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Tuesday, April 10, 2007

Health Care: The U.S. versus Europe

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Update 2: Ezra Klein adds:

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

Does this kid know ANYTHING about American immigration patterns?

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

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

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

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

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

    Posted by on Tuesday, April 10, 2007 at 11:12 AM in Economics, Health Care, Policy | Permalink  TrackBack (0)  Comments (32)


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