Health Care: The U.S. versus Canada, France, Britain, Germany, and the VHA

Two on health care from Ezra Klein. The first looks at how well the U.S. stacks up against other countries:

The Health of Nations, by Ezra Klein, The American Prospect Magazine: Here's how Canada, France, Britain, Germany, and our own Veterans Health Administration manage to cover everybody at less cost and with better care than we do...

And the second, which came out after he wrote the above, is a comparison of Canada, which is "often considered a fairly mediocre system," to the U.S.:

Canada vs. America, by Ezra Klein: ...[A] new study was released today comparing care outcomes in the US and Canada. ... [O]f the 38 studies examined, 14 showed clear advantaged for Canadian patients, five suggested US care was superior, and the remainder were mixed. The studies showing the Canadian systems superiority found effects both on income -- low-income Americans with breast or prostate cancer do much worse than low-income Canadians with the same conditions -- and care effectiveness. For conditions like kidney failure or cystic fibrosis, Canadian care was simply better. You can pick through the tables with all the results here.

It's not that the data shows unbelievable advantages for Canada, to be sure. As the authors conclude, "although Canadian outcomes were more often superior to US outcomes than the reverse, neither the United States nor Canada can claim hegemony in terms of quality of medical care and the resultant patient-important outcomes." The question raised is slightly different: How can we possibly countenance a system that costs twice as much as the Canadian system but delivers slightly worse care? Even assuming diminishing returns, our expenditures should result in care outcomes at least 20% or 30% better than Canada's. Instead, they're about 5% worse, but cost around 187%. Does it sound like we're getting a good deal?

Comments

[ZH]

The issue of outcomes over the past 15 or so years (the years covered by the various studies) is not what we should care about. The true costs of the system in Canada are not yet fully realized and probably will not be for a some more years. I have a few Canadian friends currently in college in the US doing pre-med studies and all have told me that they do not plan on practicing medicine in Canada after completion of medical school given the relatively poor doctor compensation. If the US is "stealing" many of Canada's best young prospects in medicine, or if those young prospects choose to enter a related field (i.e. biomedical engineering or biochem-pharmaceutical research), but not actively practice medicine, I fear for the medical situation in Canada 20 years from now.

[Snorri Sturluson]

Since ZH wants to play the "meaningless anecdote" game, I can play too. I know a lot of young physicians (myself included) who would prefer to practice in a national health care system where you could work for a good salary and treat everyone you want to. Unlike the present situation, where doctor's salaries are being squeezed, not in the interest of patient care or national wellbeing, but to fatten insurance companies' and pharmaceutical companies' profit margins. Forget about Canada in 20 years, I fear for the medical situation in the US right now!

[David]

I'm not sure how big of an effect this is, but at least some of the savings that Canada and other socialized systems achieve comes from outsourcing R&D to the US. We pay full price for pharmaceuticals and a sizable chunk of the salaries of doctors at research universities are paid by clinical work. When wealthy people anywhere in the world need a cutting edge procedure, they usually come here. Obviously our health care system isn't doing very well in the aggregate and needs some sort of reform, but comparing costs with Canada is a bit like comparing the costs of software here and India. It isn't cheap there because we are getting ripped off. It's cheap there because we subsidize the development costs.

[marcello]

"It's cheap there because we subsidize the development costs."

Riiiiight... : Canada _IS_ staffed by backward witch doctors living off the medical scraps that fall off US research tables. It is about time that someone of your penetrating logic and intellectual rigour had the courage to speak up and utter these incontrovertible truths. As a Canadian, I can only hope that some of that cerebral mastery can spill across the border and enrich us all.

god bless you.

[Isabel]

Truth will out, Marcello! :-)))

[reason]

David...
what fraction of the world market in health care is in the US? Are you sure that major advances in medicine are overrepresented in the US (especially if scale effects are considered)?

[anne]

No question; there will soon, sooner than soon be no doctors in Canada or likely any other country, all having set up practice in America. Similarly, there will soon be no Swedish or Swiss or British or French or Japanese or ... drug companies or research, all having "ripped off" America sufficiently or what such nonsence might mean.

[anne]

Whenever the expression "socialized medicine" is used, I understand discussion is at an end and I am merely dealing with meaningless ideologic mimicry.

[David]

"Canada _IS_ staffed by backward witch doctors living off the medical scraps that fall off US research tables"

I'm not saying the Canadian doctors are worse. Most of the US doctors aren't involved in research either. But I'm confident that US health care consumers bear a proportionally larger fraction of the research costs than Canadians.

"what fraction of the world market in health care is in the US? Are you sure that major advances in medicine are overrepresented in the US (especially if scale effects are considered)?"

Well, in terms of money spent, we are a really big fraction. In terms of patients treated, we are a much, much smaller fraction. Some of that difference is waste, some is research. I'm not sure the magnitude of the effect. But a citation count or list of the best medical research MD / PhD programs would show the US as the dominant research country.

[person]

i dont agree that due to research health care costs are high in usa.

How can you explain the high fee charged by a clinic for treating a simple sore throat, how is it related to research??

same logic, fee for delivering a baby, how is it related to research....you can go on and on...take each example and see if research is involved in that area..

from my knowledge research mostly involves understanding reasons for illness and finding drugs for treatment (atleast 80% of research) which is explained by the high cost of drugs.

i am not exactly sure about the real reason, but i can try to list the few i understand:

1. doctor's pay (say $50k in canada, to around $100k in usa)
2. too much liability insurace to cover up for SUE-Friendly USA.
3. Too many middle men between the doctor/hospital and the patient like Health insurance.

in other words....at the cost of rising health care, many other sectors like liabiltiy insurance, healthcare insurance are prospering....

[anne]

http://www.epi.org/printer.cfm?id=2670&content_type=1&nice_name=webfeatures_snapshots_20070425

April 25, 2007.

Access to Sick Days Vastly Unequal
By Elise Gould

On average, 57% of private-industry workers in the United States have access to paid sick leave. That means that 43% of all private-industry workers have no paid sick days. When workers get sick, they are either forced to go to work or stay home without pay and risk losing their job. What this number masks, however, is how vastly unequal access to sick leave is depending on workers' wages. Workers at the bottom of the wage scale, those making less than $7.38 an hour, are five times less likely to have sick days than workers at the top of the scale, those making greater than $29.47 an hour. Only 16% of low-wage workers have access to sick days, whereas 79% of high-wage workers do.

