The Economist's Free Exchange urges caution about the finding that the income-health gradient is even steeper in Canada than it is in America:
If the best evidence is not very good, then we need to be careful about drawing hard conclusions, and more careful still about "screaming them from the rooftop." I thought that the combination of the qualifier "slightly" in the phrase "the health-income gradient is slightly steeper in Canada than it is in the U.S.", along with the questionable nature of the data was sufficient to give us pause before beginning to evangelise. Apparently, that's not the case.I would suggest that we ought to be very circumspect in analysing the health-income gradient--especially when making cross-country comparisons. For instance, research findings show that the health-income gradient is far flatter among Latinos--in general, Latinos are much healthier than their income levels imply. In America, Latinos make up a far larger share of the population than in Canada, and they are almost certainly overrepresented in the population of the uninsured. Have the NBER paper's authors taken such factors into consideration?
Research also shows that the income-health gradient for the population as a whole depends on the importance of within-group effects of income on health for subpopulations. If within-group effects are strong, then greater economic inequality between population subgroups can actually flatten the income-health gradient for the population as a whole.
It isn't easy to say how these different effects stack up, and that's entirely the point. Screaming from the rooftops inplies certainty of which there is none here. What we do know with certainty is that access to health insurance is more equitable in Canada, and total health outcomes are better in Canada. Without better data on the income-health gradient, I don't believe there is cause to question the arguments of those emphasising the equity benefits of single-payer systems.
Point well taken. Except . . . how come advocates for single-payer are so rarely interested in exploring these holes in the data when they support the argument for equity? Why don't we hear about the problems in cross-country comparisons of commonly used metrics such as infant mortality? Moreover, why doesn't the blogger mention that America also has a much higher percentage of African Americans, who, for reasons that are not clear, have higher mortality and premature birth rates even when things like income and education are controlled for?
You cannot argue, on the one hand, that cross country comparisons make it hard to really know whether Canada's income-health gradient is steeper; and then turn around and say that "for half what we spend, Canada offers insurance to all its citizens and produces better outcomes in practically every category listed: life expectancy at several ages, infant mortality, mortality from chronic conditions, mortality from various other diseases (including respiratory diseases, despite a higher rate of smoking), and so on." I agree that cross-country comparisons are fraught, though also, unfortunately, the best we have. But either you rely on that sort of data, or you don't; you can't use general arguments about the reliability of international data to dismiss specific studies that don't bolster your case.
"Why don't we hear about the problems in cross-country com-parisons of commonly used metrics such as infant mortality?"
We hear about it constantly, from Megan, John Stossel, and others. What we don't hear is whether the differences in the method of enumerating infant mortality are numerically significant. We also don't hear why Medicare, the single-payer system best known to Americans, is evil. And we don't know what she suggests retired auto workers do as their medical insurance slowly evaporates.
Well, of course "America also has a much higher percentage of African Americans" than Canada. America has higher percentages of hyphenated Americans of all types.
Wow, Cynic. Willfully ignorant and pedantic at the same time. Not an easy feat, that.
What we don't hear is whether the differences in the method of enumerating infant mortality are numerically significant.
They are. But more importantly, statistics like infant mortality rate and average life expectancy tell us virtually nothing about the quality of a nation's health care system. Costa Ricans live about as long as Americans, despite spending only about 5% as much per capita on health care, and having only half as many doctors per capita. Behavioral and environmental factors have a much greater impact on the health and longevity of a national population than the services provided by its health care system.
Mixner -
They are? Prove it, and don't use John Stossel as your source. Regarding your second point, do you really think preventive medical care is unimportant? My sister-in-law is alive because her ophthalmologist found a malignant but treatable tumor in her brain during a routine eye exam. Ditto for one of my brothers, but this time the tumor was in his colon. Ditto for me, when my arteries were seriously gunked up. If medical insurance is so unimportant, why is it one of the first things people ask about when they take a new job? Do you think medical insurance is unnecessary? Get real.
