Paul Krugman: Prostates and Prejudices

Will the media call Rudi Giuliani on his repeated use of false claims to support is policy positions?:

Prostates and Prejudices, by Prostates and Prejudices, Commentary, NY Times: “My chance of surviving prostate cancer — and thank God I was cured of it — in the United States? Eighty-two percent,” says Rudy Giuliani in a new radio ad attacking Democratic plans for universal health care. “My chances of surviving prostate cancer in England? Only 44 percent, under socialized medicine.”

It would be a stunning comparison if it were true. But it isn’t. And thereby hangs a tale — one of scare tactics, of the character of a man who would be president and, I’m sorry to say, about what’s wrong with political news coverage. ... Mr. Giuliani’s claim is wrong on multiple levels — bogus numbers wrapped in an invalid comparison embedded in a smear.

Mr. Giuliani got his numbers from a recent article in City Journal, a publication of the conservative Manhattan Institute. The author gave no source for his numbers... And they’re just wrong.

You see, the actual survival rate in Britain is 74.4 percent. That still looks a bit lower than the U.S. rate, but the difference turns out to be mainly a statistical illusion. The ... chance of dying from prostate cancer is about the same in Britain as it is in America. So Mr. Giuliani’s supposed killer statistic about the defects of “socialized medicine” is entirely false...

Anyway, comparisons with Britain have absolutely nothing to do with what the Democrats are proposing. In Britain, doctors are government employees; despite what Mr. Giuliani is suggesting, none of the Democratic candidates have proposed to make American doctors work for the government.

As a fact-check in The Washington Post put it: “The Clinton health care plan” — which is very similar to the Edwards and Obama plans — “has more in common with the Massachusetts plan signed into law by Gov. Mitt Romney than the British National Health system.” Of course, this hasn’t stopped Mr. Romney from making similar smears...

But here’s what I don’t understand: Why isn’t Mr. Giuliani’s behavior here considered not just a case of bad policy analysis but a character issue?

For better or (mostly) for worse, political reporting is dominated by the search for the supposedly revealing incident, in which the candidate ... reveals his true character. And this incident surely seems to fit the bill.

Leave aside the fact that Mr. Giuliani is simply lying about what the Democrats are proposing; after all, Mitt Romney is doing the same thing.

But health care is the pre-eminent domestic issue for the 2008 election. Surely the American people deserve candidates who do their homework on the subject.

Yet what we actually have is the front-runner for the Republican nomination apparently basing his health-care views on something he read somewhere, which he believed without double-checking because it confirmed his prejudices.

By rights, then, Mr. Giuliani’s false claims about prostate cancer — which he has ... continued to repeat, along with some fresh false claims about breast cancer — should be a major political scandal. As far as I can tell, however, they aren’t being treated that way.

To be fair, there has been some news coverage of the prostate affair. But it’s only a tiny fraction of the coverage received by Hillary’s laugh and John Edwards’s haircut.

And much of the coverage seems weirdly diffident. Memo to editors: If a candidate says something completely false, it’s not “in dispute.” It’s not the case that “Democrats say” they’re not advocating British-style socialized medicine; they aren’t.

The fact is that the prostate affair is part of a pattern: Mr. Giuliani has a habit of saying things ... that are demonstrably untrue. And the American people have a right to know that.

It's blatant:

Rudy Campaign To Media: We're Going To Keep Lying About Health Care -- And There's Nothing You Can Do About It, by Greg Sargent: ...The Rudy campaign has now blithely confirmed that they are going to keep on telling this lie [about health care]. ...[C]heck out this little nugget at the end of the piece about Rudy spokesperson Maria Comella's response to all this:

Asked if Mr. Giuliani would continue to repeat the statistic, and if the advertisement would continue to run, Ms. Comella responded by e-mail: "Yes. We will."

Memo to media: Rudy and his campaign think you're a bunch of chumps. ... Maybe it's time to get serious about what this guy is up to. ...

Comments

[macquechoux]

I suggest readers Google, “lancet oncology cancer survival rates” for a starter. After 50 years of socialized medicine the UK not only lags the US but it also lags the rest of Europe.

Then Google, “lancet cancer survival rates US.” This headline about sums it up: Cancer Survival Rates Improving Across Europe, But Still Lagging Behind United States. If you read enough articles you will find that the US data includes both insured & uninsured.

After reading many articles I think it is fair to conclude that the medical community in the UK and much of Europe feel that the survival rates in the US are better.

[Lafayette]

Article: none of the Democratic candidates have proposed to make American doctors work for the government.

Ah, ha! We get right to the heart of the matter.

You see, Americans would like the same level of Health Care as in Europe -- most of which nations are in the top fifteen of a WHO classification whilst the US finds itself at an embarrassing 37th place, BUT just ahead of Cuba! (Anyway, everybody KNOWS that the WHO is a pinko-socialist organization camped in the hills overlooking Lake Geneva. Yet another venue for over-paid bureaucrats ... ;^)

So, what to do about the fact that Health Services cost in the US a whopping FOUR TIMES as much as Europe ? Yes, indeed, what to do?

Well, you do what most of Europe does -- you mandate the price of Health Care services so as to make them not only affordable but allow a decent income to health care practitioners.

And I will bore you once again with a fundamental fact that nobody cares to consider: Health Care, at its exaggerated cost in the US, is an indirect tax on disposable income. To believe its cost is "nothing" because insurance companies pay for Heath Care services is literally an illusion. American companies with program insurance must pay for the cost of that insurance, which they recuperate in their pricing of their products/services. So, American incomes don't go as far as they could were those costs less dear. Also, high Health Care costs makes for all those un- or semi-skilled jobs lost to the Far East or Latin America. (Not to mention, American-based companies that try to get around paying the cost of exorbitant Health Care insurance by hiring illegal migrants to do those same jobs.)

And why do the politicians NOT wish to mention the above? Because they are scared sh*tless of ruffling the feathers of the AMA and its K-street stormtroopers -- especially after what the latter did to Hillary when she tried to tackle the problem with her "socialized medicine".

If this article shows well the claptrap that Giuliani is mouthing, then he is a first-class dork.

[pgl]

Dean Baker blogged on this. As I said at Dean's place, Bush won in 2000 as he got away with lies as well. Rudy is assuming that our press does the same pathetic job this time around. So far - he's right.

[mark]

More than 70,000 Britons will have treatment abroad this year – a figure that is forecast to rise to almost 200,000 by the end of the decade. Patients needing major heart surgery, hip operations and cataracts are using the internet to book operations to be carried out thousands of miles away.

India is the most popular destination for surgery, followed by Hungary, Turkey, Germany, Malaysia, Poland and Spain. But dozens more countries are attracting custom. Research by the Treatment Abroad website shows that Britons have travelled to 112 foreign hospitals, based in 48 countries, to find safe, affordable treatment.

Yep, that the equivalent of say 350,000 U.S. citizens seeking medical care abroad.

Looks like Thoma stewing in Krugmans chicken in every pot.

[save_the_rustbelt]

Truth be known, given how diagnoses are listed and how death certificates are prepared (inconsistently)it is likely neither country has a really solid number for death due to prostate cancer.

If the initial diagnosis is listed as an elevated PSA test, then a huge number of men over 60 would be counted, although probably very few of them die of prostate cancer.

So, who is right? Probably not Rudy. Probably not Krugman. Probably no one has solid numbers.

And Rudy is still a dangerous nasty man.

[Bernard Yomtov]

More than 70,000 Britons will have treatment abroad this year – a figure that is forecast to rise to almost 200,000 by the end of the decade.

OK. You don't like Krugman, or the UK NHS, or something. But what bearing does this have on the subject of the column Mark Thoma quotes? Does it make Giuliani's statement true? Does it mean it's OK for him to lie?

Or is citing the latest conservative talking point just a conditioned reflex whenever the subject of health care comes up, regardless of whether it actually has anything to do with the topic at hand?

[busakisama]

So in a presidential election where ALL (I must emphasize ALL) the candidates are blatant, flipant, flighty fools we are subjected to hit pieces from both sides about why their candidate(s) are the lesser of evils? This is absurd. Not one of the Repulicrats has been consistent on their issues. If Clitoooooon though it would get more votes she'd vote to pave the ocean. Zoolander, oops I mean Mitt, though his side was for abortion on demand he'd run on that platform (again). This is all smoke and mirrors.

Oh and by the way Lafayette, I don't want Europeeeeaan healthcare. Socialized medicine for everyone is a lovely ploy in politics, after all it's for the Chiiiiiildreeen who are apparently dying by the bushel in gutters in the US. If, and this is a big IF, we could guarantee the best people would still be doctors after socialization of medicine (and yes that is where it will end up maybe not now but in the future, hopefully after i'm dead) then fine, but they won't.

This country, and the world in general, needs an lobotomy.

[Holly W.]

Aside from Giuliani's exaggerations, I notice that when people want to criticize socialized medicine, they always choose the UK or Canadian systems -- they never try to make comparisons between the US and, say, France or Germany, or even Australia. France and Germany are considered to have two of the best healthcare systems in the world, so this kind of cherry-picking is clearly disingenuous in the first place.

[Gil]

If Rudy wants to blame anything, how about technological advancement? If he was diagnosed around 1800 with prostate cancer, his chances would be rather grim (assuming doctors back then could diagnose prostate cancer) regardless of how free any market was or how much rich he would be.