In recent months, legislation has been introduced that would level the playing field and provide much needed paid leave for workers who are sick. Such legislation—as exists in other advanced economies—would not only give workers an important benefit, but could provide valuable incentives for increased productivity in the workforce through worker loyalty, decreased turnover, and a decline in sick employees showing up to work and infecting others.

It is time for the United States to join the rest of the developed world and guarantee paid leave for its workforce.

[person]

I forgot to add that reasearch(non drug) is mostly funded by the government....which does not charge a cut from the health care industry to add to the cost.

private research by drug companies are the reason for high cost of drugs.

its not that a hospital does research using its own money to find a new care, and hence it charges a premium to treat patient using that new technology.....

[David]

person

Salaries for research faculty are largely paid by their clinical work. And some HMOs (like Kaiser) put money into research.

I'm not arguing that research expenditure is the major reason that our health care is overpriced. I don't know how significant the effect is. But through taxes and health care costs, the US certainly subsidizes health care in the rest of the world. I want us have universal health care, but I don't want to lose the good things about our health care system - innovation is one of them.

[anne]

"But through taxes and health care costs, the US certainly subsidizes health care in the rest of the world."

Huh? I have little idea what this could possibly mean, though conservatives repeat this continually. So, our taxes subsidize health care in Australia. So, our health care costs subsidize health care in Japan. Say what?

[Michael Haley]

Pharmaceutical companies fund a lot of research and due to Canada's government control over drug prices they pay less for drugs. American consumers are subsidizing drug company research that benefits Canada and much of the rest of the world (like Africa) by paying full price for drugs.

Anecdotes do matter. When everyone you meet from Canada tells you the health system is great, free, and if you have a heart problem or cancer you can usually get in to see a doctor within a couple months or so, then I take that seriously. They have rationing and there is no way to get away from that in a controlled market place.

All you have to ask yourself to figure this out is, if going to the doctor is free, would I go more often? If every American goes one more time a year you have a multi-billion dollar cost. If 10% of us go a lot more often, we have a system that is more broken than the one we already have.

[anne]

No question; there would be no research, no drugs, no health in Canada either were Americans not paying for Candaian health care. Conservatives simply make assertions, and having made the assertions they have to be true. Any assertions will do, I understand.

Suppose though we were to look to Dr. Marcia Angell who researches and knows of the drug industry from a career's experience:

http://www.nybooks.com/articles/17244

July 15, 2004

The Truth About the Drug Companies
By Marcia Angell - New York Review of Books

1.
Every day Americans are subjected to a barrage of advertising by the pharmaceutical industry. Mixed in with the pitches for a particular drug—usually featuring beautiful people enjoying themselves in the great outdoors—is a more general message. Boiled down to its essentials, it is this: "Yes, prescription drugs are expensive, but that shows how valuable they are. Besides, our research and development costs are enormous, and we need to cover them somehow. As 'research-based' companies, we turn out a steady stream of innovative medicines that lengthen life, enhance its quality, and avert more expensive medical care. You are the beneficiaries of this ongoing achievement of the American free enterprise system, so be grateful, quit whining, and pay up." More prosaically, what the industry is saying is that you get what you pay for.

Is any of this true? ...

[anne]

http://www.nytimes.com/2004/09/06/books/06masl.html?ex=1252209600&en=1accf3fe4a08f287&ei=5090&partner=rssuserland

September 6, 2004

Indicting the Drug Industry's Practices
By JANET MASLIN

Dr. Marcia Angell is a former editor in chief of The New England Journal of Medicine and spent two decades on the staff of that publication. If much of that time was devoted to reviewing papers on pharmacological research, it must have been spent in a state of near-apoplexy.

Her new book is a scorching indictment of drug companies and their research and business practices. "Despite all its excesses, this is an important industry that should be saved - mainly from itself," she writes....

[anne]

By the way, when 43% of American workers do not have a day of sick leave does that subsidize health care in Japan? How about in Sweden? Switzerland?

Me, by the way, since going to the doctor is free, I virtually live in the office, but I have do ulterior motives.

[anne]

Writing about free doctors, by the way, I am reminded that Brad DeLong and Mark Thoma only just showed what happened in Mississippi, and the rest of South, to poorer families when health care was made more expensive. What happened, what is happening? Infant mortality has risen.

http://www.nytimes.com/2007/04/22/health/22infant.html?ex=1334894400&en=5d5d40b319346648&ei=5090&partner=rssuserland&emc=rss

April 22, 2007

In Turnabout, Infant Deaths Climb in South
By ERIK ECKHOLM

[anne]

When we raise the cost of health care for poorer families in Mississippi, as we are, rationing in effect, what exactly are we doing to say subsidize health care in Canada? I would gladly though subsidize health care in Mississippi by having my tax dollars spent there rather than in Iraq.

[dale]

"if going to the doctor is free, would I go more often?"
It's as good as free to me- I pay only $10 per visit. But it takes a lot to motivate me to see my MD. I've got problems I have procrastinated for years on talking to my doctor.

there are studies that show that even small co-pays in some situations lead to more expensive long term costs.
I think the fears of some that more people will see their MD more often (indeed that more people will even have a primary care physician at all)are misplaced. Frequent, preventative care- catching problems early, etc. are what any decent society and health care system needs. If it costs more- so be it. But it may well cost less in the long run.

[Michael Haley]

Preventive care costs just as much as any other kind of care. I don't get the argument that preventive care will save money. I mean, if you are just doing a cold blooded analysis of costs, maybe it is cheaper to let people get sick then treat them. Most of the people who use the health care system heavily are older who end up getting some kind of health problems as they age, virtually all of us do. I don't think preventive care is going to stop that.

The problem is that once you have government setting prices you are going to get shortages, and then you are going to have sick people who can't see a Dr. There is just no way around it. It has happened in every single country that has state paid health care and was already a part of Hillary's plan when she wrote it back when. Now if you are poor you can still see a Dr. for free, and immediately, you just don't get the regular care that those with insurance get.

