News flash: health care costs so much because we consume so much, not because evil insurers are price-gouging:
Myth No. 1: Insurers' profits are responsible for our health care costs.This is the most pervasive and most crowd-pleasing of the health care myths. The profits of the big health insurance companies are central to the rhetoric of the health care debate, figuring heavily in the Democratic primary campaign. Barack Obama's platform includes a promise to force insurers to spend enough on care "instead of keeping exorbitant amounts for profits and administration." Michael Moore, the director of Sicko, has hammered the point repeatedly, thundering about how insurers maximize profits by "providing as little care as possible."
The problem here is that between them the five biggest health insurers—UnitedHealthCare, Wellpoint, Aetna, Humana, and Cigna—which cover 105 million members, last year had profits between them of $11.8 billion. This is not a small number; these are very profitable companies. But total U.S. health care costs last year were in the area of $2.3 trillion.
So, with a membership that included a little more than half of the Americans covered by private insurance, these five insurers' profits came to 0.5 percent of total health care costs. (One interesting point of comparison: In 2006, the income earned by the 50 biggest nonprofit hospitals alone came out at $4 billion.)
That seems like a fair analysis. The profits of five companies against the entirety of health care expenses for the U.S..
How about return on sales, or return on investment? And what about administrative overhead, which for most insurers comes to about 20% of premiums?
These are not trivial expenses. And the arguments for nationalized health care are only partly about cost.
Your post would be more convincing if you gave the CEO salaries for UnitedHealthCare and the other companies you mention.
I have never heard the argument that US health care spending is too high because of insurers' profits. The argument is that health care spending is too high because of insurers' administrative costs. Those are not 0.5% of total spending, but more like 20-25%. Much of that administration consists of their efforts to keep their reimbursement rates low.
Gimein is trying to shift the argument. It's not honest, but it is typical Slate "counterintuitive" pitch-selling stuff. "Hey editor, I can make it look like the conventional wisdom is wrong if I just kind of misstate what the conventional wisdom is!" "Sounds good. How about 2000 words, $1500?"
We consume so much? Are you sure? Why do we spend twice as much as any other civilized country with out any discernible benefit?
Much of that administration consists of their efforts to keep their reimbursement rates low.
This means that insurers are spending money to keep costs low. If they stopped spending that money, what do you suppose would happen to costs?
I suppose its possible that the entire industry has decided to spend a bunch of money for no reason; we're all just waiting for that brilliant middle manager to point out that premiums could be cut 1/5 with no effect on profits if only Kaiser would stop wasting money on "administration." But a more likely possibility is that all that spending has a positive ROI, which means lower costs for customers.
But if you disagree, do pass along your suggestions to your health insurer.
Stan,
Do you think those 5 CEOs make even $2 billion/year taken together?
Yeah, it sure seems like a huge source of costs in US medicine has to do with the endless cost-shifting fight between insurers/Medicare and providers. Thus, a bunch of doctor, nurse, pharmacist, and various receptionist/clerk time is spent filling out forms to justify why they should get paid, making phone calls for pre-authorization, etc. Another source of a lot of costs seems to be doctors' responding to the incentives from both insurance/Medicare and lawsuits by doing marginal tests and procedures and such, which get them paid and cover their a--es without doing a whole lot of good for patients. And another is the cost-shifting between different providers, like trying to get the hospital to take over care of the seriously ill nursing home patient for a few days, or the hospital trying to send her back to the nursing home ASAP to minimize costs. And then there's the whole nightmarishly bad idea of turning every emergency room in the country into an insanely expensive 24 hour free clinic which sometimes also treats some people who are seriously ill or injured.
I'm probably about as skeptical as Megan about whether giving everyone coverage will really fix any of these problems, though. That will solve some other problems (like having people go broke because their kid got seriously ill while they were out of work, which kinda sucks), but I don't see why it will fix costs. Has Medicare fixed rising medical care costs?
Instead of paying the CEOs and the administrative costs as part of health care, maybe we could just pay insurance carriers directly the profits they're now making and we could keep the difference.
That way we could cut costs, and yet the insurers would still make a profit. Win-win.
Hey, this magical thinking stuff is fun.
This means that insurers are spending money to keep costs low. If they stopped spending that money, what do you suppose would happen to costs? - Rob
What would happen is that they would lose the ability to discriminate out sick patients with high medical bills; sick patients with high medical bills would gravitate towards them; their reimbursement rates would skyrocket; and they would either have to hire more staff to discriminate those patients back out, thus raising their administrative costs again, or they would suck up the bottom of the barrel while their competitors skimmed the cream, and go bankrupt.
Insurance companies are in an administrative costs arms race. They have to do as well as their competitors at keeping away sick customers and fighting payment on drugs and procedures. It is not their "fault" that they discriminate against sick people; they don't do it because they're "evil". They do it because that is their business model -- that is just what their industry is, what it does.
The evil part comes where they convince themselves that their business is necessary and they are helping the American people, and then spend huge sums of money to convince citizens and politicians that they are the solution to the health care crisis rather than the problem. But you have to have some empathy for them; it's hard for anyone to admit, even to themselves, to being a parasite.
brooksfoe has it exactly right. It's all about administrative costs, and not just those borne by the insurers but also by the health care providers who have to navigate myriad labyrinthine plans, as other posters have noted. Japan and Taiwan spend per capita half of what the US does on health care, but still manage to insure their entire population and yield excellent health results. And to Joe Klein's c's point, this is all despite the fact that the Japanese populace, at least, is a voracious consumer of health care, with more doctor visits and tests, and longer hospital stays than U.S. patients. All Japanese insurers are nonprofit by law, and administrative costs in Japan are miniscule. A big reason Toyota decided to site a new plant in Canada rather than the US a couple of years ago was that there it would not have to bear the burden of providing health care for its workers. Our current health care system costs too much, doesn't give good results, and is making us economically uncompetitive. it's time to try something else. The track record of universal public health care systems around the world is far superior to that of "free market" alternatives, full-stop.
More math, please. There're some numbers in there: 105M members generated $11.8B profit. That's about $112/year/member. This is not insignificant. AND it's only profit, not total overhead.
The $2.3T number is meaningless, as it's a different population. What was the total spend of the 105M members of the top 5 companies?
Brooksfoe,
I gotta hand it to you, I have never seen anyone refute their own arguments as consistently as you do.
The $2.3 trillion consumers spend in health care costs has to go SOMEWHERE as someone's revenue. Someone has to be collecting that, whether it's insurers, hospitals, doctors, manufacturers, etc. I'd love to see a rigorous study that just followed the money.
And the study in Slate is asinine. In just that snippet, the author throws out numbers for PROFITS, COSTS, and INCOME and just sort of conflates them.
Yancey, why do you even bother typing something like that in? It doesn't have anything in it.
What would happen is that they would lose the ability to discriminate out sick patients with high medical bills
Now wait a second. We've been told over and over that a big part of the problem is that insurance is tied to employment, yet ERISA group plans cannot discriminate based on risk and therefore presumably don't spend vast sums in a futile effort to do so. So one of these premises must be incorrect.
But more importantly, the auto and homeowner's insurance industries use the same business model, yet we suffer from neither a car-care nor a house-cleaning "crisis."