[reason]

Busakisaaaaamaa,

The best people are the greediest?

(By the way do you understand what single payer means? It is not the doctors who would lose out under single payer, but the middle men - the health funds and the payment clerks).

[Esben]

Mark said: "More than 70,000 Britons will have treatment abroad this year – a figure that is forecast to rise to almost 200,000 by the end of the decade [...] Yep, that the equivalent of say 350,000 U.S. citizens seeking medical care abroad."

Mark, is this supposed to be interesting or relevant? How many of these alleged 70,000 brits go for life threatening treatment and how many go for stuff like, say, dentistry or cosmetic surgery, neither of which is covered in the UK? Also do you know that 350,000 US Citizens do NOT go abroad for medical care? Because framkly, I would consider that very likely.

So all in all there is nothing in your numbers which tell us anything about the British system doing any worse than the American.

Perhaps you can elaborate as to what all this is supposed to tell us?

[anne]

"More than [2 count 'em 2] Britons will have treatment abroad this year...."

This is meaningless rubbish with neither precise source nor precise definition nor precise explanation of the supposed data. The point is always to deceive, with the intent of masking any possible approach to recognition and resolution of a social problem.

I counted however, and there were exactly 2 Britons who flew to India to be treated in India for the dread Indian flu which would be otherwise left untreated by Indian flu fearful British doctors.

[reason]

The fact that people are prepared to pay and travel in order to avoid delays in (or refused) treatment will happen regardless of whether you have a single payer system or not. And long as somebody bears the cost and is not prepared to bear any cost, somebody will be willing to seek out an alternative. That says nothing about the effectiveness of the system as a whole. Do you know how many of the foreign treatments that were sought were
a. Effective
b. Necessary?

[Richard A.]

Did Giuliani ever have a prostate in the first place?
http://youtube.com/watch?v=4IrE6FMpai8

[Holly W.]

60 Minutes covered Americans going abroad for medical services a couple years ago -- some of them were uninsured, but others were going for elective procedures their insurance wouldn't cover, because the cost was so much lower outside of the US. And most of them were going to India, too.

In addition, I read an article last winter -- was it here or just in the paper? -- about how insurance companies in states that border Mexico are encouraging their members to go get medical services in Mexico because it costs so much less and the care is supposed to be just as good. What comment does that make on the US system?

Yesterday's NYT editorial page says, under "America's Lagging Health Care System":
Americans are increasingly frustrated about the subpar performance of this country’s fragmented health care system, and with good reason. A new survey of patients in seven industrialized nations underscores just how badly sick Americans fare compared with patients in other nations. One-third of the American respondents felt their system is so dysfunctional that it needs to be rebuilt completely — the highest rate in any country surveyed. The system was given poor scores both by low-income, uninsured patients and by many higher-income patients.

The survey, the latest in a series from the Commonwealth Fund, is being published today on the Web site of Health Affairs, a respected health policy journal. Researchers interviewed some 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom and the United States.

[Alex Tolley]

Holly, you beat me to it. Here is teh Full nytimes editorial:

"November 1, 2007
Editorial
America’s Lagging Health Care System

Americans are increasingly frustrated about the subpar performance of this country’s fragmented health care system, and with good reason. A new survey of patients in seven industrialized nations underscores just how badly sick Americans fare compared with patients in other nations. One-third of the American respondents felt their system is so dysfunctional that it needs to be rebuilt completely — the highest rate in any country surveyed. The system was given poor scores both by low-income, uninsured patients and by many higher-income patients.

The survey, the latest in a series from the Commonwealth Fund, is being published today on the Web site of Health Affairs, a respected health policy journal. Researchers interviewed some 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom and the United States.

Given the large number of people uninsured or poorly insured in this country, it was no surprise that Americans were the most likely to go without care because of costs. Fully 37 percent of the American respondents said that they chose not to visit a doctor when sick, skipped a recommended test or treatment or failed to fill a prescription in the past year because of the cost — well above the rates in other countries.

Patients here were more likely to get appointments quickly for elective surgery than those in nearly all the other countries. But access to primary care doctors, the mainstay of medical practice, was often rocky. Only half of the American adults were able to see a doctor the same day that they became sick or the day after, a worse showing than in all the other countries except Canada. Getting care on nights and weekends was problematic.

Often the care here was substandard. Americans reported the highest rate of lab test errors and the second-highest rate of medical or medication errors.

The findings underscore the need to ensure that all Americans have quick access to a primary care doctor and the need for universal health coverage — so that all patients can afford the care they need. That’s what all of the presidential candidates should be talking about. "

[Alex Tolley]

Irrespective of the merits of different systems, if Americans are generally unsatisfied with their h/c system, then shouldn't we seriously consider fixing what is broken instead of saying "it ain't broke, it works just great,"?

IMO - the insurance industry is the biggest problem. A plethora of policies with fine print loopholes, cherry-picking enrolees, denial of consistent coverage, denial of coverage when used. This system is just broken.

candidates should avoid the confrontation with insurers that feel they are entitled to continue to do business, by appealing to business groups. Pay some income taxes to cover employees, but take the burden of h/c insurance of f their backs. Large companies with gold-plated policies built into their costs should go for it. Small business that cannot offer h/c insurance because of costs should find that appealing too. Individual entrepreneurs would give their right arms for group cover. Make insurance what is is for - to take away the risk of financial ruin if you need treatment. It doesn't have to be "one size fits all", but it does have to be simple, clear and guaranteed. You get sick, you get fully covered except for the co-pays.

[save_the_rustbelt]

"(By the way do you understand what single payer means? It is not the doctors who would lose out under single payer, but the middle men - the health funds and the payment clerks)."

Sorry, but that is not true. Physicians will lose ( a few will win, most will lose). Count on it.

[save_the_rustbelt]

Speaking of a prostate exam...........

Highmark offers the ultimate get-well card
Friday, November 02, 2007
By Bill Toland, Pittsburgh Post-Gazette

Just in time for the holidays, you'll be able to buy Dad a gift card that pays for his semiannual trip to the urologist.

That's gotta rank below socks and underpants, no?

But Highmark Inc., the Pittsburgh-based health insurer, hopes its new Healthcare Gift Card will encourage people who might be reluctant to visit the doctor or spend their money on prescriptions -- namely, seniors and college students -- to do so.

The card itself costs $4.95, and can be loaded with as little as $25, which might cover a prescription co-pay, to as much as $5,000, which could pay for an elective surgery, such as Lasik.

"Ultimately, we think this product may go national," said Kim Bellard, Highmark's vice president of e-marketing and consumer relations. He expects other insurers will be interested in using the "intellectual technology," which Highmark hopes to patent.

"We do expect other people to follow," he said. "We certainly expect phone calls from other Blues plans. ... I would love to get a phone call from AARP.".................

[Karl Smith]

Few people seem to point out the fact that perhaps our spending on health care doesn't yield results because health care has little effect on health.

Not only are genetics and lifestyle such dominate factors but there ought to be substitution effects. If you think you will survive a heart attack you are probably less likely to stick to the heart healthy diet your doctor prescribed.

[Jay]

Tell me when Krugman does an article on how elevated U.S. infant mortality rates are a statistical artifact, because there is a greater prevalence of high risk (low weight) births in the U.S. than in other nations.
Krugman is right on this, but is very selective(biased) of what statistics he attacks.

[RW]

"Few people seem to point out the fact that perhaps our spending on health care doesn't yield results because health care has little effect on health."

My guess is people don't point to it because it doesn't make much sense. In a well functioning health care system genetics and lifestyle are as amenable to guidance or intervention as accident and acute illness are and no one who has ever experienced a heart attack would dream of repeating the experience for the sake of indulging in a high-risk diet.

In a poorly functioning system that forces uninsured citizens to use the emergency room as a primary provider and also commonly denies necessary procedures to insured citizens as well then, of course, genetics and lifestyle will doubtless prove at least as dominant a factor as poverty and ignorance.

[Bruce Wilder]

StRB: "Physicians will lose . . ."

Two points:

1.) Physicians, generally, feel that they have already lost.
a.) Once the door was opened (by Republicans) to "managed care" by for-profit insurance companies, physicians were plunged into an "arms race" between their billing offices and insurance company systems of claim review, which the physician could never win.
b.) American doctors are still very well-compensated, a leftover of the long era, when the evolution of the institutional structure of American medicine favored the position of the Doctor in independent, private practice. That era is over, and physician incomes will erode, are already being eroded -- it is as if Doctors belonged to a declining Union, which has agreed to a two-tier compensation scheme, in which senior workers get the old deal, and new hires are screwed -- a not uncommon pattern.
c.) The perversity of for-profit insurance company-driven "managed care" review of resource utilization and standards of care, notwithstanding, the era of the unsupervised physician in private practice is over and gone. Going forward, the practice of medicine will be bureaucratized, for the same fundamental reason an auto assembly plant is bureaucratized: for all the annoyance and stress involved, it is the only way to achieve high-quality, and high-productivity. Being a doctor, when medicine was an art and a craft was a lot more fun than being a doctor in this brave new world, but there's no going back.