I've been poor and without health insurance and got immediate care when I needed, including a free stay in a hospital with excellent care. I have also worked in social services and had to find people medical care in the middle of the night in places with low public services like Georgia. I never had a problem, in fact I was always amazed at how much help there was out there for people.

All that is now available to people. The real problem with the health care crisis is that insurance is expensive for middle class people. They are the ones raising all the ruckus. Throw in a lot of people who want to be socially conscious and get even better care for the poor. Nothing wrong with that, but it is going to break the bank, if you don't consider it already broken which I do.

[Isabel]

"American consumers are subsidizing drug company research that benefits Canada and much of the rest of the world (like Africa) by paying full price for drugs."

Like, shoppers that buy their groceries at Mom and Pop stores subsidize the groceries that other shoppers buy at Wall Mart?

"Preventive care costs just as much as any other kind of care."

This is the first time I hear or read this statement. It reminds me of a portuguese law professor that would sometimes say to his students: "In your thesis, there are many things right and many things original. Pity that the things that are right are not original and the things that are original are not right".

"The problem is that once you have government setting prices you are going to get shortages, and then you are going to have sick people who can't see a Dr. There is just no way around it. It has happened in every single country that has state paid health care..."

For example?

"Now if you are poor you can still see a Dr. for free, and immediately..."

And that, of course, is not the case in those wicked countries with state paid health care. Everybody knows that, due to the shortages, a lotery is drawn every week to see who are the happy few that will be treated next, and the only way to avoid that lotery is boarding a plane (sometimes private) to be treated in the good old USA.

Sheeeesh.

[BiJian Feng]

The fact is that someone will have to pay for our health care costs. People seem to just assume that if we nationalize health care, it'll all be free and dandy. No, you will still pay and I still haven't seen any proposals that would lower total health care costs. As soon as you start to subsidize a good, the demand goes way up, and if people start using more health care services, how are costs going to be less? I'm talking about non-drug health services here first. I've sprained my ankle several times playing basketball, twice quite badly, yet I never went to the hospital. If it were free, why wouldn't someone like me go? I couldn't put pressure on that ankle for three days and had to limp around without a crutches, bad for me, but great for those who didn't have to pay for those crutches or my visit to the hospital. And as Michael pointed out, I could go get frequent checkups and receive more preventative care, but that takes a doctor's time. So a doctor now spends the majority of his time on routine checkups instead of seeing really sick people who don't know what is wrong with them, or need a quick diagnosis before some sort of infection spreads. Plus preventative care has to be followed. You have high blood pressure so eat less fat, cut calories, start exercising, how many people would actually follow those suggestions? Come on, everyone wants the easy way out, "Just give me a couple of pills doc". The doctor says sure, and prescribes two drugs, one to lower blood pressure, the other to lower cholesterol. How is that going to lower costs?

As for pharma, drug companies need profits to provide incentive for them to keep on cranking out all the miracle drugs that make up for our laziness. Without profits, who is going to create all the new breakthroughs? The government? Research costs billions and often ends in a dead end. Drug companies balance out the costs and risks of a dead end versus the profit they can make (and thus how many people will benefit from a breakthrough). Is the government going to be more efficient? The government is going to figure out who is most worthy and which theory has the most promise? These difficult questions have to be addressed. It's too easy to just cry for "free" health care and just assume we'll have an utopia if we just muster enough "courage" to demand one. So stop the rhetoric and start giving solutions to the problems that are going to be faced instead. Now that's REAL courage.

[reason]

BiJian Feng ...

The fact is that someone will have to pay for our health care costs.

Is someone disputing this? Or are you volunteering?

No the issue is
1. The costs are demonstrably higher than they need to be
2. The system stiffs some people. (i.e. it isn't fair)

Address them.

As for the anecdote about your ankle - all I can say is - what if you had broken it and didn't know and had permanent damage as a consequence. You were lucky but not necessarily wise.

[Icarus]

The US health care system, with all of its pooled insurance schemes, will fail if our political system cannot, or will not manage costs. The great illusion sold in the US is that health care is a 'right', despite the costs potentially involved.
We would be better off insuring every citizen for basic care, which is minimal in cost (minimal in comparison to the project cost of not treating as well).
Concomitantly, we cannot, and should not cover expensive health care procedures, in a national health insurance scheme. (private insurance can make up for such things).
The US spends a disproportionate amount of its health care costs on a small minority of patients. This is the problem, and it is not solvable under our current system.
Terry Shiavo is a cast in point. She costed the state of Florida something close to $15 million. That is obsene. There has to be a mechanism, however seeminly cruel, to cut off these costs, and force them upon the private economy (ie, the individual must be covered through private insurance, or, cables are pulled).

This issue destroys the concept of emergency medicing, and health coverage in low income neighborhoods as well. High costs bankrupt the system, and the overall welfare of the population is compromised. If indigents medical care costs tens of thousands of dollars, there has to be a mechanism to deny such coverage or treatment. Again, it sounds cruel. But, we should rather focus on the overall care in that community, within a framework of what's affordable for the whole.

The problem with the US system is that health care is seen as a 'right'. It is not. It is a service, like any other, albeit one that is critical. In no other service, can an individual accrue tens of thousands of dollars in costs, without any capacity to pay that bill. In no other service.
Many physicians agree that we must find a better attitude towards death. We stave it off at all costs, despite the negative effects to the collective health.
Medicare/aid will follow the same path. It becomes so expensive to cover these costs, that the very system is in jeapordy.

I suspect that in the near future, we will explore offshoring many of these costs, in order to faciliate better affordability. A radiologist making $400k a year is obsene, and the market needs to rectify that.

A national insurace policy, single coverage, or any other insurance scheme will not work unless costs are reigned in. In order for costs to be reigned in, we must cut off expensive procedures which have no revenue stream. In order to do that, we have to take those decisions out of the hands of physicians (who should only be responisble for treatment, and not decision making like this).
This is the dilemma. And, until we deal with it, despite the partisan politics which characterize health care debates in the US, we will slowly bleed our health care service offerrings to death.

[anne]

"If indigents medical care costs tens of thousands of dollars, there has to be a mechanism to deny such coverage or treatment. Again, it sounds cruel."

No question; amoral lunacy is loosed among us, not to sound cruel because sounding cruel is what we sould never sound like, though looking at the problem from the perspective of a cancer sufferer, well, an indigent cancer sufferer, well, you know, not to sound cruel.