The "crisis" here is that most people of all income levels do not want to pay prices commensurate with services rendered for health care. Some of them want free access to treatments they can't afford; others want free access to treatments they can afford, but feel affronted when asked to actually pay full price. Most of our problems (many of which are actually "problems") stem from this mentality.
Japan and Taiwan spend per capita half of what the US does on health care, but still manage to insure their entire population and yield excellent health results.
I don't suppose that could have anything at all to do with diet, lifestyle, or genetics, could it?
brooksfoe,
Sigh...
You asserted that costs are high overall because of the administrative efforts of insurance companies. When Rob points out that insurance companies could just cut out all their overhead and keep it as profit since it is having no effect on rate of return, you return with this classic:
In other words, you conceded the argument that the administrative costs incurred lowered the costs to their customers, and improves the companies profits.
Joe's Conscience: Well, for one thing, "health care expenditures" includes both incredibly expensive and statistically useless terminal care, and cosmetic care.
In a system where you don't have the option of paying $50-100k to keep Grandma alive for another few weeks, you, well, obviously won't. She dies earlier, but that's statistically unlikely to even be counted (since health stats for mortality tend to, from what I've seen, go by age - and the difference is unlikely to be significant in terms of old people making it to one more birthday).
So what the family might see as a large benefit appears on the stats as simply a giant expenditure for "no benefit".
(And stats, of course, show no benefit to "health" from cosmetic or non-seriously-health-impacting voluntary procedures, which still cost a lot. And still provide serious benefit to the consumers of such care, or they wouldn't pay for it.)
And that doesn't even touch the issue of comparing "national" expenditures of healthcare between a relatively free-market system and one with a national monopoly or near-monopoly (such as the NHS).
In one, people more-or-less choose to spend whatever amount of money they wish on healthcare (outside of the VA or Medicare systems), even if part or most of it is from insurance provided by their employers (since after all, such benefits are just replacements for salary).
In the other, the State decides how the rationing works, and who can get what services.
Brooksfoe: I believe Yancey meant that in the absence of evil health-care insurers, the State will "discriminate out expensive care, especially for terminal cases.
Thus reminding us that rationing of healthcare will happen one way or another - the big difference being whether it's the State or the individual's pocketbook doing the rationing.
Do try and explain how it is that it's the "industry" that doesn't want to throw unlimited losses at very sick people (and that this is "evil" somehow)... when the State will do the exact same thing, and does everywhere I've ever heard of that has State healthcare.
(And whether or not the State doing it will cause contraction in supply or quality, which seems to be the case damn near everywhere the State is in control.
The State, after all, has even less incentive than an "evil" insurer to try and serve the customer.
For that matter, "as little care as possible" seems to be a guiding light of the NHS and indeed any other central rationing system. Finite funding for infinite demand has that effect.)
Yancy,
brooksfoe is going to respond that although admin improves profits, it would be unnecessary in a universal system because there would be no use for actuaries. Everyone's covered, so risk discrimination is unnecessary, so the people who do it all get fired, lose their health insurance, and drive up costs by spreading untreated resistant TB to the rest of us.
My question in response to this argument is: how much is really spent to keep out sick people, given that ERISA plans (which are supposedly the majority) forbid risk-based pricing (but do allow exclusions for pre-existing conditions)? How much admin is devoted to fighting fraud or resisting unnecessary treatments, both essential cost-controlling functions in a universal system?
"I have never heard the argument that US health care spending is too high because of insurers' profits. The argument is that health care spending is too high because of insurers' administrative costs."-my pal, Brooksfoe
I suppose Brooksfoe thinks that governments are well-known for their low administrative costs. Actually, the truth is that for profit companies have ample incentive to contain costs, while government employees have very little, as for example, Nobel laureate Gordon Tullock has explained (see his book Government Failure).
Brooksfoe seems like a clever fellow, but he also seems all too willing to ignore the basic findings of economics when those findings conflict with his own statist predelictions.
Look. Health insurers routinely deny payment on a large percentage of doctors' claims, just to see whether the hospital or patient will actually press for them. They know some percentage of those claims will get dropped, and the extra time the appeal costs them is made up for by the reimbursals they don't have to make. So far so good -- some poor bastards are getting screwed, but savings should feed through into lower premiums. Except that hospitals and doctors just respond to this practice by raising fees uniformly to make up for the lost revenue. So now the procedures cost more, so there's even more incentive for insurers to routinely deny procedures. Now, one insurer could say, okay, forget it - we're firing that department that handles all the paperwork for the denials and appeals, that'll save us some money, we can lower premiums. Except hospitals won't drop the prices of procedures just because one insurer decided to stop stiffing them. Rather, that insurer who reimburses all comers will now be paying out more money than any other insurer, and their premiums will thus be higher, they'll lose customers, and so on.
Those huge administrative costs represent insurance companies trying to beat each other at insuring fewer sick people and reimbursing less care. No one insurer can stop doing either one of those things. They can only be stopped by government imposing community rating on the whole sector.
"I have never heard the argument that US health care spending is too high because of insurers' profits. The argument is that health care spending is too high because of insurers' administrative costs."-my pal, Brooksfoe
I suppose Brooksfoe thinks that governments are well-known for their low administrative costs. Actually, the truth is that for profit companies have ample incentive to contain costs, while government employees have very little as, for example, Nobel laureate Gordon Tullock has explained (see his book Government Failure).
Brooksfoe seems like a clever fellow, but he also seems all too willing to ignore the basic findings of economics when those findings conflict with his own statist predilections.
"A big reason Toyota decided to site a new plant in Canada rather than the US a couple of years ago was that there it would not have to bear the burden of providing health care for its workers."
Last week on this blog, this plant was sited in Canada rather than the US because US workers were illiterate. Could we also blame it on US workers dislike of hockey as well?
Brooks,
While you are usually very good - you missed it on this one. The vast majority of health insurance is sold to companies not to individuals - there is very little weeding out of sick patients going on. The weeding only occurs on the individual market, which is a small percentage of the total.
I tried to cancel the first post when I noticed the misspelling of predilection, but alas. Anyway, brooksfoe's response to Yancey, Rob and others who have been pointing out that insurance companies have a great deal of incentive to contain costs is this:
Perhaps he is unaware that this is a tired and oft-refuted idea in the history of economics--that competition is somehow wasteful and redundant and that government monopoly would be more efficient.
The intellectual poverty of that idea is one reason why John Kenneth Galbraith has fallen into such disrepute in the profession. In general, competition reduces price and increases quality, which is why, as David Wessel points out in the Journal today, even Democrats have moved away from statist solutions to some extent (though not enough).
Does the conversation have to be as theoretical as this?
We have real-world examples of governments with universal health care, whether this is nationalized health care or nationalized health insurance.
Japan, Canada, and several countries in Europe come to mind.
So in spite of the fact that we know that government can be extremely inefficient, we also know that governments in countries with heath care systems which provide a life expectancy and level of health that is comparable to ours.
Another major difference in the aforementioned countries is that health care is available to everyone, and this is better in my view.
So what's the problem with these counties? Is there something going on in these countries that we don't want to happen here?