2.) Physicians, especially younger physicians, are fully aware of 1.), and resigned to it. The sociology of being a doctor has changed radically in the last 20 years, and the kind of people, who become doctors and their expectations have changed as well.
"Socialized medicine" does not sound so bad to younger doctors, because any kind of single-payer framework is going to allow the evolution of what I am calling the "bureaucracy" of medical practice -- the scheme for organizing medicine not as a craft, but as a standardized, hierarchically-managed service -- to continue in direction, which is less perverse and frustrating and destructive.
This change in attitude, and the weakening of physician-opposition to many aspects of medical reform, is one major reason something major might actually go forward.

[Bruce Wilder]

The rhetorical combat between Democrats and Republicans on this issue, as on so many, is going to be a great example of how cynical Republicans use the Ideal and the Perfect, as a club and a switchblade knife, to destroy the Good.

The shameless lying is a tactic, not the strategy. The strategy is to create a alternative-reality fantasy, where the lies are true, and Republicans feel good about themselves and their country. It is a very powerful strategy.

Everyone, who has ever done any public speaking, knows the necessity and power of praising your audience, and knows that the praise that works well can be the most transparently insipid lie -- "I know I stand before the best class in the history of Middlevale Community College" charms, every time.

Republican claims that the U.S. has the best health care in the world, charms its intended audience. It is a lie, but the fact that it is a lie does not diminish its charm. And, the truth is not charming.

Democrats do indeed have a serious obstacle to overcome in a Media, which is owned and controlled by the Plutocracy, and in which the profession of journalism has failed to maintain any kind of standard of practice.

But, they also have to find a rhetorical jiu-jitsu, which will inoculate the American people against the charm of Republican lies.

[anne]

This is deceiving rubbish:

"Tell me when ------- does an article on how elevated U.S. infant mortality rates are a statistical artifact, because there is a greater prevalence of high risk (low weight) births in the U.S. than in other nations."

This is the truth:

"Tell me when ------- does an article on how elevated U.S. infant mortality rates are in the South as Medicaid services have been reduced for pregnant women."

[Hederman]

"This is deceiving rubbish:

"Tell me when ------- does an article on how elevated U.S. infant mortality rates are a statistical artifact, because there is a greater prevalence of high risk (low weight) births in the U.S. than in other nations."

Well, there have been published studies in the medical profession that look at US infant morality b/c of the high risk birthrate, the higher pre-term birth rate and the more active attempts to save at-risk babies. So it's not rubbish at all. A better response, would be say the cut in Medicaid services could be a causation of the low-weight birth rate. Or the fact that prenatal care services could be improved for low-income pregnant women etc.

Calling it rubbish is willfully ignoring published studies.

[save_the_rustbelt]

Bruce W:

If insurer managed care is not good for Americans, wait until we get the ultimate in managed care, government care.

We need to be careful what we wish for.

[Patricia Shannon]

The U.S. is 42nd in life expectancy.
More than 10,000 people (I have seen figures ranging from 14,000 - 90,000) DIE every year because they don't have health insurance.

A few years ago, when I was working as a waitress, and poor, I got a terrible case of food poisoning at a different restaurant, like I have never had before or since. I was yelling in pain for hours in my bed. I was in too much pain to drive myself to the emergency room, but I didn't call an ambulance because of the cost. I was pretty sure, because of the timing, that it was food poisoning, but it did cross my mind that I could have appendicitis or some other serious emergency. By morning, the pain was pretty much cleared up, except for pain from the muscle strains caused by the powerful spasms.

In the last couple of years, I read about the case of a teenager who died from a brain infection that started with an abcessed tooth, when his parents couldn't afford dental care.

Some years ago, Parade magazine had a short article on the results of personality tests on medical students. The highest ranking value was desire for status. The second was sadism! (This was one of those one-inch items, no information on what this specifically meant.) The third ranking (which I thought would be first or second) was desire for money. I found this very credible from my own experience of doctors. A change in the types of people who become doctors could be a good thing.

[anne]

This is deceiving rubbish:

"Tell me when ------- does an article on how elevated U.S. infant mortality rates are a statistical artifact...."

Artifactually speaking, that is.

[Holly W.]

STR: Physicians will lose ( a few will win, most will lose). Count on it.

Not arguing with you, but aren't physicians kind of losing under the current system, anyway? I thought I've heard recently that doctor unhappiness is at an all-time high, partly due to insurance companies trying to tell them how to run their businesses.

[Holly W.]

Oops, I see Bruce Wilder beat me to this!

[Icarus]

Hederman...I would ignore anne and the use of the word 'rubbish'. It means nothing analytically. Neither does 'cruel' by the way. These are easy words to dismiss real questions.

We're glossing over a potential solution here, which is medical tourism, and a more open market for health care services. Right now, it's in its nascent phase, but, it will only grow. There are numerous clinic/hospitals in India right now, and more being constructed, due to the influx of european/canadian/american patients eager to get procedures done (not just elective) faster than their mollasses like system allows for.

This may be the right answer...it addresses costs effectively, and, it's difficult to sue, so litigation fears don't raise costs even further.

Perhaps in the near future, we can have medical facilities parked 3 miles offshore (literally), which offer procedures for a better price.

That way, the medical consumer can be encouraged. That is, a person who proactively takes care of themselves, and manages their own health, their own health care costs, and even some of the logistics.

I agree with some of the above statements...labelling "health care" a right, despite costs, leads to poor behavior. Right now, the US is obese, and lazy. Health indices will obvioiusly spiral downward.

[save_the_rustbelt]

Holly (and Bruce):

Bruce does a good job identifying trends, but his reading is that the trends are well advanced, I don't think so.

There are differences:

1) primary care versus specialty
2) surgical specialties versus non-surgical
3) private practice versus employed
4) geographical (the mix of insurers is different)
5) physicians offering diverse services (ambulatory surgery, imaging centers, etc.)
6) cerain special specialties (the plastic surgeons are making tons of money implanting you-know-whats)

So while Bruce gets the trends the progress of the trends differs greatly.

[Gavin Kennedy]

It is not quite true that 'doctors in the UK work for the government'.

General Practitioners (GPs) who work in the community, are all self-employed in the UK and have been so since the NHS was founded in 1949.

They own their 'surgeries', employ staff such as nurses, cletks and receptionists, and provide their services to patients, who can choose which GP to register with. They vary their income to their partnerships by the amount of work they undertake.

The NHS buys their services by independent contracts with them. They are not employed by the NHS. Their professional conduct is monitored by the General Medical Council, an independent professional body and they are represented by the BMA (British Medical Association) which is in all but name their 'trade union'.

[Karl Smith]

In a well functioning health care system genetics and lifestyle are as amenable to guidance or intervention as accident and acute illness are and no one who has ever experienced a heart attack would dream of repeating the experience for the sake of indulging in a high-risk diet.

Except that this is not true.

The much acclaimed UCLA health insurance study shows no effect of health care (not just insurance but health care itself) on health outcomes.

The number of people who refuse to alter lifestyle even after being diagnosed with chronic illness are quite high.

On a personal note, if you like those, my father had 5 heart attacks and died with a cigarette in one hand and a cherry coke in the other.

Education even after controling for insurance is the strongest determinant of health. The most likely explination is that both education and healthy lifestyle require a personality that gives up immediate gain for long term benefit.

I'll even bet that if you ask your doctor what the most important things you can do for your health are, he or she will mention common sense lifestyle changes, not throwing a bunch of money at your body.

There are a few cases were health care can make a big difference but most people don't get sick and die of exotic diseases diagnosed by Dr. House and a team of wiz kids.

They die or heart disease, stroke or lung cancer. They die of smoking, obesity and lack of excercise.

[Esben]

Of course many people are idiots when it comes to health. And in general health care is probably one of the areas where economic incentives are the LEAST effective. Staying healthy or not, is not an economic decisions based on whether you can afford to get sick or not. It is a decision based on will power and self discipline and whether you have much to live for (which is why any right wing politician saying that having free health care doesn't give people enough incentive to stay healthy is an idiot).

But whether you have self discipline or not, it is always better for your life expectancy to have health coverage, than not have it. Even if you don't follow your doctor's advice you might still get his treatment.

[Bruce Wilder]

StRB: "the progress of the trends differs greatly"

I wouldn't necessarily argue with StRB on this -- but, my argument would not be that the "trends" are "well-advanced", per se, but that the trends I identified are recognized and mostly accepted by doctors as "the way things are going".

As far as progress on the ground is concerned, I think the general state of things is profoundly mixed, as StRB indicates, "mixed" to the point of chaotic breakdown. For physicians, who have not retreated completely to salaried positions, the business side of their business, even if they are currently raking it in, seems wildly uncertain. Technological innovation in the organization of medical care, such as the advances in medical record-keeping, just add to the experience of chaos.

Politically, the trends I identified really should be seen not as "well-advanced" on the ground, but, rather, as an expectation of hope amid chaos.

Students of revolution will tell you that revolutions take off, when people are fed, first, the expectation of improvement thru change, followed by disappointment in the pace of improvement.

[Patricia Shanon]

My father, like many others, has not followed a healthy lifestyle, and had a heart attack a couple of years ago. Because of health care, he survived. (Luckily, he has good genes, so he didn't get the heart attack until he was in his 80's. He's 85 now.)

Many people with kidney disease are alive because of dialysis.

Our chances of getting cancer are about 1/3. Many of those are skin cancer, which is easily cured if you can afford medical care in time.

Many/most of us wouldn't have survived childhood, we wouldn't even be conceived because our parents wouldn't have survived childhood, if it weren't for vaccinations against diseases that used to kill infants and children.

