]

More on why high-tech testing may not result in better health outcomes can be found in a recent Chance News article:

Lung Cancer Screening May Increase Your Chances of Dying.