Why wouldn't we be able to get similar results?
"Brooksfoe seems like a clever fellow, but he also seems all too willing to ignore the basic findings of economics when those findings conflict with his own statist predelictions."
That may be because empirical evidence disagrees with your Nobelaureate in this specific instance.
Regardless though, administrative costs or profits are not the problem. Even if they could be knocked down to zero and we'd only save 30%, and that includes administrative costs on both sides of the provider/insurer divide - most of which is on the provider side (going from memory on that last bit).
No, Rob hit the nail on the head when he facetiously (I assume) said, "I suppose its possible that the entire industry has decided to spend a bunch of money for no reason".
While every entity in the chain has good economic reasons for what they do, the result as a whole is an irrational waste of money. The market system that worked well years ago, no longer functions as a market. What the ultimate consumer wants to buy, and what the ultimate provider decides to sell are no longer related by market forces. It is a pantomime that mimics what the market used to be, so it looks like a market at first glance, but it isn't rational anymore.
Except hospitals won't drop the prices of procedures just because one insurer decided to stop stiffing them...
You are aware, I presume, that the price your insurance company pays is not taken from a price list posted on the wall, but rather negotiated with the hosptial in advance as part of a contract? The insurance company doesn't just pay whatever the list price is, it bargains for a lower price based on the relative certainty of payment. It's the same principle behind cash discounts at gun stores and high interest rates at payday loan shops.
If an insurer chose to fight payment less, it could presumably negotiate lower rates with hospitals, on the grounds that it pays out more often. Such a company might still go bankrupt, but not merely because it was paying a higher percentage of its claims (remember that it would pay less per claim). It would go bankrupt because it would come to be seen as a relatively easy cash cow that doesn't watch carefully for fraud and overtreatment.
Any system other than patient pays will require that the payor choose between 1)fighting with the payee to cut costs, and 2) accepting fraud and overtreatment as costs of doing business.
The point being, you can't escape admin costs for free. There's an optimal point where the marginal cost of stopping the next fraudulent bill is equal to the price of paying that bill, and it's theoretically that possible both that we're far from that point and that the government can bring us closer. But it's unlikely that there's a free lunch waiting to be grabbed here.
"Perhaps he is unaware that this is a tired and oft-refuted idea in the history of economics--that competition is somehow wasteful and redundant and that government monopoly would be more efficient."
Perhaps you are unaware of the actual reality that proves that overhead costs are much lower in centralized health care systems.
http://www.consumeraffairs.com/news03/health_costs.html
http://www.pnhp.org/news/2003/august/administrative_costs.php
Cananda is only one example. PBS recently did a study of health care systems. The US market approach has much higher overhead and administrative costs than Canada, the UK, Germany, Switzerland, Japan, and Taiwan. Even within the US, you can see that the VA is much more efficient. VA patients typically live longer than the average person despite their patients begin inherently less healthy. And lower administrative costs per patient. Perhaps this is why what passes for conservative economic thought is so throughly discredited these days? They ignore basic facts and statistics when they don't align with the "theory".
I suppose Brooksfoe thinks that governments are well-known for their low administrative costs. Actually, the truth is that - rwe
Actually, the truth is that administrative costs at Medicare are about 2% and at Medicaid are about 6% and administrative costs at private health insurers are around 20%, and that's what the truth is. And, yes, Rob, that was the argument I would make, and that's an interesting point about ERISA and actually sounds worth looking into. But I have to go to bed now so good luck!
On this, which I never responded to, from Yancey:
you conceded the argument that the administrative costs incurred lowered the costs to their customers, and improves the companies profits.
That's because "their customers" now no longer include the people who are actually sick. I could offer you health insurance for $5 a month with a system like this: I guarantee to reimburse all your health care, no questions asked. Except if you get sick and need health care. Then you're out of the plan. But obviously that would be illegal. Finding a legal way to do this requires a lot of staff, so the premiums will be more like $500 a month. And if everyone else is running their insurance plan this way, and I come out and offer a plan for $400 that doesn't drop you when you get sick -- guess who I get as customers? All the sick people. And I have to up my premiums to $1000 a month. End result: instead of everyone paying $400 a month for insurance, we now have healthy people paying $500 a month to employ doctors to make sure they're not sick and lawyers and admin staff to kick them out if they are, and sick people paying $1000 a month. No one wins, everyone loses -- except the lawyers and admin staff, who get jobs. Though if we got rid of the whole idiotic system, maybe they'd find productive things to do with their lives, like raising free-range chickens.
Congratulations Ms. McArdle, for continuing to cover a critical if sometimes seemingly "unsexy" issue.
However, I don't think it's that "we consume so much" per se- but that we waste fully 30% of our health care dollars on unnecessary/ineffective care and devote another 30% to administration costs (and yes, insurers overhead and profits contribute to that high figure).
Of course, there is some overlap between these- but that's ultimately around HALF of health care dollars not contributing to actual improvements in health outcomes.
Needless to say, both of these rates are also the highest on the planet.
As rising health costs are the biggest contributor to the unfunded entitlements that former comptroller David Walker keeps warning now threaten the country with insolvency in the next generation- You could make a defensible argument that this is the single biggest national security issue that we face.
Here's a keeper:
The Health Insurance Mafia.
Insurance makes sense for catastrophic coverage, not paying for each visit to the doctor and part of each prescription.
And I do think health insurers bear some responsibility for getting us into the current mess: They've lobbied state legislatures and state insurance commissioners to "regulate" health insurance policies and premiums in such a way to keep out competitors. It's typical rent-seeking behavior.
Jay, a couple points.
The countries you cite buy pharmaceuticals essentially on a cost-plus basis negotiated by the government. That means that pharma has to recoup its R&D costs in the U.S. in the five or so years typically left on patent term when a drug is approved.
In addition, at least in the UK, health care is rationed by the NHS. Care for those above a certain age is palliative rather than therapeutic. (Anecdotal instance: one of my wife's relatives didn't receive surgery for breast cancer because she was in her late 70s. The NHS decided - and she (a former nurse) agreed - that she'd had her three score years and ten, and that was that.)
The story brings up another point, namely that Americans are perhaps uniquely individualistic. That's good in the context of entrepreneurial pursuits, but not so good in the healthcare context. Virtually every American expects heroic efforts on his behalf. The idea of writing one's self off, as my wife's relative did, is literally un-American.
Also, I should add that insurers aren't necessarily evil or to blame for all our health ills. I believe that the combination of a highly sedintary lifestyle combined with really cheap food that is abundant, highly processed, devoid of nutrition, and full of fat and sugars is a large part of our problem. If people lived healthier, they would be healthier. As Matt Yglesias is fond of pointing out, some of the biggest advances in life expectancy came from such things as improved sanitation and increased use of soap, not new medical treatments. So many cutting farm subsidies to corn growers and refiners of high fructose corn syrup is a good start to reducing our health care costs.
Thanks Occam's Beard,
If we switched to a Canadian style nationalized insurance, I suppose pharma would be in the same boat here that they're in many other counries.
Is there any reason to believe that if pharma was not able to recoup its R&D costs in the U.S. the way it does now, that something really bad would happen?