As has been suggested by other comments, many poor people have few sources of healthy pleasure, and so don't find life worth living w/o their unhealthy pleasures.

Also, most people are unrealistically optimistic. This factor can be helpful to health, by avoiding the effects on the body of prolonged stress, but it can also cause people to not take seriously the need to change some of their unhealthy habits.

Anyway, all of us have habits we should change, but we are humans, not perfect. And as exemplified by many comments on this blog, a normal trait of humans is to judge others faults more harshly than our own.

[Bruce Wilder]

StRB: "If insurer managed care is not good for Americans, wait until we get the ultimate in managed care, government care.

We need to be careful what we wish for."

Do you write these things yourself, StRB? Or, do you have a bot to generate them, on some irregular interval? For me, these posts don't pass Turing's Test.

[ScentOfViolets]

Karl, just what, specifically, are the facts the study purports to show that would lead to this conclusion? Was this a differential comparison between health care programs where early detection and intervention was encouraged vs wait until more invasive care is needed? Or was it something else?

If it was the former, I'd say you'd have a point. If it was anything else, I'd wonder how such conclusions could be reached.

[James Killus]

Ah well, since no one else has pointed it out...

The U.K. spends less than half of what the U.S. does on health care per capita. The fact that there is any argument at all in comparing the two says that the U.S. system sucks. The U.K. also has pretty close to the worst health care in Western Europe.

I took macquechoux's advice and found first, that his particular search has largely been "Google-bombed" by right-wing think tanks peddling propaganda. If you dig a bit deeper into cancer survival epidemiology, you will find a substantial debate amongst people who actually do epidemiology (as opposed to those who cherry-pick results for talking points and outright lies) about the way that early detection of cancer affects statistics in ways that are not necessarily indicative of beneficial outcomes. One is that early detection sometimes catches slow growing tumors that would never grow to be life-threatening. Prostate cancer in particular is notorious for this, but there have been indications that CAT scans for lung cancer and frequent mammograms may also be subject to this phenomenon.

The second worry is a purely statistical artifact. Cancer survival is usually analyzed as "time of survival after diagnosis" statistic (with "five year survival rates" being an often arbitrary, and erroneous, measure of being "cancer free", but if you diagnose a cancer early, you have added time to the survival statistic, even if there is no treatment.

The best indication that the early-detection-and-treatment medical standard is better lies in the differences in population mortality outcomes for people in the U.S. who have access to medical care vs those who don't. And there is some difference, for most cancers, just not nearly as great as the other sorts of statistics would indicate.

Of course, such differences for overall incidence and mortality statistics among different U.S. populations is a damning indictment of the U.S. health care system in itself, though I'm sure that there are those here who believe that the uninsured are getting no worse than they deserve. In fact, I'll bet that there are some who think that the uninsured are getting a free ride. After all, they can always haul themselves down to the emergency room to die.

[save_the_rustbelt]

Bruce:

We agree on the trends, if not the stage. I think we are a bit away from chaos, but there is definitely pressure, and the docs talk constantly. The greatest gossip land in the world is the OR scrub sink.

Gee, I write this stuff myself. Maybe concise writing is hard to read after reading some stuff we see here frequently :)) Not referring to you, of course.

I often write in breaks from other action, with little time. Being concise is an asset.

It is pot roast night, so I must be off, treasures await.

[spencer]

One of the point about the British system of National Health that keeps being ignored in all the discussion of British health-care is the point that in addition to National Health the UK has a fully functioning private health care system that operates along side the public National Health system. So any comparison of the British results incorporates the public system that cares for the poor and middle class and the private system that cares for those that can afford it.

This seems to be one of the best kept secrets in the discussion of various health care systems/

For example, the blogs recently discussed the case of British medical tourism. But all those who pointed to this with alarm failed to point out that all the British medical tourist were rejecting a purely private system as well as the public system.

Has anyone seen any responsible studies of the cost of the British private health-care system? I have no idea how the British private health-care system compares to the public systems or other systems. Does anyone else have any ideas?

[RW]

"The much acclaimed UCLA health insurance study shows no effect of health care (not just insurance but health care itself) on health outcomes."

Which 'acclaimed' UCLA study are you referring to? The UCLA Center for Health Policy Research (http://www.healthpolicy.ucla.edu/) has conducted quite a few major studies and as far as I am aware has never issued a conclusion that sounds even vaguely like "health care shows no effect on health outcomes." Such a notion frankly appears absurd on its face.

This 2002 press release (available http://tinyurl.com/2n46t9) announcing one of their major studies is typical: "Although there are costs to ensuring that all residents have coverage, there are greater costs associated with a large portion of our population remaining uninsured – lost earnings, lost school days, lost potential and lost life," said Thomas Rice, study co-author and professor of health services in the UCLA School of Public Health.

What source are you citing for that conclusion, precisely? I strongly doubt it is actually from UCLA or from any other primary research source if it comes to that.

[TurnKey]

The guy who wrote the article that Rudy cites responded thus:

"So why do the critics think that Britain’s survival rates are as high as America’s? The main reason is that they are citing overall mortality rates, which are indeed, as Ezra Klein writes, similar across various countries. That is, the percentage of all Americans who die from prostate cancer is similar to the percentage of all Britons who do. But this misses the point, since a much higher percentage of Americans than Britons are diagnosed with prostate cancer in the first place. If you are a patient already diagnosed with prostate cancer, like Rudy Giuliani, your chances of survival—as Giuliani correctly said—are far higher in the United States."

[JRossi]

A few comments from a family physician:
UK cancer death rates are higher than the European average, probably at least in part because of their health care system. Of course few in this country want to replicate the UK system. France and Germany have better models.

Prostate cancer is a heterogeneous disorder whose survival depends on the grade and stage of the disease, as well as on the aggressiveness of screening. Exuberant screening (think US) could lead to detection of indolent cancers that would never kill the pt even without treatment, thereby lowering apparent death rates.I'd be hesitant to believe Giuliani absent the references.

Karl Smith is correct that marginal health care spending in the US, given the current level of health care spending, probably has relatively little effect on population death rates. Surprised? Goggle "NEJM we can do better" for free access to an interesting article. I have not seen the data on morbidity. And of course in many individual cases HC is life-saving or life-extending.

RW, Sorry but Smith is right. Genetics and lifestyle are not very amenable to modification by the HCS, at least at this time.

Bruce Wilder is correct the a lot of MDs feel that they have already lost. Definitely true here in family-practice-internal medicine-land. But I'm 47 and unqualified for anything else. And it's still a pretty good job--compared with other jobs. Some of the med students and younger docs have a well-developed social ethos and are less money-oriented, but a lot are hoping to take the dermatology-radiology cure (lots of $$$, not so much work). I precept first-year University of Washington med students a half-day per week. The last 4 hoped-for specialties: orthopedics, family medicine (yeah), neuro-radiology, dermatology. It might or might not work out for them.

Save the rustbelt is right that the new realities are only slowly dawning on the medical community. But then again prospective med students know about buttering bread--see above. In a few years the next cohort might morph into prospective business students or attorneys. As a guy who's getting older I sure hope not.

[anne]

http://krugman.blogs.nytimes.com/2007/11/02/socialized-rudy/

November 2, 2007

Socialized Rudy
By Paul Krugman

Sure enough, Rudy Giuliani got his prostate treatment from a government-run insurance plan, very similar to the plans that would be available to all Americans under the Democratic health care proposals. Joe Conason has the goods. *

http://salon.com/opinion/conason/2007/11/02/healthcare_lies/index_np.html

[anne]

"The much acclaimed UCLA health insurance study shows no effect of health care (not just insurance but health care itself) on health outcomes."

Good grief; and I turned away from faith healing when I was 5. Sort of like asking a faith healer why she wears glasses.

[anne]

Spencer:

"One of the points about the British system of National Health that keeps being ignored in all the discussion of British health-care is the point that in addition to National Health the UK has a fully functioning private health care system that operates along side the public National Health system. So any comparison of the British results incorporates the public system that cares for the poor and middle class and the private system that cares for those that can afford it.

"This seems to be one of the best kept secrets in the discussion of various health care systems."

Precisely; but we prefer not knowing such things. Where by the way is the documented reference on the British fleeing to India to be treated for the Indian flu? The point seems to be to know nothing and pretend everything.

[anne]

J Rossi:

"UK cancer death rates are higher than the European average, probably at least in part because of their health care system."

Please set down any reference that comes to mind, when possible. I have trouble understanding if this is so or why this should be so.

[anne]

http://www.guardian.co.uk/print/0,,330604749-103690,00.html

August 21, 2007

UK Cancer Survival Rates Lagging Most of Europe
By Polly Curtis - Guardian

Cancer survival rates in the UK are trailing behind much of the continent and in some cases struggling to stay ahead of eastern European countries despite significantly more funding, according to a study published today.

The government was left defending its cancer strategy last night after a damning editorial published alongside the findings in the Lancet Oncology medical journal suggested the cancer plans introduced in England in 2000 and Scotland in 2001 are not working and that remedying the problem would take a fundamental overhaul of NHS services.

Cancer charities blamed the poor results on deficient radiotherapy services and the fact that people are still waiting too long after discovering a lump or another sign of cancer to see a doctor.