[dale]

"The great illusion sold in the US is that health care is a 'right',"
When you look at rights in terms of relationships, then what we are currently going through in the US is a struggle to grant the right of acess to quality health care to each individual. That involves the recognition and creation of a new relationship between citizens of this country. A new form of social solidarity. A new expression of equality- of the inherent worth and dignity of each individual.

If that comes with a price tag- so be it. Although adoption of a single payer like scheme in the US would in itself be a great source of cost savings- eliminating the waste entailed in the health insurance industry.

People too often act as if this is some new, uncharted territory that we are exploring here. It's not. We are the last developed nation to jump in the universal health care pool. I expect that we will find the water to be just fine.

[anne]

http://www.nytimes.com/2007/04/26/opinion/l26south.html?hp

Infant Deaths: Shame of a Nation

To the Editor:

"In Turnabout, Infant Deaths Climb in South":

It is troubling that progress in reducing the black infant mortality rate has stagnated and that the rate is rising in Mississippi.

For half a century, the black infant mortality rate has been approximately double the white rate. This disparity is complex and cannot be explained solely by medical or socioeconomic factors.

We know that the mortality rate of infants of foreign-born black women in this country is significantly lower than for infants of native-born black mothers and that Hispanics, in spite of high poverty and very low education rates, have infant mortality similar to whites.

It is likely that this new trend among blacks in areas of the South is related, in some fashion, to chronic emotional stress secondary to persistent poverty, a feeling of hopelessness, racial discrimination and health conditions.

A comprehensive approach beyond just the medical model is called for.

Patrick Dowling, M.D.
Los Angeles, April 24, 2007
The writer is a professor and chairman of the department of family medicine, David Geffen School of Medicine at U.C.L.A.

[anne]

http://www.nytimes.com/2007/04/26/opinion/l26south.html?hp

Infant Deaths: Shame of a Nation

To the Editor:

Your article shows what many in the public health community have long known to be true: reductions in public health services and insurance programs, especially on a state or community level, have very real health consequences. Infant mortality is the most sensitive measure of that health impact.

Perhaps more important, however, is your portrayal of the strong connection between health and poverty. While aggregate health measures in the United States have greatly improved over the last century, there remain vast regional, racial and economic health inequities, as your article demonstrates.

To target these inequities, public policy must adopt a broader perspective that recognizes the importance of the socioeconomic determinants of health.

Alexander Hertel-Fernandez
Evanston, Ill., April 22, 2007

•

To the Editor:

As a medical student at an inner-city hospital, I see poverty all the time, but not the poor black towns in your article. We have pockets worthy of the third world in our midst, and no one has noticed it until now! It's about time that health care is brought back to the forefront of the political ground; no mother should bury a baby just because somewhere along the way, somebody forgot that people like her need help.

Farheen Qurashi
Mission, Kan., April 22, 2007

[anne]

http://www.nytimes.com/2007/04/26/opinion/l26south.html?hp

Infant Deaths: Shame of a Nation

To the Editor:

Everywhere across this country, you will find similar issues associated with the infant mortality: pre- and post-natal care, poverty, access to medical care, health insurance and so on.

When we conducted our analysis of infant mortality in Tennessee last year, we found that even when we controlled for income, African-American mothers had a higher infant mortality rate than white mothers. Why is this? We need to look at other plausible risk factors like intergenerational stress among African-American populations.

Pramod Dwivedi
Nashville, April 22, 2007
The writer, an epidemiologist at the Tennessee Department of Mental Health and Developmental Disabilities, was formerly with the Tennessee Department of Health.

[Isabel]

"People too often act as if this is some new, uncharted territory that we are exploring here."

Yes, that is my great befuddlement at some posts. And makes me think that if you find people like that in a blog like this, I don't even want to imagine how parochial are the views of the average American on health care. I suppose that is what explains the absence of marches to Washington with torches and pitchforks.

[anne]

Isabel has a comedic genius among other nice attributes.

[Isabel]

It's NOT funny!

[anne]

No, it's not funny, and we are not marching on Washington with torches and pitchforks as we should. Nonetheless the imagery is of genius and sad in a wildly comic sort of way.

[Isabel]

Look, this is an economics blog. People that hang around this place are supposed to be able to do more than count up to 100. The idea that some defend here that the so-called greatest economy on earth cannot afford universal health care and that "maybe it is cheaper to let people get sick then treat them" is just egregious to me. I don't think they have the remotest idea of the costs for a society of the solutions they advocate. Third world countries are not third world just because they lack resources, it's because they squander them, namely their human resources, among other things by failing to give a chance to their weak, sick, disabled to leave a productive life, abandoning them to be a burden to their family and their community. Children, old people, disabled can be left to their own devices. Or not. Guess what is cheaper? I'll tell you:

I read in the San Francisco Chronicle (yeah, yeah, that pinko commie bastion) that a legless homeless man nicknamed Skateboard was run over by a truck that failed to see him crossing the street on his skateboard. That brought memories of Portugal in the late 50s early 60s where that kind of sight was fairly common. And of the people that would come to me and my minder to talk about the niece or the cousin they had at home and were crippled just like me, but stayed at home because they had no way to move around in the street and, of course, no way to go to school. I was an eye opener for these people, you see. Because I was on my way to school, first carried by minder, then on my braces, that costed a small fortune. My middle-class well educated family never dreamt of not doing whatever sacrifices were necessary to give me an education that would allow me to earn my living. Others didn't even dream it was possible. THAT is what third world health care means.
Now, my braces still cost as much as a small car. But my job of international civil servant comes with an excellent health cover, better than the one that post-Salazar Portugal has, and even better than the one of my host country (braces are not any better here, mind you). I sometimes wonder about those kids that stayed at home. I guess that universal health care came too late for them. And for their families.

[anne]

Thank you, Dear Isabel.

[reason]

Of course the rich in America can't afford to pay taxes. It costs them too much to bribe the politicians.

[me]

US costs are 30% higher just to cover the paperwork and profits for the middlemen.

And what research costs are being referred to here for the US. The US accounts for about half of pharma and most big drugs are not coming from the US because they waste money trying to extend patents on existing drugs instead of developing new ones.