And I probably should have stuck to nationalized health insurance, since a UK style system seem very unlikely in the U.S.
Mark,
"Insurance makes sense for catastrophic coverage, not paying for each visit to the doctor and part of each prescription."
I buy insurance so I don't get stuck with a $200,000 hospital bill.
My insurerer bribes me to get regular check-ups so that they don't get stuck with a $200,000 hospital bill.
Actually I’ve read those reports (and not just the results reported on PBS). What the researchers did was send a survey to doctors and nurses in the US and Canada and ask them how much time a week they estimated that they spent performing “administrative functions” and then they took that time, divided it by a 40-hour work week and prorated it against the average salaries of a doctor or nurse in United States.
The dirty little secret – and why it’s important to actually read the study and its methodology – is that the researchers found that US doctors and nurses actually spent less time doing administrative functions but because doctors and nurses are paid more in the US than in Canada, it showed up as a higher administrative cost which is contrary to what the proponents of a single-payer system have claimed.
So basically in the United States we actually spend less time performing administrative functions in our health care system than Canadian doctors and nurses do under their single payer system but it appears that our administrative costs are higher because our time is more valuable. So basically when proponents of a single payer system say that we’ll have lower administrative costs, what they’re really proposing is that we cut the salaries of doctors and nurses while forcing them to spend more, not less time, complying with government paperwork then they do now complying with insurance company paperwork.
Jay, it depends on what you consider really bad.
R&D costs - which are huge - have to be recouped somewhere, or there won't be any R&D, obviously. Europe and Japan pretty much have their hands in their pockets on this one, so it's down to Americans.
So if R&D on new drugs becomes uneconomic, there won't be any. There will just be today's drugs, which would all soon become generic, and cheap.
In some perspectives, that's not so bad. We have a huge demographic bulge of boomers, and not going to great lengths to prolong their (our!) lives might not be such a bad thing. A shift to viewing life on a higher philosophical plane, rather than focusing on mere longevity, wouldn't be entirely amiss.
But I think that most people would reject that notion, and want new drugs developed, expecting that one day they themselves will need them - philosophy notwithstanding.
Thorley, cites for the reports you are talking about?
If the researchers actually did what you said, asked Canadian and US doctors and nurses how much time they spent doing administrative stuff and prorated it against US salaries, then the numbers should be directly comparable.
But the other question is, do Canadian doctors' offices have to have a dedicated staffer who only does insurance administration? US doctors do have such a staffer; I have heard that Canadian doctors do not. So then, even supposing that US doctors and nurses do less administrative work, that could be because they have enough administrivia to need to hire an additional staffer to do it.
brooksfoe,
However, you have missed a step- you have provided no evidence that they actually weed out those who get sick, only that they try to control costs of treatments and procedures- something that no one is denying- even you, apparently. And, it has been noted that there are quite stringent regulations preventing health insurance companies from doing this kind of weeding out in the first place.
Pre-existing conditions are another matter, however. I don't know of a single auto-insurance company that will let me file a claim on a car I wrecked before I signed up for coverage. Pre-existing medical conditions are no different. I suspect little overhead is spent denying policies to such people.
"Is there any reason to believe that if pharma was not able to recoup its R&D costs in the U.S. the way it does now, that something really bad would happen?"
Really bad? No.
First, they would recoup some R&D costs from abroad that they are not getting now, though they would probably not come close to making up the shortfall. Research would decrease here in the US. Again, there would be increases in other countries that would probably not make up the shortfall. This would result in a decline in new drug research.
What industry shills will not say is that the money not spent on research will be spent elsewhere. Nobody will pile it up and set fire to it just because it isn't as profitably invested in drug research anymore. It may be spent in other health care fields, or in entirely unrelated ways, but it will presumably benefit someone. To continue protecting this practice, it is incumbent upon the proponents to make an affirmative case that the money involved is being put to better use than it would be otherwise.
Treating drug research as an unqualified good is often used to justify measures that enhance drug company profits. But the same argument justifies the government giving matching funds to these companies for money spent on research... or double matching funds, or triple, or quadruple etc. It is an assumption that drug research is always the best possible way money can be spent.
Njorl, it might make sense for the ins. co. to provide incentives for its insured to reduce their risks of contracting some illnesses that are cheap to treat if discovered at an early stage, but astronomical later on.
But the idea that health insurance is necessary for each visit to the doctor -- an idea unfortunately now the conventional wisdom -- encourages abuse. Some people are hypochondriacs, others malingerers. Your premium pays for their unwillingness to watch costs.
There are also doctors who have figured out ways to scam the insurers by diagnosing whatever the patient wants as long as the insurer would have a difficult time disproving the diagnosis. There's ample room for fraud on both sides.
Jay J and freddiemac--
Just to address the Canada example, a recent Supreme Court (of Canada, natch) decision overturned the ban on private health insurance.
Why?
http://content.nejm.org/cgi/content/full/354/16/1661That sounds like a less than ringing endorsement of the Canadian system by their own Supreme Court.
On a more anecdotal level, here's a story about Canadian women increasingly being sent to the U.S. to give birth due to a lack of beds in Canadian hospitals: http://www.komotv.com/news/local/10216201.html
That's all I could come up with just off the bat but I've heard horror stories about the treatment of the old and terminally ill in British hospitals as well.
Our system clearly has its problems but let's not pretend that the easy answer is to emulate one of the utopian systems that are working flawlessly all around us.
Um no, that’s not true either.
First, most of the actual administrative costs that sustain Medicare and Medicaid aren’t counted as part of their budget, they’re either passed along to providers through the regulatory power of the government (whereas private insurance companies have to account for them since they can’t simply pass them along to providers) or they’re coming out of other parts of the federal budget. Example: Medicare premiums are collected by the IRS which acts as Medicare’s accounts receivable department but since it isn’t part of the actual “Medicare budget” it isn’t counted as an administrative expense for Medicare while a private insurance company using activities-based costing would count it as part of the administrative overhead.
The other reason is that the percentages brooksfoe is claiming are actually based on a percentage of payments and Medicare payments tend to be larger (about 60% more or double what the average payment made by most private insurers) so you can have a situation where while it actually costs more to process a request for Medicare/Medicaid payment but because the actual payment will be larger, it shows up as a smaller percentage of the payment.
So basically what brooksfoe’s numbers are based on is (a) funny accounting whereby the government doesn’t count it as an “administrative cost” if it’s coming out of someone else’s budget (even though it makes no difference to the taxpayer or patient since the costs is just being passed along) and (b) differences in the size of Medicare payments rather than the size of administrative expenses.
"The other reason is that the percentages brooksfoe is claiming are actually based on a percentage of payments and Medicare payments tend to be larger (about 60% more or double what the average payment made by most private insurers) "
That is a worthless point. Medicare's patients are exclusively elderly. Comparing their costs to a typical private insurerer, who has alomost no elderly patients is unilluminating.
Medicare and medicaid get better prices than private insurers. This is not because the government has better negotiators, it is because the government has a bigger batch of clients.
Bob,
I am aware of the flaws in the Canadian system. I never said that we should emulate it. I simply pointed out that they have lower overhead costs than the US system, contra what has been typed here previously. This makes sense, due to the comparative advantage a large system has over smaller ones.