The survey of cancer survival rates of 2.7 million people with cancer across Europe, Eurocare, shows that the gap between the highest survival rates, in the Nordic north and the lowest, mainly in eastern countries including Poland, is narrowing. But those in the UK remain stubbornly low.

The research suggests that if all countries were achieving the survival rates of the most successful Nordic countries, then there would be 12% fewer deaths across Europe - 150,000.

Survival rates for people diagnosed with breast cancer in 2000-02 were 77.8% in England, 77.3% in Scotland and 78.4% in Wales. In Iceland women in the same period had a 93.4% survival rate and in Sweden 86.3%. The Lancet Oncology says: "Overall, survival for all cancers combined in the UK as a whole is not only below the European average, it is also noticeably similar to some eastern European countries that spend less than one third of the UK's per capita healthcare budget." Addressing the problem would require "fundamental reassessment of the ways in which the NHS operates".

The British researchers involved in the paper said the cancer strategies had not been in place long enough to improve services for the patients in the study. The cancer tsar for England, Mike Richards, suggested that the shortcomings were down to late diagnosis of many cancers rather than poorer treatments.

Ian Kunkler, from the Edinburgh Cancer Centre and a co-author of one of the reports, said: "The research shows that survival rates are improving overall particularly for colorectal, breast, thyroid and prostate cancers. But within the UK if you look at breast cancer there's still a difference of 8.5% of five-year survival rates compared with Sweden. England is still behind. But the effect of the national cancer plan introduced in 2000 is unlikely to be seen in this particular study. The dividends are unlikely to show that fast."

Richard Sullivan, director of clinical programmes at Cancer Research UK, said: "We're improving but we're still chasing the northern European countries....

[anne]

http://www.thelancet.com/journals/lanonc/article/PIIS1470204507702462/abstract

September 2007

Recent Cancer Survival in Europe: a 2000–02 Period Analysis of EUROCARE-4 Data
By Dr Arduino Verdecchia PhD, Silvia Francisci, Hermann Brenner MD, Gemma Gatta MD, Andrea Micheli PhD, Lucia Mangone MD and Ian Kunkler FRCPE

Summary

Background

Traditional cancer-survival analyses provide data on cancer management at the beginning of a study period, and are often not relevant to current practice because they refer to survival of patients treated with older regimens that might no longer be used. Therefore, shortening the delay in providing survival estimates is desirable. Period analysis can estimate cancer survival by the use of recent data. We aimed to apply the period-analysis method to data that were collected by European cancer registries to estimate recent survival by country and cancer site, and to assess survival changes in Europe. We also compared our findings with data on cancer survival in the USA from the US SEER (Surveillance, Epidemiology, and End Results) programme.

Methods

We analysed survival data for patients diagnosed with cancer in 2000–02, collected from 47 of the European cancer registries participating in the EUROCARE-4 study. 5-year period relative survival for patients diagnosed in 2000–02 was estimated as the product of interval-specific relative survival values of cohorts with different lengths of follow-up. 5-year survival profiles for patients diagnosed in 2000–02 were estimated for the European mean and for five European regions, and findings were compared with US SEER registry data for patients diagnosed in 2000–02. A 5-year survival profile for patients diagnosed in 1991–2002 and a 10-year survival profile for patients diagnosed in 1997–2002 were also estimated by the period method for all malignancies, by geographical area, and by cancer site....

[Patricia Shannon]

So we don't know whether the British are getting diagnosed sooner or really dying more often of cancer.
What would be helpful in making comparisons is rates of death in differenct countries by age.

[anne]

http://www.thelancet.com/journals/lanonc/article/PIIS1470204507702450/abstract

September, 2007

Survival for Eight Major Cancers and All Cancers Combined for European Adults Diagnosed in 1995–99: Results of the EUROCARE-4 Study
By Dr Franco Berrino MD, Roberta De Angelis BS, Milena Sant MD, Stefano Rosso MD, Magdalena B Lasota MD, Jan W Coebergh MD and Mariano Santaquilani

Summary

Background

EUROCARE is the largest population-based cooperative study on survival of patients with cancer. The EUROCARE project aims to regularly monitor, analyse, and explain survival trends and between-country differences in survival. This report (EUROCARE-4) presents survival data for eight selected cancer sites and for all cancers combined, diagnosed in adult (aged ≥15 years) Europeans in 1995–99 and followed up until the end of 2003.

Methods

We analysed data from 83 cancer registries in 23 European countries on 2 699 086 adult cancer cases that were diagnosed in 1995–99 and followed up to December, 2003. We calculated country-specific and mean-weighted age-adjusted 5-year relative survival for eight major cancers. Additionally, case-mix-adjusted 5-year survival for all cancers combined was calculated by countries ranked by total national expenditure on health (TNEH). Changes to survival were analysed relative to cases diagnosed in 1990–94.

Findings

Mean age-adjusted 5-year relative survival for colorectal (53·8% [95% CI 53·3–54·1]), lung (12·3% [12·1–12·5]), breast (78·9% [78·6–79·2]), prostate (75·7% [75·2–76·2]), and ovarian (36·3% [35·7–37·0]) cancer was highest in Nordic countries (except Denmark) and central Europe, intermediate in southern Europe, lower in the UK and Ireland, and worst in eastern Europe....

[anne]

http://www.thelancet.com/journals/lanonc/article/PIIS1470204507702462/abstract

August 21, 2007

Recent Cancer Survival in Europe: a 2000–02 Period Analysis of EUROCARE-4 Data

Findings

For all cancers, age-adjusted 5-year period survival improved for patients diagnosed in 2000–02, especially for patients with colorectal, breast, prostate, and thyroid cancer, Hodgkin's disease, and non-Hodgkin lymphoma. The European mean age-adjusted 5-year survival calculated by the period method for 2000–02 was high for testicular cancer (97·3% [95% CI 96·4–98·2]), melanoma (86·1% [84·3–88·0]), thyroid cancer (83·2% [80·9–85·6]), Hodgkin's disease (81·4% [78·9–84·1]), female breast cancer (79·0% [78·1–80·0]), corpus uteri (78·0% [76·2–79·9]), and prostate cancer (77·5% [76·5–78·6]); and low for stomach cancer (24·9% [23·7–26·2]), chronic myeloid leukaemia (32·2% [29·0–35·7]), acute myeloid leukaemia (14·8% [13·4–16·4]), and lung cancer (10·9% [10·5–11·4]).

Survival for patients diagnosed in 2000–02 was generally highest for those in northern European countries and lowest for those in eastern European countries, although, patients in eastern European had the highest improvement in survival for major cancer sites during 1991–2002 (colorectal cancer from 30·3% [28·3–32·5] to 44·7% [42·8–46·7]; breast cancer from 60% [57·2–63·0] to 73·9% [71·7–76·2]; for prostate cancer from 39·5% [35·0–44·6] to 68·0% [64·2–72·1]).

For all solid tumours, with the exception of stomach, testicular, and soft-tissue cancers, survival for patients diagnosed in 2000–02 was higher in the US SEER registries than for the European mean.

For haematological malignancies, data from US SEER registries and the European mean were comparable in 2000–02, except for non-Hodgkin lymphoma.

Interpretation

Cancer-service infrastructure, prevention and screening programmes, access to diagnostic and treatment facilities, tumour-site-specific protocols, multidisciplinary management, application of evidence-based clinical guidelines, and recruitment to clinical trials probably account for most of the differences that we noted in outcomes.

[RW]

JRossi, sorry, but your recapitulation of Smith's comments is not in fact what Smith said -- 'not very amenable' is not the same as 'none' -- but the NEJM source you referred to does not even support your more generous interpretation of Smith's assertion. Granted it's not a primary study but I am willing to grant the NEJM as authoritative so let's use it.

That article by Steven A. Schroeder, "We Can Do Better — Improving the Health of the American People" (N Engl J Med 2007;357:1221-8. © 2007 Massachusetts Medical Society) agrees neither with the conclusion Smith cited nor your characterization of that conclusion nor with the broader right-wing trope that the US has a superior health care system than those socialized monstrosities in other developed countries (why that would matter when health care apparently has no impact on health outcomes is a paradox I will leave to minds more 'flexible' than mine).

To quote Dr. Schroeder, "[T]he united states spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox? The two-part answer is deceptively simple — first, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care."

Now I'm sure I don't need to parse this in detail but the statement "not generally depend" does not mean "has no effect on" and his immediately following statement immediately excludes a more restrictive interpretation of "not generally" since, rather trivially, it is obvious that health care must have an effect on outcome because people suffer from either not receiving health care or when it is of poor quality. The article goes on to reinforce this by making it clear that health care does indeed have a major impact on a number of health outcomes but behavior and genetics are indeed resistant categories (not entirely devoid of progress however). To quote Dr. Schroeder again:

"In my view, there is room for cautious optimism. One reason is that despite the epidemics of HIV–AIDS and obesity, our population has never been healthier, even though it lags behind so many other countries. The gain has come from improvements in personal behavior (e.g., tobacco control), social and environmental factors (e.g., reduced rates of homicide and motor-vehicle accidents and the introduction of fluoridated water), and medical care (e.g., vaccines and cardiovascular drugs). The largest potential for further improvement in population health lies in behavioral risk factors, especially smoking and obesity. We already have tools at hand to make progress in tobacco control, and some of these tools are applicable to obesity."