And that research? Anyone heard of India or China? US big pharma is moving R&D offshore, just like everything else.

[Michael Haley]

Isabel, as I mentioned in my earlier post, Canada is one place, so is England, France, etc, gee, every place that has socialized medicine.

Here is a link for you:

http://www.tnr.com/doc.mhtml?i=w070416&s=cohngratzer041907

which is a TNR discussion which presents both sides of this issue. You can argue it, but when I have friends from Canada who are not the least bit political explain to me how great their health care system is unless you have a serious problem then you have to wait quite a while to see a Dr., I tend to believe they mean it.

Everyone says that there is rationing here in an indirect way due to lack of money to pay for it, but having worked in social services much of my life in several states, I just have not seen it. In fact, I defy anyone to have someone in need of just about any kind of help including medical or otherwise and not be able to find a place that will give it to you for free in thirty minutes or less. 24/7/365, I mean at 3:00 am on Christmas morning because I have done it. I have personally done that for other people over and over.

The fact that our health care system costs 30% more in part reflects that, a lot of people are already getting low or no cost help and the rest of us are already paying for it. Note the crisis is supposedly in terms of insurance, not available medical care. We are even providing free prenatal care for half of northern Mexico down in So California right now.

I am not opposed to helping people and think that there may be some way universal medicine will improve our situation, but I am not convinced that it is the panacea that some seem to think. If government employees run it, their unions will make sure the cost skyrockets like they have every other government program they inhabit.

Also, I don't get your and Anne's condescending attitudes toward people who don't agree with you. Do you two already know everything? One thing you should know then is that you can't get five people in a room together and get them to agree that they all like their mothers. And it is not because two of them are brilliant and the rest are stupid rubes.

[anne]

No agreement is not the issue, nonsense is.

[anne]

"If government employees run it, their unions will make sure the cost skyrockets like they have every other government program they inhabit."

Huh??? Just sampling.

[BiJian Feng]

Isabel, I find that immigrants like us share a similar perspective towards America that a lot native-born people don't have. We understand that the United States is rich because it deserves to be due to its economic structure, capitalistic values, and efforts of its residents. For some reason, those who are born here don't understand why this country is so well off while so many others are mired in poverty and despair.

Immigrants like us KNOW what real poverty is. Growing up, I had to share ONE bathroom with three other families; that kind of situation is just unimaginable to native born Americans. All food was rationed--we had rice rations, meat rations, cooking oil rations. Milk was a luxury only the fairly well off could afford. My left eye is permanently damaged because I was pulled out of my mother's womb with a pair of tongs, one of the ends clasped directly into my eye. My mother had difficulty giving birth and the hospital had no other method available; welcome to real poverty.

We saw that it was the socialist policies our native countries followed that caused this poverty and suffering. We were supposedly guaranteed food, health care, and shelter, but for some reason, America, which guaranteed none of those things, had more of everything! In time, I began to realize that it was those guarantees and other socialist policies that caused our poverty. So when I hear the same kind of socialist talk today in America, I think, oh no, this is the same path China went down and it's a dead end. You don't want to follow this path. The reason America is rich and why I came to the United States is because it avoided that path to poverty, I don't want to go back.

It's counter-intuitive that trying to help the poor in this manner would CAUSE more poverty, but it's true. The United States is rich because it didn't try to help the poor in the same manner China did, and everyone, including the poor in America, are richer because of it. Native born Americans have never experienced the other side, so they don't know that what they propose won't work. The posts above explain why they won't work.

You can only hope that on an economics blog, reason and logic will overcome emotion and anger. That people will use economic theory to show why and how cost savings can be achieved under a government run health care system. Unfortunately for them, economic theory says the opposite, it can't be done in reality based on all we know about economics. Hopefully logic can overcome emotion, but some people are just too angry and filled with hate to think straight. Don't be offended Isabel, just keep on asking for detailed solutions based on sound reasoning and ignore the rhetoric that we've all heard a million times before.

[reason]

BiJian Feng...
1. Isabelle is not an immigrant (read carefully her previous posts)
2. She said that there are many examples to show that other countries have better results at less cost using single payer health systems, how is you think it is impossible.
3. There is no reason to think that a mixed economy is synonomous with communism. Anarchy is the opposite of Tyranny but that doesn't necessarily make it better than Democracy.
4. Ideology is a form of stupidity, be very wary of it. Some point of every ideology is always false, the world is complicated.

[reason]

BiJian Feng
Correction - Isabelle is not an immigrant to the USA.

[evagrius]

BiJian Feng;

Go visit Mississippi or a Native American, ( you know, the original natives born in the U.S.), "reservation" before making your conclusions.

[evagrius]

Michael Haley;

Does your ability to find help for people at 3.a.m. also include those with chronic illness, ( i.e.; diabetes)?

[Noni Mausa]

Michael Haley said: "Most of the people who use the health care system heavily are older who end up getting some kind of health problems as they age, virtually all of us do. I don't think preventive care is going to stop that..."

Well, actually preventative care can reduce or eliminate many ailments typical of aging people, and not by small amounts but by big whomping amounts. Some samples:

>>Type II diabetes and the disorders which derive from it, such as amputation, blindness, impotence, kidney failure -- these are common, and NOT cheap to treat. Changes in diet and exercise (cheap like borsht!) can practically eliminate this.

>>Heart disease, stroke disorders, and chronic obstructive pulmonary disease (COPD). Most could be dramatically reduced by preventing tobacco addiction. These are also pricey to treat but cheap to prevent.

>>Depression and other mental disorders. Expensive to treat, devastating to the sufferers and their families -- do we know what easily-changed contributing factors would effect these? Diet, exercise, lowering the pace of life, all these cheap, unpatentable measures can mitigate these disorders.

>>Obesity. See above.

In actuality, preventative measures would cost far less than treatment for these very common conditions, by at least an order of magnitude.

Noni

[Isabel]

"Correction - Isabel(le) is not an immigrant to the USA."

Thank you, Reason ;-)

BiJiang Feng, it is interesting that you seem to have read my post as abounding in your direction when it is virtually the opposite. I certainly don't compare China under Mao with Portugal under Salazar, although they were both totalitarian regimes in poor countries (although at levels of poverty not comparable).