One could compare anecdotes all day long about the problems of various health systems and health policies of different nations, including our own. It is disingenuous to state that are system is so great and then off handedly dismiss the mountain of evidence that suggests the huge flaws in our system compared to others.
The reality is that America dedicates and enormous amount of our GDP to health care, a lot more than other industrialized nations. We spend more per capita on health care than any other nation, but there is very little evidence to suggest that we have anything to show for that huge amount of money.
I am no expert on health care laws, rules, and regulations. But I suggest that much of the problem is structural. As I said before, we have a very unhealthy lifestyle in America. That our health care would cost so much and reap so little is therefore not too surprising. I'm sure there are many other problems indemic to the system that I don't know about. But I also see no reason why we might not realistically examine other systems to see what works and what doesn't. Isn't that the American way?
Njorl,
You seem to be missing Thorley's point about the percentages of overhead.
The Pharma R&D issue is overblown. They spend twice as much on advertising than R&D.
Njorl,
It is true that the money spent on R&D will not be burnt if the return on R&D is set to zero. The people who would have invested in that will find something else to invest in and get a return there.
It seems, though, that you're arguing that the market wildly over-estimates the value of R&D, at least partially because of perverse government incentives applied to the industry, and thus it might be beneficial to eliminate the return on R&D.
I would question whether the government's influence on the returns to pharma R&D is significantly greater than the maelstrom of tax-breaks, grants, zoning, etc., etc. that every other large industry lobbies for.
Assuming that the perversion of the market is not significantly greater in pharma than industry in general, then it seems to be that if you eliminate the return on pharma R&D you will by definition be forcing that money into less productive investments.
Testing drugs is certainly not an unqualified good, if you mean that there is no amount to spend that is too much. The question is where is the point of diminishing returns? How much should we spend on drug R&D?
The free marketer's answers is: let it compete for scarce investment dollars along with everything else. The amount we spend on it will be the sum-total of our collective desire to spend on drug research as opposed to other worthy things.
An alternate answer is to have the government decide how much to spend and then collect and appropriate that much.
One's ideology will significantly influence how one feels about each of these options. I tend to believe that decades of evidence around the world indicate that government is not particularly adept at efficient allocation of resources. Because of that, I'd prefer to see less government overrides of the market in all cases but especially so in sectors of vital importance like health and health-related research.
I seem to be in the minority on that, though, as people generally seem to believe that the more important something is the more government should be involved.
I'm sure brooksfoe and other worthies who share his mindset could give me arguments and evidence about why the government is actually much better at allocating resources and my belief to the contrary is mistaken and ignorant of significant evidence.
In a system where you don't have the option of paying $50-100k to keep Grandma alive for another few weeks, you, well, obviously won't. She dies earlier, but that's statistically unlikely to even be counted (since health stats for mortality tend to, from what I've seen, go by age - and the difference is unlikely to be significant in terms of old people making it to one more birthday).
So what the family might see as a large benefit appears on the stats as simply a giant expenditure for "no benefit".
Do explain how keeping a dying elderly person alive for a few more weeks is a "large benefit" to the family. Especially if, as is so often the case, the dying person is too far out of it to communicate.
The real elephant in the room here is that too many people want a free lunch and there's no such thing. Also no point in comparing to Japan, they eat much healthier and exercise, so they get better results from their hospital visits.
Healthcare costs are high because of government subsidies. Same thing can be said of education. Agricultural goods, too. What hyperinflationary sectors are not subsidized?
Contra exercise: What deflationary sectors (telecom, electronics, etc.) ARE subsidized? Nothing comes to mind.
Stop subsidies, please. Thank you, George Stigler!
Do explain how keeping a dying elderly person alive for a few more weeks is a "large benefit" to the family. Especially if, as is so often the case, the dying person is too far out of it to communicate.
Posted by Peter | May 1, 2008 4:09 PM
Except 99% of the families go for the $100K "keep grandma alive" option. Religious reasons, guilt. Who knows, but someone else will pay the tab. You and me.
bbeans, that line about advertising budgets in the pharma industry will, I suppose, continue to be used until the end of time.
But it's similar to the argument above about administrative costs in health insurance companies. The purpose of those advertising budgets so that the companies have *more money* than they would have had, even after spending what they did on promotion.
It's not like there's this fixed bucket of cash, and you decide that some of goes to the research labs - never to be seen again, for the most part, and I work there and do my part - and some of it goes to the ad budget and disappears over there. Advertising is a profit center.
Also no point in comparing to Japan, they eat much healthier and exercise, so they get better results from their hospital visits.
Dunno about healthier eating. As I understand it, the Japanese diet is very high in sodium.
Japan's long life expectancy might be at least partly genetic. Asian-Americans, including those of Japanese descent, have longer life expectancies than almost any other group in this country.
Peter,
The Japanese diet may not be the paradigm of health, but I'm sure it is much healthier than the average American diet. High in sodium is usually preferrable to high in sugars and fat.
There may be a genetic correlation to health. It also may be that certain ancestries are less suitable to the American diet than others. Some conjecture is that people of Native ancestry are less adept at eating grains and starches because their ancestors didn't start eating a diet filled with bread and cheap grains until only a few generations ago, while some Eurasians have been eating a largely grain based diet for a millenium or more.
Plus, on the Japanese diet front, it must be stressed that sushi is delicious.
But not the really weird pieces. Those are just gross.
Note: Please feel free to define "weird" in the above statement anyway you like up to and including all sushi.
Peter:
What do you suggest we do in terms of long-term care? I'd love to hear some suggestions.
The market is not the appropriate mechanism for health care because people do not voluntarily consume health care. I don't want to shop around for cheaper cancer care -- I don't actually *want* to pay for cancer care at all, since I'd much rather not get cancer.
And our current market is really not a good market for people who have a pre-existing condition. A car insurer won't pay for an already wrecked car, as someone here observed. But you can get a new car. You don't get a new body -- your wrecked car is you.
Those above (like Brooksfoe and Njorl) who claim tremendous efficiencies will come from a government controlled system are dreaming. As anyone who has been in an NHS hospital knows this is a common refrain in Britain:
The Labor government has increased the NHS budget at a rapid rate, and yet popular discontent with medical treatment has been rising. So, according to the British public, more money has brought a reduction in quality, as hospitals are widely described as filthy and people worry that they come out sicker than they went in.
The Economist has a slightly more optimistic view, arguing that health care is marginally better than it was before New Labor, but that the marginal return on all of that extra spending has been very low.
So much for government efficiency. The truth is that the idea that governments will be able to control costs without reducing quantity and quality of care is a fairy tale.
Governments are simply not more efficient. they can only fix prices and ration care. Again, that's a lesson anyone who has studied basic economics ought to have learned.
"Contra exercise: What deflationary sectors (telecom, electronics, etc.) ARE subsidized? Nothing comes to mind."
Is this a straight line or something? Telecom is subsidized.
"But the idea that health insurance is necessary for each visit to the doctor -- an idea unfortunately now the conventional wisdom -- encourages abuse. Some people are hypochondriacs, others malingerers. Your premium pays for their unwillingness to watch costs."