Note that Schroeder explicitly refers to favorable changes in behavior in the above. So we can either play more semantic games here or agree that health care does indeed have an impact on health outcomes and that statements to the contrary are untrue or, less charitably, intentionally misleading. I am quite willing to concede that impact may not as great with reference to behavior ('lifestyle choices') or genetics as I thought although that is, anecdotally, contrary to my own experience and the experiences of people I know, most of whom have either successfully modified behavior or counteracted the effect of medically unfavorable genes (in the case of one colleague, both).

[Jay]

These posts are hilarious.
It is getting to the point that for some people the statement "All health outcome differentials can be explained by varying degrees of government interference in the process of consuming health care services" is as dogmatic a belief as a faithful theist who believes "All outcome differentials can be explained by God".

Would someone please tell me when it became acceptable to begin modeling a complex system by saying F(x) = ax + b + error, ALL OTHER THINGS HELD EQUAL?

[anne]

Notice:

a.

“My chance of surviving prostate cancer — and thank God I was cured of it — in the United States? Eighty-two percent,” says Rudy Giuliani in a new radio ad attacking Democratic plans for universal health care. “My chances of surviving prostate cancer in England? Only 44 percent, under socialized medicine.”

b.

"The European mean age-adjusted 5-year survival calculated by the period method for 2000–02 was high for...prostate cancer (77·5% [76·5–78·6])...."

c.

Survival for patients diagnosed in 2000–02 was generally highest for those in northern European countries and lowest for those in eastern European countries, although, patients in eastern European had the highest improvement in survival for major cancer sites during 1991–2002 (prostate cancer from 39·5% [35·0–44·6] to 68·0% [64·2–72·1]).

[Patricia Shannon]

http://www.eurekalert.org/pub_releases/2007-11/cf-uam103007.php

US adults most likely to report medical errors and skip needed care due to costs
International survey finds one-third of US adults call for completely rebuilding the health care system
Washington, DC, October 31, 2007—At a time when the U.S. spends more than double what other countries spend for medical care—$6,697 per capita in 2005—a new Commonwealth Fund seven-nation survey finds that U.S. patients are more likely to report experiencing medical errors, to go without care because of costs, and to say that the health care system needs to be rebuilt completely. U.S. patients, along with Canadians, are also the least likely to be able to get a same-day appointment with their physicians when sick and the most likely to seek care in emergency rooms as an alternative. The study, published today in a Web Exclusive in the journal Health Affairs, finds that U.S. adults also have the highest out-of-pocket costs and greatest problems paying medical bills.

In the survey of 12,000 adults in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States, one third of U.S. adults called for rebuilding the system, the highest rate in any country surveyed. The U.S. also ranked last in saying only minor changes are needed in the health system.

In addition to cost concerns, U.S. patients report more fragmented and inefficient care, including medical record and test delays, perceptions of waste and more time spent on paperwork, compared to patients in other countries.

In terms of patient safety, adults in the U.S. report the highest rates of lab test errors and among the highest rates of medical or medication errors. Patient-reported errors were highest for those seeing multiple doctors or with multiple chronic illnesses. One-third of U.S. patients with chronic conditions reported a medical, medication, or test error in the past two years.

Despite assertions by some that universal insurance systems result in long waits for care or “rationing,” only Canada (22%) ranked behind the U.S. (30%) in the low percentage of patients saying they could get same-day appointments with their doctor when they are sick. In contrast, half or more of patients in Germany, the Netherlands, and New Zealand report rapid access to physicians. Notably, in the U.S and Canada, along with Australia, two-thirds or more reported difficulty getting care on nights, weekends, or holidays—the highest rates in the survey.

Easy access to elective surgery has also been cited as a benefit of the U.S. health care system. Yet, similar to the U.S., the majority of patients in Germany, New Zealand, and Australia waited less than a month for elective or non-emergency surgery and waits of 6 months or more were rare in these countries and the Netherlands. In Canada and the U.K., about 15 percent of patients reported waits of more than six months for elective or non-emergency surgery. In the U.K., waits dropped dramatically compared with the 2001 Commonwealth Fund International Health Policy Survey, when 28 percent reported waiting more than six months for elective surgery.

[ilsm]

Lafayette points out the important obvious, missed by Krugman and many.

Cancer survival is about .001% of a weighting factor to measure "success" of any national (the US has none) "health delivery system". The US is 37th using a more broad metric.

It is like arguing that at $700 B a year we are not spending enough on defense.

If you look at maiximizing the far right tail of the spending distribution you will always pay too much and get too little.

The CONservation argument is we need to be best at cancer survival, or star wars.

Even though neither amnount to anything significant in the grand scheme of what is good for the 99% of the US population not making a lot of money on war machine profits or health industry dividends.

Not to go too far off, but the US is incredibly superior in several useless military techniques, not only star wras, but hot shot figter aircraft, aircraft carriers, amphibious assault ships (no one else has any much less 12), stealth everything, airmobile tanks (no one else here), huge cargo aircraft that can land in places where there is no fuel for them to take off (again unique to the US profit machine), I could go on.

But maximize the left tail and that is wht you get.

Extremism in the work of impoverishing the American citizen is a seldom recognized virtue.

And yes the US' top 1% in income accumulation is quite large in themselves.

The great con.....................

[anne]

Patricia, thank you for the survey.

Ilsm, I agree as I am sure Paul Krugman does but nonetheless this is an important issue to understand for it will be fiercely fought over.

[jefff]

"TurnKey says...

The guy who wrote the article that Rudy cites responded thus:"

Wow. That is.... exactly what I would expect from the denizen of a right wing think tank.

"But, but... see in this narrow technical sense, if we add a few words to what he actually did say, he wasn't lying and neither am I!"

[zinc]

Guilliani told the American people a huge, bald face lie and probably knew he was lying when he told it. This is not the first lie he has told to scare the American dumb Bunnies and he intends to keep telling this lie. Mitt Romney is of the same ilk.

Now, pay attention. Don't get up in the Republican talking points.

[JRossi]

Rw, I'm glad you have learned that the impact of health care is less than you thought it was.

[RW]

JRossi, and far greater than you (and Smith) asserted.

[Lafayette]

Well, this subject has really and truly stirred up a hornet's nest around here, hasn't it.

It's a good sign that something in this subject touches all of us ... deeply. That's a good sign. Let's hope the luminaries presenting themselves as saviours of the nation's soul as presidential candidates take heed.

Doctors recognize that a patient cannot be cured until they themselves understand they are sick. Health Care systems are subject to the same rule.

We can get to the moon. We can waste billions in a useless desert war. But, we can't seem to put together a decent system of Health Care that is available to all Americans at a reasonable cost.

And, we have the hubris to think we are a "developed" nation? Yeah, right ...

[James Killus]

It is getting to the point that for some people the statement "All health outcome differentials can be explained by varying degrees of government interference in the process of consuming health care services" is as dogmatic a belief as a faithful theist who believes "All outcome differentials can be explained by God".

Would someone please tell me when it became acceptable to begin modeling a complex system by saying F(x) = ax + b + error, ALL OTHER THINGS HELD EQUAL?

Probably at about the same time that responding to the arguments of "some people" became the standard manner making a point in argumentation.

And I'll miss you most of all, some people.--Dorothy

[Lafayette]

From « Accounting for the Cost of Health Care in the US”
(McKinsey & Co.)

The United States spends more of its income on health care than other developed countries and that share is rising. It is an arresting statistic that the U.S. now spends more on health care than it does on food.

In this new report MGI finds that the United States spends approximately $480 billion ($1,600 per capita) more on health care than other OECD countries and that additional spending is not explained by a higher disease burden; the research shows that the U.S. population is not significantly sicker than the other countries studied.

Instead, MGI found that the overriding cause of high U.S. health care costs is the failure of the intermediation system — payors, employers, and government — to provide sufficient incentives to patients and consumers to be value–conscious in their demand decisions, and to regulate the necessary incentives to promote rational use by providers and suppliers.

Given the less than optimal access for all U.S. citizens (relative to peer countries), MGI concludes that major opportunities for cost improvement —even if not the full $480 billion—are as possible as they are necessary although no single reform is likely to succeed in achieving the needed rebalancing. To be effective, reform in health care will need to apply sound principles on both the demand and supply side of the system.

This presumes that the present system of "private enterprise" health insurance should be maintained. If the best Health Care systems in the world are government run (like Defense or Education), maybe America should also consider that route?

At least as an alternative? Can't we find a mechanism that will allow private practice doctors to work either regimes -- patients covered by private insurance and patients covered by an extension of Medicaid.

That is, Medicaid extension to all Americans who want it? And, we require ALL employers to provide either coverage? But, Medicaid will mandate the price of practitioner services? GPs can opt for either or both in their practice?

What GPs loose at the high end (program insurance) they will recuperate at the low-end -- more patients will seek services earlier. This will certainly lower overall Health Care costs, since prevention is less costly than curative medicine. Less traumatic for the patient as well.

[Lafayette]

Here's a document, from the Cato Institute, regarding the WHO worldwide study of Health Care systems.

Rightist journalism deserves its play in the sun. As you will see the journalist hammers away at the "methodology" employed and then derives the conclusion that the WHO "had an agenda". (No doubt, trying to develop a methodology that would show credibly a ranking of systems does require some tinkering with the data and also the manner in which it is collected.)