Stan wrote: If medical insurance is so unimportant, why is it one of the first things people ask about when they take a new job?
Where did he say anything at all about medical insurance, Sigmund Quixote? Also, you're at risk of making his point for him: Many cancers and arterial conditions have at least some origin in "behavioral and environmental factors" (which both defends his assertion and says nothing about individual blame). The benefits of having the technology to fix things that go wrong can be vastly outpaced by having a population that tends, for any number of reasons, not to become ill in the first place.
If the null hypothesis were true and all countries health care systems were equivalently ineffectual, that seems like a point against the U.S. system, given that it's the most expensive and the insidious employer/insurer connection serves as a drag on the economy.
The data are different. I took issue with the specific data used in the paper Tyler cited. Maybe you'll disagree, but I think we can put more stock in OECD counts of dead and sick people than we can in self-reported survey results. I thought about mentioning differences in the black population, and maybe I should have. But Latinos make up a larger share than blacks in the US, and are probably more heavily represented in the ranks of the uninsured than blacks. (Blacks make up 2% of the population in Canada, and Latinos 1%).
But hey, you're right: we should look critically at any of the data we come across, no matter which side it supports. Personally, I wish I could have written a much stronger post, but I went as far as the results I've seen let me.
how come advocates for single-payer are so rarely interested in exploring these holes in the data when they support the argument for equity?
Harry and Louise. If that's what the industry is prepared to stoop to, how much time do you really expect reform advocates to spend examining the holes in their own data and moderating their arguments in a responsible fashion?
Doesn't "petard" mean a bomb (as in "hoist by his own petard")? The only way I can make sense of a bomb one wears in the heading is to think of suicide bombers. But you don't seem to be suggesting that the Economist's Free Exchange is a terrorist entity (even metaphorically). Is this just a mistaken word or am I completely off-base here?
Carolyn
Carolyn: I think over the centuries, since the Shakespeare reference is the only continuing context, a lot of people have come to believe "petard" is some kind of funky neckwear, like an ascot. I think it's because "hoist" in modern usage immediately connotes being pulled up by something, rather than blown into the air, as in the Shakespeare.
If that's what the industry is prepared to stoop to, how much time do you really expect reform advocates to spend examining the holes in their own data and moderating their arguments in a responsible fashion?
I for one don't expect them to do any time at all doing that; I expect them to offer lame tu quoque excuses for not doing so, while claiming the moral high ground all the while. They rarely disappoint.
brooksfoe: Shakespeare may well have been using the phrase in the sense of being pulled up by or at least with something. Petards were often hoisted (lifted up suddenly) out of a trench, and then swung over to the gate to try and destroy the gate. If you where snagged in the ropes of the hoisting engine you could be pulled up by it and sent in to or near the gate with the bomb.
But seriously, why don't we hear about all the US citizens who go to Canada for medical treatments not available in the US? And I'm not talking about buying drugs that were manufactured in the US but cheaper in Canada. As long as those nice Canadians want to subsidize our drug costs I think we should let them.
Swen - I don't think the Canadians are subsidizing the drugs. They are forcing the drug companies to sell them for less.
Swen, you really nailed me. Obviously I should have said my brother had a colonoscopy. On your other point, the one about Canadians coming to the US for treatments not available at home, I don't know to what extent this occurs. Do you? And what does it prove? Everybody knows that Americans with good health insurance get good medical care. Does this require having so many uninsured? Will medical standards in Boston collapse because of the new Massachusetts medical insurance program? Do you really think medical care in western Europe is substandard? I'm waiting breathlessly for your answers.
The petard isn't quite an ascot. It is indeed a multi-defined word, depending on context. In the 'Hoist by his own petard" type, it would be a trap or plan to get the explosive (the petard) over to the gate to blow it at the right moment. As this was discovered by those on the other side, they'd set a counter-trap so that when they went to blow the petard (as in gunpowder blow, not the other), then the secondary trap would spring, hoisting the bomb engineer on his own petard (turn the tables as it were).
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