Since 80% of health care costs come for people in the final month of life, I find it hard to believe that fakers cost much money.
Great post rwe. That'll show em.
Derek Lowe: Is it wrong to point that out, similar to administrative costs?
RWE: I guess I'm just so jealous of the American healthcare system.
Njorl,
You seem to be missing Thorley's point about the percentages of overhead.
Yancey,
If someone tells me that they have a cat and that they are a leprechaun, I am not likely to debate the existance of their cat.
But if you insist...
The free ride that government medical insurance gets from the IRS doing its bill collection is a fact of life. It causes virtually no additional expense to the IRS. This synergy is available only to government healthcare systems.
If the IRS charged medicare the market rate, that might be expensive, but they don't. The only cost we are concerned about is the cost to the taxpayer. That is negligible because the IRS is collecting taxes anyway. The marginal cost of collecting more tax to fund medicare is tiny. The cost to the taxpayer for this service is the marginal cost of the next collected tax dollar, not the unit cost of the average tax dollar.
Peter is more frank than some of the other advocates of nationalized health care:
That's indeed one way that the NHS "controls costs." It simply permits some people to die, when it deems them unlikely to respond to care. I saw that with my own eyes. Older people are more or less expendable.
The NHS is always strapped for cash, despite a ballooning budget, and is therefore always rationing care. That means some people have to wait a long time for treatment, while others get no treatment at all.
That solution always struck me as rather macabre--"Let 'em die. They cost too much. We don't need 'em." But Peter at least deserves credit for admitting the economic reality that there are tradeoffs involved in imposing price controls.
The free marketer's answers is: let it compete for scarce investment dollars along with everything else. The amount we spend on it will be the sum-total of our collective desire to spend on drug research as opposed to other worthy things.
An alternate answer is to have the government decide how much to spend and then collect and appropriate that much.
I never said that the government should control drug research. What I believe (but didn't say), is that if the government wants to promote research, then they should find a mechanism to promote research rather than promoting drug company profits and hoping it promotes research.
Can some define "end of life" care in a legal definition sense? If I'm gonna sign up for poor / non-existent end of life care, as that is the only way to control costs it seems, I'd like to know where that starts.
In-patient care after 80? 70? 65?
Joint replacement at those ages?
End stage cancer treatment?
Coma care at all?
My fourth heart bypass? fifth? third?
Organ transplant after 40? 50? 30?
GI stuff after 50?
Second knee replacement?
And I would like to hear an advocate of this speak openly about it: government run health care will be cheaper because we won't do X, Y and Z to people we don't beleive will benefit and this will save us Z dollars per annum
Skullberg, thanks for trying to flesh this out. Those who advocate such rationing are rarely willing to provide details.
I will say that as a relatively young man, I am more than willing to pay for/provide end-of-life personal/medical care to both my parents and my wife's parents; as such, I'm prepared to pay for it, financially and otherwise. I'm less willing to suggest this to others, but we all durn well know it's coming.
Njorl:
Interesting claim, but unless 80 percent of health care costs are caused by scads of people dying expensively to get into Medicare, these costs would seem to be borne by that income redistribution system (when people are no longer under the care of private health insurance).
Or is the claim supposed to mean that a person incurs 80 percent of his or her lifetime's worth of health care costs in the final month of life? Does it reflect the fact that a procedure performed decades ago was more expensive than a newly developed procedure performed on an end-of-life patient today for an ailment inadequately described just a few years ago?
I'm not sure, but it doesn't really matter if we just want to toss random speculative statistics around.
Diana,
The market is not the appropriate mechanism for health care because people do not voluntarily consume health care.
Consumption of health care is at least as voluntary as consumption of food, shelter and clothing, all of which are funded primarily by the market. Are you therefore proposing to nationalize the funding of food, housing and clothing too? And what about health care delivery--drug companies, MRI manufacturers, hospitals, physicians groups, etc.? Are you proposing to nationalize those, too? I don't think you've thought your argument through very well.
And our current market is really not a good market for people who have a pre-existing condition. A car insurer won't pay for an already wrecked car, as someone here observed.
But he will insure a high-risk driver, for the right price. Everyone is insurable at some price, whether it's car insurance or health insurance. In cases where pre-existing conditions preclude access to affordable health insurance at market rates, the government can step in to make insurance available through some combination of regulation and subsidy. It doesn't require the nationalization of the entire health insurance market.
Bob,
I agree that we shouldn't pretend that an easy answer is to emulate Canada.
I believe actually that there are no easy answers.
But let's not also pretend that a health care system that leaves millions without access is the best system in the world.
The free ride that government medical insurance gets from the IRS doing its bill collection is a fact of life. It causes virtually no additional expense to the IRS. This synergy is available only to government healthcare systems.
What you're claiming, then, is that the government presently has a budget surplus more than sufficient to begin covering a national healthcare scheme, or at least some sort of national health insurance/indemnity scheme. You might want to notify your friends in the Democratic Party, since they have this misguided notion that the Bush tax cuts were fiscally irresponsible.
Sarcasm aside, the only way this country will be able to fund a national health scheme of any sort is through a substantial tax hike. The only way I can see that happening practically is through an additional payroll deduction under FICA, and people will be accutely aware of exactly how much this non-free lunch is costing when the FICA deduction on their payroll stub jumps to, say, 24%.
Although people overall might willingly pay a greater percentage of their income in exchange for the beneficial aspects of the tradeoff, a much greater percentage of income is at stake, increasing the incentive to cheat; and the IRS now has to handle a greater volume of paperwork to process the collections. Add those together, and I fail to see how the IRS would have to do anything less than grow in order to handle the additional collection and enforcement burden.
If you've got another interpretation, I would like to hear it. Otherwise, your "synergy" is spin, and collection costs at the IRS are a real, but unmeasured, portion of total Medicare administrative costs, both right now and under any future universal insurance or care scheme. Correspondingly, the factoid Brooksfoe reeled off is, and remains, a work of creative fiction.
Re: yet we suffer from neither a car-care nor a house-cleaning "crisis."
??
What does cleaning have to do with it? We don't suffer from a grooming and hygiene crisis either because of the high cost of healthcare. I would however suggest you visit Florida if you want to sample a property insurance crisis. Let's also take note of a fact about healthcare: its costs are potentially unlimited, unlike most other forms of insurance. At absolute worst your car insurance may have to replace your vehicle and pay out to the limit of your liability coverage (often fairly low). Your homeowners policy is similarly limited, albeit houses cost more than cars, though are far more rarely "totaled". Life insurance has a fairly strict and predictable limit for its payoff. Even a disability policy will only pay out a limited amount yearly, so the insurer knows what the worst case scenario will cost. Healthcare issues (if only mild ones) arise at least yearly for most people and the cost of a serious, chronic illness or injury will be many times the maximum likely to be paid on an auto or property policy.
Re: I don't suppose that could have anything at all to do with diet, lifestyle, or genetics, could it?
Obesity and especially smoking are extremely common in Asia too. And I have never seen any evidence that Asian people are genetically healthier. You are grasping at straws. Why not accept the obvious: most other nations have healthcare systems deliver care at entirely acceptable levels and cost less. What's not to like?