Still, the WHO conclusion, that the US is 37th on a long list of 191 countries in a ranking of Health Care Systems is probably supported by anyone who has ever had to use the American system but could not afford to do so. Meaning this: The "greatest country in the world" does not even make it into the top tenth percentile of the ranking.

What the author (of the above linked article) overlooks is that the WHO DID have a primary weighting factor in their analyses -- and it was "access" (meaning easy availability) of Health Care services. And, there, by any measure, the US is in piss-poor standing.

In the country of Uncle Sam, if one doesn't have insurance and is also seriously ill ... they are roadkill on the highway of life. Hospital Emergency Room care is the practice of palliative medicine and neither preventive nor curative health care.

Where is the social justice of having some of the best Medical Technology in the world, if only the comparatively richer have the insurance with which to pay for it? An insurance, btw, that is recuperated from the pricing of products/services that even those who do not have Health Care insurance must purchase in order to live. Meaning they pay for the insurance without even benefiting from it.

NB: Please, no rabid comments about the Cato Institute. We all know well on which side of the political divide their sentiments lie.

[ilsm]

Lafayette,

Thank you.

[anne]

Having read carefully through the Lancet studies referenced, along with a research physician, the Manhattan Institute lied about treatment efficacy for prostate cancer in Britain and Europe, and Rudi Giuliani is reciting the lie. As usual, rightists simply echo any lie that suggests we might improve health care in America. Paul Krugman was as usual right.

But, the Giuliani ad will continue to run and the argument shows just how difficult it will be to make clear the need and possibility of significantly improving the American health care system. Simply shout "socialism," and rightists try to set an end to reasonable discussion. there is a perversity here I do not understand.

What is interesting in looking carefully at the treatment efficacy for cancer as a whole is just well the Nordic countries do, and the gains that are being made by eastern European counties.

[anne]

Notice:

a.

"My chance of surviving prostate cancer — and thank God I was cured of it — in the United States? Eighty-two percent," says Rudy Giuliani in a new radio ad attacking Democratic plans for universal health care. "My chances of surviving prostate cancer in England? Only 44 percent, under socialized medicine."

It would be a stunning comparison if it were true. But it isn't....

You see, the actual survival rate in Britain is 74.4 percent. That still looks a bit lower than the U.S. rate, but the difference turns out to be mainly a statistical illusion.... *

b.

The European mean age-adjusted 5-year relative survival for 1995–99 for prostate cancer was 75·7% [75·2–76·2], highest in Nordic countries (except Denmark) and central Europe, intermediate in southern Europe, lower in the UK and Ireland, and worst in eastern Europe. **

b.

The European mean age-adjusted 5-year relative survival for 2000–02 for prostate cancer was 77·5% [76·5–78·6]. ***

c.

Survival for patients diagnosed in 2000–02 was generally highest for those in northern European countries and lowest for those in eastern European countries, although, patients in eastern European had the highest improvement in survival for major cancer sites during 1991–2002.

Eastern European prostate cancer survival for 1991-2002 improved from 39·5% [35·0–44·6] to 68·0% [64·2–72·1]. ***

*http://www.nytimes.com/2007/11/02/opinion/02krugman.html
** http://www.thelancet.com/journals/lanonc/article/PIIS1470204507702450/abstract
*** http://www.thelancet.com/journals/lanonc/article/PIIS1470204507702462/abstract

[anne]

What will have to be overcome for meaningful health care change, as for meaning domestic social or foreign policy change, are meticulously false data and the immediate rightist propaganda cries as socialized this and socialized that, and far worse shouts, which are meant to stop thought and discussion on change. We went to war and are occupying another country because of falseness and propaganda, so terrifying people about becoming ill in Sweden is simple for rightists of no ethics.

[Cyrille]

OK, before I say that I will acknowledge that in politics you tend to tweak things just a little bit. But:

I am a chess player, and if I want to check that one of my potential move is better than another one, I try to estimate the situation following the BEST reply in each case.
Whereas in the US, all comparisons to Europe are actually with the UK, and never in terms of costs but in terms of efficacy. Whereas it is reckoned here that the British system is the worst European one in term of quality (it may well be better than the US one anyway, but I can't be sure of that) -though the best by some distance in terms of affordability.

It really is like saying that USA are colder than, say, Poland because Krakow is warmer than Anchorage. Or the US denser than Western Europe because New Jersey is denser than Sweden.

[save_the_rustbelt]

I don;t think anyone has good statistics on prostate mortality, due to the fact that elderly men tend to have multiple diagnosis, and death certificates are not prepared consistently.

And Rudy is still scary, with or without statistics.

[ScentOfViolets]

Actually, I haven't seen any evidence for JRossi's position; unless I missed it, I didn't see any comparisons between different health care strategies. What I saw was a single slice, and the breakdowns in that single slice.

How is this 'evidence'?

And of course, as a measure, no one has argued convincingly that it's a particularly good one. You might as well say that the US is the best health care provider based upon the number of breast augmentations, collagen injections and tummy tucks.

[save_the_rustbelt]

"Some of the med students and younger docs have a well-developed social ethos and are less money-oriented, but a lot are hoping to take the dermatology-radiology cure (lots of $$$, not so much work). "

I've negotiated contracts with some of these young docs, and they tend to shift attitudes over time. :)) Barracuda!

Joke in medical circles - a dermatologist is a doctor who is not smart enough to operate a pager, but doesn't need one anyway. (hey, I didn't write this)

[RW]

ScentOfViolets, you didn't miss JRossi's evidence because he presented none and the article he referenced not only did not support Karl Smith's (JRossi endorsed) absurd contention, that "health care has no impact on health outcomes," it directly refuted it as did executive summaries of two of the large-scale UCLA studies I examined; I assume Smith was thinking of one of these UCLA reports when he made his argument but, perhaps not surprisingly, he never explicitly referenced the putative research he was presumably citing.

OTOH I did find some modest support for the notion that health care has less impact on human behavior than I originally surmised and probably a more modest impact on death rate than would normally be expected; the impact is greater than JRossi proposed (Smith's position now being discredited) but JRossi doesn't appear to have been speaking completely out of school, at least as far as I could tell.

It was actually not a bad discussion from my POV and forced me to do some homework that cured a few misunderstandings I had but also left me even more convinced that the health care system in the United States is fundamentally and irremediably dysfunctional in its current corporate dominated form w/ a single payer system on the French or German model being the gold standard against which all reform proposals should be gauged; i.e., even John Edward's proposal doesn't go far enough IMO.

[anne]

http://content.nejm.org/cgi/content/full/357/12/1221

September 20, 2007

We Can Do Better — Improving the Health of the American People
By Steven A. Schroeder, M.D.

The United States spends more on health care than any other nation in the world, yet it ranks poorly on nearly every measure of health status. How can this be? What explains this apparent paradox?

The two-part answer is deceptively simple — first, the pathways to better health do not generally depend on better health care, and second, even in those instances in which health care is important, too many Americans do not receive it, receive it too late, or receive poor-quality care. In this lecture, I first summarize where the United States stands in international rankings of health status. Next, using the concept of determinants of premature death as a key measure of health status, I discuss pathways to improvement, emphasizing lessons learned from tobacco control and acknowledging the reality that better health (lower mortality and a higher level of functioning) cannot be achieved without paying greater attention to poor Americans....

[anne]

Remember, when we discuss health care and effect. We have just had both a cut in Medicaid coverage for disabled adults and children and a denial of health care coverage for 3.8 needy children through SCHIP. The Administration Medicaid cut for the disabled has received almost no attention, but a small majority of Congress attempted to restore the cut in the SCHIP bill the President vetoed and Congressional Republicans would not counter.

A mere $7 billion a year would have protected 3.8 million needy children, a cost both relatively insignificant and already covered. But, the helath care protection was denied.

[anne]

We have already experienced an increase in infant mortality in the South in the wake of Medicaid cuts that effect pregnant women, but imagine turning away from care of the needy disabled and children for the sake of an ideology that is beyond my understanding.

Another 11,000 workers for Chrysler will soon be dismissed and soon lose health insurance. Does this matter, politically?

[anne]

http://krugman.blogs.nytimes.com/2007/11/03/shape-of-the-planet/

November 3, 2007

Shape of the planet
By Paul Krugman

Yesterday I complained that news reports on Rudy Giuliani’s fake facts describe his position as “in dispute”, when it’s actually just false, and describe the truth as something “Democrats say” rather than as, simply, the truth.

I’ve said this before: *

"If a presidential candidate were to declare that the earth is flat, you would be sure to see a news analysis under the headline 'Shape of the Planet: Both Sides Have a Point.' "

The thing to notice is the date on that quote: November 1, 2000.

Have the news media learned nothing from the past 7 years?

* http://query.nytimes.com/gst/fullpage.html?res=9F0DE6DA1330F932A35752C1A9669C8B63

[ScentOfViolets]

RW, my thinking is that we have to compare this with a health care system that stresses prevention and early diagnoses. And this does not have to be in a strictly medical setting. One type of instance would be the PSA's that a lot of people seem to credit for the reduction in smoking and for the by now nearly universal practice of wearing seatbelts.

So, for example, what if there was a concerted campaign to implant the necessity of exercise in the national psyche? Not hokey ads like 'exercise is cool', or lame ads like 'all my friends exercise' or just plain bizarre ads that show buff young people engaging in impossibly intense workouts. But commonsense ads aimed at sedentary office types urging them to mallwalk, ads showing a couple of grannies walkin' and talkin' about their health while waving to pairs of grandpas out strolling the hood?