Michael Haley and BiJiang Feng, I will answer later when I will have some time free...

[Isabel]

Michael Haley, I don't mean to sound condescending, but one thing is to underline the shortcomings that all systems have, including those that I defend, or even to say "it won't work here because of this, this and that". Another is to state things like " preventive care costs as much as any other kind of care" and "... once you have government setting prices you are going to get shortages, and then you are going to have sick people who can't see a Dr. ... It has happened in every single country that has state paid health care". Your phrase implies that shortages are inherent to state paid health care.

It happens that various people in this blog live or have lived in one or another of those countries and have a first hand knowledge of those presumed shortages. I know that, due to the barrier of language, Americans are often (dimly) aware of what is going on in Canada and UK only. Both countries, like Portugal, too, have a gatekeeper system and I can't say that I'm very enthusiastic about it. (It might be cheaper, the way industries that don't have to clean after themselves are cheaper, but I often wondered about the hidden costs for society of having people spend a lot of their productive time seing a GP, maybe having tests done, etc, before they are referred to a specialist. My dermatologist brother abolished that nonsense in his service, in a hospital in Portugal, because he figured that most people can tell if they need a dermatologist or not). Anyway, in Belgium, France, for example, there are no waiting lists that I know of and I can assure you that health care works very smoothly. Might be more expensive than what the State would like, but it does work well. And if you are indigent and need help, you will get it as quickly and efficiently as is your experience in the States.

My husband experience, in the States, is slightly different. While he had excellent care when he was consideredd indigent, he almost died of lack of it in a slightly more affluent time of his life. A friend of his was also commenting the other day that her asthma was under control now, that she had health insurance. I really don't think it is a good place to have a chronic disease and not be insured nor being indigent.

Feng, I assume you are young and healthy, so you might not know yet what a bad idea in the long run is to ignore a sprained ankle. But you might start wondering one of these days why is it that you sprain your ankles so frequently ;-)

More to the point, my post was about the squandering of human resources that a third world sort of health care (where each one fends for himself) represents. You seem to disapprove all this socialist rubbish of helping the most vulnerable, to which you attribute your country's poverty. All I know is that, if you were not born in that socialist hospital the chances are that you would not be here with your damaged eye to tell your story. And probably neither would be your mother. Many, many countries are very poor and not all are socialist...

[anne]

Nice.

[real person from the real world]

Why is the automatic assumption that prices being charged by med entities are fair or reasonable? I have said this before, but it bears repeating. A friend (nurse practicitioner) told me that the AMA looks at the range of incomes in an geographical area, and bases rates for a procedure on that. Also, doctors can charge more if they so choose. Drugs and other items in our society are now engineered costs. That means that the price is not based on actual research costs, but rather, on what the market will bear. Education Inc., is a business that leaves students with huge debts, so they charge more for hours worked to pay that off. If prices were based on actual costs, with a reasonable margin, we would see everything cost less. If education was a social policy that made education of citizens a priority, not a business, we might have more doctors, with less student debt. But the old greed factor is the rule of the day.

When you look around, you see other coutries where the health outcomes are as good or better than the US, and cost LESS. Doesn't that tell you something right there?

[Michael Haley]

We don't need universal health care to know we should stop eating so much sugar and and quit smoking, we know that already. I am a type 2 diabetic and will live longer taking "preventative medication" but that is just going to cost the health care system more. Because eventually even with medication I am going to get some kind of illness and die, and in the meantime my drugs and doctor visits are expensive. If I never went to the doctor I would be dead sooner and spend a lot less on drugs.

It is better to be healthier and it is great that they have all these new drugs to help me, and everyone else, but it is costing a hell of lot more to keep me alive longer. And the longer I live the more it is going to cost. The idea that preventitive medicine is going to save money is just wrong.

[Michael Haley]

evagrius, are you thinking about it here? Every county in the US has an emergency room open 24 hours a day that will see indigent people. Not only for diabetes but if they show up with a bullet through them or with a cold they will get seen. Find that anywhere else in the world if you can.

Many hospitals are financially strained, particularly in places like Los Angeles where there are massive amounts of immigrants coming in for care from Mexico, yet even there no one gets turned away.

says...

Shortages are inherent when prices are set artificially, like by a government run health system, not because the government is running it. Price fixing leads to shortages. Like Medicare when Dr.s wouldn't take medicare patients because the prices were too low, or like the old Soviet Union when everyone had to wait hours in line just for a roll of toilet paper because prices were set on everything by the government and everything was scarce. It is a basic economic reality.

So if we have a government run health system inevitably they will have to set limits on services or it will eat up the entire GDP. That is a given. There is no way to get away from that, and since your husband got immediate service for whatever he wanted in Beligium that means they were spending a huge amount of money on their health system, and more and more all the time, all coming from taxpayers. It is just inevitable, because economic resources are limited.

Here's another example for you:

"Emergency patients ‘put in danger by waiting list targets’

http://www.sundayherald.com/news/heraldnews/display.var.1362910.0.emergency_patients_put_in_danger_by_waiting_list_targets.php

Writing in The Surgeon: Journal Of The Royal College Of Surgeons Of Edinburgh And Ireland, the doctors warn that issues such as staffing levels have had a strong impact on patient care and that the situation is likely to get worse as the number of unplanned admissions rises. And they argue that increasing centralisation of services will be necessary if the arising problems are to be avoided in the future.

Their report stated: "The introduction of waiting-list targets and initiatives has resulted in the concentration of resources in politically important medical disciplines. This has meant that other medical disciplines, many of which involve emergency or unplanned admissions, have diminished resources."

I copied a few random paragraphs, but in Ireland and Scotland this is what socialized medicine has come to. One can see articles like this frequently, and things like this just do not happen in the US.

Here, poor people are not going to see Dr.s as much, and yes that means that some things are not going to get treated until they are an emergency. But on the other end when they start not having medical help available even if you go and want for ANYONE! that is far worse.

Overall it is a worse system and would be a big mistake.

I made another post on preventative medicine above, but one more point on that is that going to a Dr is going to a Dr. My Dr charges me just as much for a cold as he does for my diabetes. The amount of money saved by me staying healthier from preventative medicine is going to be offset by the fact that I am going to the Dr. a lot more than I otherwise would plus the fact that I will live longer and therefore use more service in the years longer I live.