Re: The State, after all, has even less incentive than an "evil" insurer to try and serve the customer.
Bullshit. A state that is democratic has every incentive to give the people what they demand. Hard to stay in office if you don't.
Re: I suppose Brooksfoe thinks that governments are well-known for their low administrative costs.
well, um, Medicare actually is well-known for low administrative costs.
Re: Health insurers routinely deny payment on a large percentage of doctors' claims, just to see whether the hospital or patient will actually press for them.
This is not true. Most claims are denied due to paperwork errors (and yes, the paperwork is a problem). I've worked at a healthcare payer company. Accuracy is an absolute requirement for claims payers. We allowed only a 2% error rate, and if they exceeded that they were out the door. Insurance companies do NOT deny claims for the fun of it.
Re: Except 99% of the families go for the $100K "keep grandma alive" option.
Except for the parents of Terri Schiavo, I've never known anyone who wanted to keep a dying person alive beyond the point of rational hope. Certainly none of my realtives were maintained like that: all had DNRs and/or living wills, and in a couple cases plugs were pulled or large doses of narcotics helped ease their final hours. My take on this is that it's the medical profession which runs up high bills on the dying with useless tests and the like: because often these people are well insured and sometimes because the providers fear lawsuits when nature takes its inevitable course.
Re: Finite funding for infinite demand has that effect.)
The demand for healthcare is not infinite-- would you go in for a daily lower GI even if you were rich as Bill Gates? Hello! Hypchondriacs do exist, but most people only consume healthcare when they need it-- and sometimes not even then since healthcare is often inconveient and annoying, sometimes painful and humiliating, occasionally dangerous. There are plenty of disincentives to consume healthcare apart from cost. What reality do you inhabit?
3rd party payer creates a moral hazard. Both the doctors and the patients what the best care available regardless of cost... as long as someone else is paying. Why is this so hard to understand?
Obesity and especially smoking are extremely common in Asia too. And I have never seen any evidence that Asian people are genetically healthier. You are grasping at straws.
No, you're talking nonsense. Rates of smoking, dietary patterns, exercise patterns, crime and accident rates, pollution levels, climate and all sorts of other variables that have a profound influence on health vary significantly between different countries. These variables could easily account for the modest differences in average life expectancy between industrialized nations. You have absolutely no basis for attributing those differences to differences in the health care systems.
Why not accept the obvious: most other nations have healthcare systems deliver care at entirely acceptable levels and cost less. What's not to like?
Rationing, waiting lists, suffering, death, denial of drugs, tests and surgeries. That kind of thing.
We have suffering, death, lack of access to drugs, etc, due to the fact that so many lack access to health care.
It would be helpful to go ahead and admit that the cost of providing universal health care any time in the near future may be prohibitive, at least in the U.S.
But is anyone suggesting that those in Scandinavia, Japan, or Australia have more suffering, death, denial of care/lack of access than we do here in the U.S.?
"Rationing, waiting lists, suffering, death, denial of drugs, tests and surgeries. That kind of thing."
Then why don't all these countries go over to our system? Are they dictatorships? Are their citizens blind to the superiority of the American system? Don't they understand the joys of capitalism, American style? I'm sure Mixner has the answers.
We have suffering, death, lack of access to drugs, etc, due to the fact that so many lack access to health care.
Sure we do. All countries do. That's kind of the point. Show me your analysis proving that our health care system causes more suffering, death, lack of access to drugs, etc., than your favored alternative.
But is anyone suggesting that those in Scandinavia, Japan, or Australia have more suffering, death, denial of care/lack of access than we do here in the U.S.?
I don't know if they do or not. I don't think you do, either. Again, that's the point. If you want us to change our health care system to be like Scandinavia's, Japan's or Australia's you need to present a clear and convincing case that that would be an improvement over our current system. That means taking into consideration the strengths and weaknesses of each system, rather than just focusing on the weaknesses of ours and the strengths of theirs.
stan,
Then why don't all these countries go over to our system? Are they dictatorships?
If their systems are so much better than ours, why don't we switch to theirs? Are we a dictatorship?
Actually, there is plenty of evidence that Britain, Canada and France, for example (countries with health care systems dominated by public funding and strict regulation), are moving towards a greater role for private funding and deregulation. They haven't "gone over" to our system, but they're moving in that direction.
Mixner,
It has already been done:
http://www.pbs.org/wgbh/pages/frontline/sickaroundtheworld/etc/synopsis.html
As I and others have said many times, the US clearly pays more and gets less health care for its dollar.
rwe,
I'm not sure I understand the point of your dirty hospitals post, unless it was meant to be a red herring (which seems most likely). Anecdotes about dirty and understaff hospitals in Britain A) haven't demonstrated that hospitals in Britain are more or less dirty than hospitals in the US and B) that dirtiness equals higher overhead. Once again conservatism proves itself to be a bankrupt ideology. Nevermind the facts. Nevermind the higher per capita spending on health care in the US. Nevermind the fact that no one on here has presented one shred of evidence to suggest that health services in the US are in any way superior to those of other industrial nations. Nevermind the fact that the US doesn't even have the highest longevity. Instead someone who cleary doesn't even understand econ 101 is going to attempt to chide posters for not understanding econ 101. It is called ECONOMIES OF SCALE.
Mixner,
I actually acknowledged that the costs of moving to universal health care may be prohibitive, so there's no need to argue with me as if I'm Michael Moore.
Moving on, would you agree that Scandinavia, Japan, and Australia have rates of health and access to health care on par with ours?
Moving on, would you agree that Scandinavia, Japan, and Australia have rates of health and access to health care on par with ours?
I think they probably have better health, in general, than America. Not because of better health care systems, but because their lifestyles and cultures are less conducive to unhealthy behaviors (obesity, smoking, drugs, crime, stress, lack of physical exercise, etc.)
As for "access to health care," the phrase is so vague it's hard to give any clear sense to it. "Health care" consists of a huge range of products and services and "access" can be limited in a number of ways (cost, regulation, geography, etc.) I think they probably have better access to some kinds of health care than we do, and worse access to others. For example, I think that in general Americans probably have better access to high-tech and cutting edge health care (MRI scans, recently-developed pharmaceuticals, etc.), whereas, say, Australians probably have better access routine health care like antibiotics and blood tests. But I'm not sure even about that. It's a very complex issue.
freddiemac,
As I and others have said many times, the US clearly pays more and gets less health care for its dollar.
You can say it as many times as you like, but unless you can back it up with evidence, saying it isn't going to get you anywhere.
And "evidence" here means more than just soundbites about the number of uninsured or the average life expectancy.
So I suppose you believe the fact that they have similar life expectancies and health is that they live differently? I would partially agree with this.
To lay all my cards on the table, I think the argument usually is too stark. Some say that we have the best health care in the world, in terms of quality. Others only emphasize the millions of uninsured.
A good friend on mine talks about how if Russia had an awesome police force, but that it was capable of only protecting politicians, no one would say that this actually a great system.
I'm not saying we are in such a situation with health care, but I think the point is that there are issues of quality, and there are issues of access. If millions of Americans don't have access at all, this is really bad for the idea that we provide equal opportunity in America, even if those who have access get the best care in the world.