This wouldn't change the national health profile to any significant extent over a period of a year or so, or even a decade, but the long term effects, over a generation or so, could have the effect of saving hundreds of billions of dollars a year.

Oh, and I am one hundred percent behind levying drastic penalties on people who refuse to live even a moderately healthy lifestyle. People, as always, are free to do what they want. But a 400 lb man who consumes over 10,000 calories a day, most of it of the fatty sort, whose longest walk is from the parking lot to an indoor space, and then suffers an early heart attack despite repeated warnings? And he then rings up over $200,000 of medical bills?

Not. On. My. Dime. His kids can sue him for bad parenting for all I care.

[anne]

There are problems we need to be sensitve to. I think nothing of going a matter of blocks to a Whole Foods or Trader Joe's market, both of which have an array of fine food for prices that other than for special items match discount markets. The poorer you are in America however, the less likely you have access to low cost neighborhood markets, let alone to Whole Foods or Trader Joe's. Preaching to the poor for problems that are societal is no moral preaching at all.

Mark Thoma had to figure out how to properly and sensitively portray overweight women in poor Mississippi communities, and not stigmatize the women as lacking in will. We have a country when it is a simple matter to be hungry and malnourished and overweight.

[Icarus]

Anne...

Again with the overweight hungry people. When will anyone on the left ever embrace some ethic of individual responsibility, and stop looking to the state/federal government to regulate the basic day to day activities of our lives? It's preposterous.

Teach family planning, proper food intake, and basic exercise. Instead, you want to offer people public money to do the things any human should be able to self-regulate.

Obese people are hungry because they eat too much. This level of self-pity, self-indulgence, and self loathing is exactly what's the problem in america.

[anne]

Without relying on Paul Krugman, I was easily able to find reliable and interesting and important Lancet studies on cancer survival in Europe, and I understood at once that the Manhattan Institute research was a lie, not simply in error or deceptive but a lie. Immediately though, simply from headings, I noticed rightist echoes of the lie. Lie on lie.

We do not and cannot and will not care for needy disabled children, and ideological fiends worry about "socialized" medicine. As though any French children coulkd be so lacking in health care.

[anne]

"Again with the overweight hungry people. When will anyone on the left ever embrace some ethic of individual responsibility, and stop looking to the state/federal government to regulate the basic day to day activities of our lives? It's preposterous."

Simply notice the language.

[anne]

"A lot of donkeys are braying about Rudy Giuliani’s radio ad in which he has the audacity to applaud the American health care system."

Simply notice the language.

[anne]

"Looks like Thoma stewing in Krugman's chicken in every pot."

Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized Socialized

Simply notice the language.

[ScentOfViolets]

I'm sorry anne, but with the greatest of good faith, do you think these women are exercising? Real exercise, not five minutes of 'workouts' once every couple of weeks or so. If these no doubt virtuous ladies are walking/swimming/biking/etc for ten hours a week and they are still overweight, I wouldn't say that their condition is their fault.

But if they are not . . . well, they don't deserve to be stigmatized for their appearance certainly. But hypertension, joint breakdown, diabetes? That's all on them, and I certainly don't want to foot the bill for their folly.

[Icarus]

What I notice is Anne's language, and childishness.

Bush didn't choose to uninsure millions of children. That, in a nutshell, is deceptive language. We have a private insurance system, which needs to work. Parents have to budget child care costs effectively. Government is not a solution to every problem, and once the left understand that, the chances of more progressive results will improve.
Until then, these cries for socialized medicine will seem like the crazy rants of easily dismissible bloggers, like the one above.

Crazy rants...

[anne]

"Bush didn't choose to uninsure millions of children."

This is a lie, not ignorance however ignorant, not meanness however mean, but a horrid lie meant to foster ignorance and meanness. What the President has done is both deny Medicaid coverage to qualified disabled adults and children, and in addition to deny needy children SCHIP health care.

[anne]

SOV; I completely understand and am completely sympathetic to the need for education and emphasis on personal attention to health. I know however this can be a luxury, and I know of how complex the problem is, but have only respect for building to an increased emphasis on personal health.

[NLS]

Icarus,

You denounce socialized health care on the basis that fat people are fat because they can't stop eating and stupid people have kids they can't afford.

That really doesn't add to anything. Sure, throw out the Pima indians and all the genetic studies. Throw out the fact that kids are having kids, not because they can't plan, but because they are kids.

Then you could blame the fat people and the poor people for their problems. I guess I'm starting to see where you're coming from, a world of delusion.

Please keep abstaining from having kids. I sure don't want Kid Icaruses running around, unless it's on the 8-bit NES, of course.

[DJM]

I have read the comments and this point doesn't seem to have been made yet;

excerpt from;
Columnists Miss Chance to Educate on PSA Testing
http://www.gooznews.com/

"...thousands of American men are incorrectly diagnosed with prostate cancer each year. The prostate specific antigen (PSA) test has a very high false positive rate, identifying "tumors" that will never threaten patients' lives or well-being. Moreover, to "survive" that non-cancer, they are subjected to needless treatments -- costly operations, drugs, and/or radiation -- that leaves many of them impotent and incontinent. ...... Americans need to hear the message that many aspects of our vaunted "best health care system in the world" are wasteful when not downright harmful. And for men over a certain age -- about 70 -- they would be better off if they adopted a "watchful waiting" strategy if diagnosed with prostate cancer rather than letting their specialist docs operate, chemically castrate or radiate."

[DJM]

One question I have, for anyone who might have an idea, is how many "thorough autopsies" are performed on adults who have died of apparent natural causes.

Like STR said ; ...the fact that elderly men tend to have multiple diagnosis, and death certificates are not prepared consistently.

How many autopsies are done on the poor and uninsured unless there is cause to believe they died by homicide (out side of all the CSI shows) my assumption here is they could have some sort of cancer that wasn't diagnosed (and so not included in any statistics) because they could not afford medical care or the follow up care recommended in an emergency room visit....(the bottom line is still many of the treatments are just not available if you can't pay)

[Cyrille]

Icarus: "We have a private insurance system, which needs to work."

Well, that is not so. It doesn't NEED to work, because there are very good, and in fact vastly superior, alternatives, to a private insurance system.

[Syaloch]

ScentOfViolets:

"If these no doubt virtuous ladies are walking/swimming/biking/etc for ten hours a week..."

Are you kidding? I work only a single, 40 hour per week job, and have a spouse to split taking care of the kids, and I can't imagine the luxury of having ten hours a week for walking/swimming/biking.

If you're a single parent working two jobs to make ends meet? Uh, hello, could we please stay in touch with reality here?

[anne]

http://www.nytimes.com/2006/01/10/health/10pros.html

January 10, 2006

Report Casts Fresh Doubts on Prostate Cancer Testing
By NICHOLAS BAKALAR

Men who have been screened for prostate cancer by the most commonly used tests have no greater chance of surviving the disease than those who have not been screened at all, new research has found.

A report on the research, published yesterday in The Archives of Internal Medicine, found that neither a prostate specific antigen test, known as a P.S.A., nor a rectal examination worked to reduce deaths from prostate cancer.

The value of the screening has long been a matter of debate. A P.S.A. level can be abnormal even when a man does not have prostate cancer. But when an abnormal P.S.A. level is discovered, typically the next step is a biopsy.

Even a biopsy is inconclusive, however. The tissue samples from a negative screening, for example, may by chance have come from parts of the prostate that are free of cancerous cells.

Even if a cancer is found, an operation, which often causes erectile dysfunction and incontinence as side effects, may not be necessary since many cancers are so slow growing that they will never cause a problem.

Dr. John Concato, a researcher at the Veterans Affairs Connecticut Healthcare System and the lead author on the paper, stressed that a physician was obligated to clarify all the issues for patients.

"He should explain the benefits and risks, in the context of each patient's values," Dr. Concato said. "For example, some patients place such a high premium on avoiding incontinence and impotence that a positive P.S.A. test can be problematic."

The research involved nearly 72,000 men over 50 who received outpatient care at any of 10 Veterans Affairs hospitals in New England.

Of this group, the scientists identified 1,425 men with prostate cancer that was diagnosed from 1991 to 1995 and then studied the records of 501 patients who had died of the disease as of 1999.

For each case, the researchers randomly selected a living patient to be part of a control group.

Screening with P.S.A. had been performed for 70 of the men who died and for 65 men in the control group used for comparison.

If screening had been effective, a lower proportion of screened patients would have been found among the group of men who had died. But this was not the case.

An editorial accompanying the report states that 78 percent of male primary care physicians and 95 percent of urologists over 50 have themselves had at least one P.S.A. screening, so they apparently have decided that the test is useful....

[Lafayette]

JR: Karl Smith is correct that marginal health care spending in the US, given the current level of health care spending, probably has relatively little effect on population death rates.

Do you then mean that preventive HC is not worth much more than curative HC? Because, preventive HC in a country that does not have general HC coverage, as the US presently, could supposedly reduce considerably curative HC spending.

Or not? If prostrate cancer cannot be predicted, then other preventive methods are useless as well?

Just what are you inferring? Death rates are just one indication of general levels/quality of Health Care systems.