Which will be wonderful if people have that, but it sure is not going to cost less. I think it will cost more.

[Isabel]

That reminds me of the first comment my (Italian) housekeeper (with no schooling but with plenty of intelligence and a healthy mistrust of governement, the European way) made after the heatwave of 2003 that killed so many people, in France especially:

"I'm sure that the Government is very happy for not having to pay all those pensions!"

[My American Husband tells me
"We would have to contend with far fewer injuries in Iraq if we stopped issuing body armor."
and
"What about that compost pile?"]

[BiJian Feng]

Well it was only due to trust of government that those elderly were left to die. No reason to cut a vacation short to help mom and dad, the State will take care of it. Of course, the State proved incompetent as usual.

Sorry for misrepresenting your post, but my point remains. I don't understand why there is so much trust in the government among some people. More often than not, you get incompetence. How is it that Wal-Mart was able to get water into New Orleans while the government wasn't? Don't they drive on the same roads? And let's not forget the Coast Guard ship upgrade debacle where the Coast Guard spent billions to develop and buy 7 or so ships that were so crappy that they had to be scuttled before they entered service. Those are only some of the more memorable recent examples of government incompetence. What makes anyone think government can run health care better?

[anne]

"Well it was only due to trust of government that those elderly were left to die. No reason to cut a vacation short to help mom and dad, the State will take care of it. Of course, the State proved incompetent as usual."

Absolute rubbish and profoundly mean-spirited.

[Isabel]

Well, maybe, just maybe, the Republican party wants the government to look and BE incompetent? Isn't it their main point? How would you expect them to disprove their main raison d'être?

[anne]

Ah, a note on lunacy and being perverse; the Coast Guard does not, well, really does not, build ships and outfit ships. The Coast Guard buys ships from, well, private ship builders and buys outfits from, well, private outfitters. Go figure. Say what?

[Michael Haley]

Isabel, you have missed my point although I stated it explicity. Preventative care is a good thing and may well be worth the money to obtain it. But it will not save us money in a government health plan, which many keep trying to claim. That is my point, it will not save money, not that it is not a good thing to do.

And speaking of France, 10,000 people would never die in the US during a heat wave because we have the facilities to treat them thanks to our health care system. A reason a lot of them died is that services were so limited they wouldn't even bother to take people to the hospitals--no room. A reason, not the only reason, please read carefully, but an important factor indeed.

Here's another article for you from today's Times in London:

http://www.timesonline.co.uk/tol/news/uk/health/article1722284.ece

"Govt defends NHS ban on smokers and obese

Times Online and agency

A ban on smokers and the obese getting certain NHS treatments in some parts of the country was defended by Health Secretary Patricia Hewitt today.

She said it was “perfectly legitimate” for primary care trusts (PCTs) to set a collective policy to deny operations to certain patients.

Ms Hewitt was responding to a Sky News survey which found nine PCTs refused joint replacements to obese patients and four blocked orthopaedic surgery for smokers."

Saving money are we? What's next, a ban on care to people who eat candy? Sugar is bad for you, ban on care to those who drink alcohol?, maybe if they ban enough care down to only people who are healthy then they will be able to afford "universal" health care.

[Michael Haley]

Anne, profoundly mean spirited and rubbish? The French government themselves told people not to come to the hospitals because they were overwhelmed and that is why a lot of people died. It is not mean spirited, it is a simple fact.

Do a Google search. I mean, one of the reasons is that they didn't have ice at the hospitals. No ice? There is ice at every corner 7-11 in America. No ice and 14,000 plus people die in two weeks. Amazing. Can you imagine if people were dying by the thousands in America and they announced it was because they had no ice? There would be enough ice to cover the North Pole within 24 hours delivered to hospitals here.

[Icarus]

The limits of health care?

What are they? When can treatment be refused. This is the difficult question which an attempt at universal healthcare has to answer. If an individual behaves in a depraved manner regarding health, such as smoking enough to guarantee lung cancer, or eating enough to become morbidly obese, does the collective have an obligation to treat?
Perhaps...but, at whose costs?

Universal healthcare is an improbable solution, because it doesn't address the central issue with our collective health...which is, how do we further engineer a society which lives in a good standard of health? If people live reckless lives, or have children they cannot take care of, or fail to work...well, then, the seems of our social insurance start to fray.

The solution is not in the emergency rooms or the corporate offices. They behave in predictable manners. The solution lies in our sense of limits. Our current health care system has a poor sense of limits. How much is a life worth? Who pays? How much debt can a facility incur before being insolvent? How much can a product cost?

These are tough questions, which have market oriented answers, as well as public policy oriented ones. The two one day have to overlap.

[Icarus]

Taxes...

The idea that the wealthy evade taxes, and this is to blame for our poor financing of a health care system is also insane. The percentage of income tax paid by the top quintile is gigantic. And, medicare/aid take up nearly a fifth of that total.
Plus, any scheme which requires a tax base in the US to finance health care for a chunk of northern mexico, and many others not paying into the system will eventually capsize.
A modicum of wealth distribution is necessary for a functioning society, no doubt...but, to propose blank check economics on any system is not possible.

While we may dream of the days of a booming welfare state, aka western europe, or, of days of social solidarity (only in utopian novels), this humanist rhetoric betrays the very spirit of US commercial capitalism. We have (de)evolved into a hyper-individualist consumer civilization. Our very identity is bound to our capacity to consume. This individuation, seemingly greedy, is responsible for our great growth rates, and rise in standards of living (not real income, but standards of living).
The onus to live a good life is on the individual, and no longer rests with any imaginary society. Health care, education, pensions, and all the rest of the known and predictable life-costs have to be managed and bourne by the individual. It may sound cruel, but, responsibility is the answer. Don't have a child unless you can afford the health care required. Don't smoke for 30 years, and expect the state to cover a lung transplant. Don't eat 8000 calories a day, and yada yada yada.
Any belief that big brother, or a national health care system should take care of everyone simply for the sake of the value of human life is ridiculous.
A system will take care of an individual, if that individual is deemed worthy. In our society, and individual is deemed worthy if they're employed, and receiving health care, or, if they privately pay for it. On top of that, we throw in a medicare/aid, which will soon be insolvent. There is no equality of humans...there is no equal access (to any good or service, I may add).
People need to take responsibility over their lives. It really is that simple. And, people need to re-calibrate their attitude towards death.

[anne]

"Well it was only due to trust of government that those elderly were left to die. No reason to cut a vacation short to help mom and dad, the State will take care of it. Of course, the State proved incompetent as usual."

Absolute rubbish and profoundly mean-spirited, just as always and evermore. Duh.

[Zorro]

To Bi Jian, have you never ever lived in a Democratic system? We selected our government to solve our country problems, to create an environment for us so that we can lead a peaceful lives etc. etc. We trust our government and we cast a vote to them. If the government can not take care of our wants then we will kick them out with our vote. Remember, US government do not become government by guns, but, by the people power. It is an elected government. If government is not to help its' citizens and people, why the hell we have it in the first place?

Another thing to BI Jian, we can have good days and we can have bad days. That's life. We help other people in need and other people also help us when we are in need. That's the meaning of community, or rather more, sociey. We live in a society and not in the hell hole. Nobody want to be in bad situation. Ask homeless people on the street that he want to live like that? What do you expect his answer will?

To people who think that US is funding other countris health care and things like that, cut that crap and put your over patriotic spirit in the cage. Go see the world and see how they do things. We can learn from them and see our imperfections. And also, our strength. The day somebody think that he is at the top and he don't need to learn from others is the day of his demise. That's I am sure.

Anyway, that's just my 2 cents.

[Zorro]

Sorry, I miss something.

To Bi Jian, US embraced you and let you in when you were in need. Do you see how somebody helping hand can change you very life?

[Jono]

I've lived in both Canada and the US (in the US, I lived in Pittsburgh, which has strong care by US standards).

Certainly, the line-ups are longer in Canada, but it's a matter of degree. I've had, and I know others who have had, comparable waits either to schedule a visit to a specialist or even to get into an emergency room. Actually, emergency room waits have been comparable in my experience.

However, it does seem to me this kind of argument is "playing the meaningless anecdote" game. And it's probably confused in other ways.

1. These are anecdotes. No one's presenting data on this.
2. Why focus on waiting time at all? What exactly is bad about waiting times? As far as I can see, two things could be bad about them: (i) the person waiting for care's condition could deteriorate; (ii) it wastes people's time (eg, emergency room line-ups). Given the stakes, (ii) seems like a trivial consideration to me, so I'll leave it aside.

So the problem with longer waiting times, I take it, is that people are essentially getting worse care--the wait could allow their condition to deteriorate. But if that's the argument, if we're worried about the quality of care and the health of recipients of health care, let's focus on outcomes. And by this metric, Canada mops the floor with the US.

In other words, granting that Canada has higher waiting times (though we don't know how much longer, since people making this charge seem generally averse to citing data), the relevance of waiting times are really just to quality of care, to the outcome. And other benefits of the Canadian system are proved by the data to far outweigh this disadvantage.

[Jono]

http://www.reason.com/news/show/29303.html:
Third, health care is a paperwork nightmare for patients, doctors, insurers, and employers. In 1999 The New England Journal of Medicine published a study that found it cost $300 billion annually to administer various health insurance plans. It takes some 3 million clerks and managers to run our health care system; that's nearly four times the number of doctors practicing medicine in the United States. It costs between $8 and $18 to file each insurance claim, and a third of them have to be refiled. In a survey published last year by the American Hospital Association's Trendwatch, 64 percent of doctors said they were either extremely or very concerned about the level of paperwork and administration they have to deal with."

More on this point (from http://content.healthaffairs.org/cgi/content/full/23/3/10):
"To quote economist Henry Aaron on this point: "Like many other observers, I look at the U.S. health care system and see an administrative monstrosity, a truly bizarre mélange of thousands of payers with payment systems that differ for no socially beneficial reason, as well as staggeringly complex public system with mind-boggling administered prices and other rules expressing distinctions that can only be regarded as weird."17

"Aaron’s comment was part of his response to a recent paper by Steffie Woolhandler, Terry Campbell, and David Himmelstein, who find that administrative costs for insurers, employers, and the providers of health care in the U.S. health system (not even including the time costs patients bear in choosing health insurance and claiming reimbursement) were "at least" $294.3 billion in 1999, or about 24 percent of total U.S. health spending.18"

And, importantly, the same kind of "over use" occurs among the insured in the US. Think about it. It costs me $10 to see a specialist in Pittsburgh compared to $0 in Canada. The $10 is no deterrent at all; if anything is going to deter me, it would be the time spent (probably 2hrs round trip, which is worth much more than $10). Here is data on this, from the same website:
"Employer-provided medical coverage is itself another major reason for the high cost of heath care. Rather than pay workers wages that will be taxed, companies use pre-tax dollars to purchase health insurance as a benefit. Instead of paying an employee $1,000 more in wages, of which $400 will be taxed away, companies purchase $1,000 in additional health insurance tax-free. In this way companies funnel more than $140 billion a year in federal tax breaks to their workers. The tax-free status of employer-provided health insurance encourages generous coverage that allows employees to ignore the prices of medical services, which in turn encourages providers to charge more and more. Employees, seeking to take advantage of their coverage, tend to overutilize the system, which also puts pressure on prices."

At least in Canada, though, you don't have providers who are "encouraged to charge more and more".

Now, as for the claim that higher R&D spending accounts for the (or most of the? or a significant part of the?) difference in per capita spending: as the article says, the Americans pay 187% per capita of what Canadians do. How much of these costs go into research? Here's how pharmaceutical companies spend on R&D:

"In 2002 the thirteen largest U.S. pharmaceutical companies allocated their sales revenue to particular objects of expenditures and profits as follows: cost of goods sold, 25.3 percent; selling and administration, 32.8 percent; R&D, 14 percent; taxes, 7.3 percent; and net after-tax profits, 20.6 percent." (http://content.healthaffairs.org/cgi/content/full/23/3/10)

Obviously this 14% plus some contributions to the salaries of researchers in universities won't account for the full extra 87%. (In fact, the article I link to above doesn't even consider this as a possible explanation of any significant part of the higher costs.)

[Enrico Palazo]

Is anne hilary clinton?