The idea that Australia or Japan or Sweden may have inefficiencies that we don't is not a devastating argument against universal health care, since there are characteristics of our system that many of us find unacceptable as well. Pointing out problems with other systems is only an argument against someone who claims that those system are examples of utopias or perfect systems.
It's perfectly coherent to say that we would prefer to trade our flaws with theirs and the resulting gain of universal care would be worth it too us. In other words, I may choose to live with certain inefficiencies I don't now, if everyone in the country could have the same basic access that I do.
That said, the transition may be too painful for us right now, I don't know. All I know is that there is nothing obviously wrong with the view that the gain of universal access would be worth the trade of some inefficiencies. At the very least, the countries I've mentioned haven't experienced anything catastrophic because of their universal health care, and they don't leave millions with no access.
So the issue seems to boil down to values, rather than elegant economic theories. Of course there would be no way to adjudicate between these values, if one says it's worth the resulting inefficiency for universal access, while others say that freedom of choice, market efficiency, and or/quality of care (for the sake of quality) is more important. So we may be stuck, and in what Milton Friedman saw as a dead end, when men disagree over values.
Mixner, walking into a subject that's as widely covered as this one and demanding to have all the specific evidence presented to you ad novum is ridiculous. You know perfectly well the US spends between 1.7 and 2 times as much per capita on health care as every other advanced industrial nation, and you appear to know our health outcomes aren't any better. If you have an explanation for that that doesn't begin with "waste and inefficiency", I'd say you're the one who needs to present it.
BTW, Njorl is really amazingly pithy here. Especially on that IRS-collection issue. Thorley's argument boils down to: "Governments are inherently more efficient at collecting premiums than private industry is because they just make it part of general revenue collection, and that's not fair."
No doubt.
Also, no one has posted a shred of evidence to validate the claim that other countries with better stats have 'healthier lifestyles', or a better gene pool or what have you.
I, otoh, am reality-based:
http://www.wpro.who.int/media_centre/fact_sheets/fs_20020528.htm
The money quote(s):
----begin----
JAPAN
* About 51% of men smoke in Japan - this figure has dropped from the 1980s, but it is still very high for a developed nation.
* Prevalence of smoking among women, once considered almost taboo, has risen dramatically in the last decade to nearly 10%.
* Japan's Finance Ministry is a major shareholder in Japan Tobacco, a multinational.
* A survey in the early 1990s found that 44% of male physicians smoke in Japan.
* With 500,000 cigarette vending machines, the young can easily buy cigarettes.
* It's estimated that about one in eight deaths is due to smoking, (about 100,000 deaths a year). Smoking may also contribute to four of the five leading causes of death.
* Lung cancer is the leading cancer, with more than 50,000 deaths a year.
* More Japanese men die of lung cancer than suicide. The rate of lung cancer deaths is 46 per 100,000 people while the suicide rate is 30 per 100,000.
* Japan has some of the weakest anti-tobacco laws for a developed nation, with few smoke-free public areas.
----end----
I trust WHO is an acceptable source?
How about the United States?
Well, according to the American Heart Association:
"Among non-Hispanic whites, 24.0 percent of men and 20.0 percent of women smoke (2004)."
This is 2004 and smoking rates have dropped since then.
Seems to contradict the 'fact' - offered, of course, with absolutely zero support - that Americans have 'healthier' lifestyles.
If the Usual Suspects want to claim that the difference is due to 'healthier lifestyles', they need to get on the stick and provide some, you know, evidence.
If the Usual Suspects want to claim that the difference is due to 'healthier lifestyles', they need to get on the stick and provide some, you know, evidence.
Oh, I suspect the statistics might stack up differently if you compare factors like prevalence of obesity and its complications, including increased incidence of diabetes, heart disease, joint failures...things like that. Allegedly due to a greater prevalence of sedentary lifestyle and availability of low-cost, processed foods. It might even explain why Americans have the highest healthcare costs in the world, yet don't have the longest life expectancies.
Albeit on that last point, to maintain statistical consistency, you do need to adjust for differences in counting infant mortality (made possible by high healthcare expenditures) whenever that factor is relevant.
I'm not sure if prevalence of smoking is the best possible indicator of healthy lifestyles, overall, since the French also like their cigarettes. Or, stated another way, smoking damages one organ system primarily, while obesity can damage several.
If I understand the libertarian take on health care, it says a) the reason the US spends so much on medical expenses is that our medical care is superior to that provided in other industrial countries, and b) the reason our life expectancy is lower and our infant mortality higher than in other industrial countries is our unhealthy life style in the first case and our way of keeping infant mortality statistics in the second. I think this is sophistry, but I'm willing to change my mind if I see objective evidence backing the libertarian argument. Is there any such evidence?
The Mouse makes a salient point. To expand on it, the difference in other factors affecting health in international comparisons make a difference. Among these are not only obesity and smoking, but also the rates of violent crime, traffic accidents with injuries and fatalities, and societal homogeneity.
I can tell you folks, though, that what you will pay to enter into European-like health care nirvana will be approximately 12 to 14 percent more of your pay withheld by the benevolent government to cover the costs of your altruistic utopian dreams -- at least that's what it costs to join the system mandated by statute in paradisaical Germany. This will give you free visits to the doctor no matter what your complaint, and it will tax "each according to his means," but it will also allow major exemptions for those with the most money and influence: These, after all, lobby for the greatest exemptions and benefits through the circuitous route of loopholes. And once you start going after them, they quickly up sticks and move to places where their assets are better sheltered.
'What you suspect'. Uh-huh. How about providing some actual evidence to back up your 'suspicions'. You being the one actually making the claim and all.
Stan,
The infant mortality ploy has already been debunked, and quite easily, with only a minute or so of research.
It Just Ain't So.
aMouseforallSeasons
Yes, and, as noted above, this only does partial explanatory duty. Another reason for higher American health care costs is the availability of experimental treatments and procedures. The costs of such "new" treatments and procedures are high for the first hundreds of applications, but generally fall, as elsewhere in productive industry. What used to be in-patient fixes have become out-patient processes in various cases.
Europeans have been hesitant to pay for the former and loath to experiment on the general public for the latter. Health bureaucrats avoid the political pitfalls of procedures wealthy, desperate patients are willing to try as a cure. These new-fangled treatments are included in overall health-care accounts for the US but are only unofficial, unrecorded efforts wealthy Euros have to seek abroad or forget.
For an example, someone should compare the costs of an open-heart bypass surgery performed 20 years ago to the costs of modern bypasses or stent implants today. In the early days, it was a six-figure expense, today it's surely in the lower five-digit range if paid out-of-pocket (although I admit I may be mistaken).
At least part of the problem here is that we're treating as "insurance" a whole collection of things --- like occasional doctor visits --- that occur with probability near 1. By asking health insurance companies to pay those things, they are inherently going to have to charge more than the original doctor's cost: someone has to pay the clerks and computer operators, whether it's a profit or non-profit, or even a government.
For a long time, this was hidden, since companies paid the insurance companies with pre-tax dollars, and so had a relative discount, but it also meant that there were few market incentives: the buyer got something more cheaply than the market rate, and didn't feel the effects of increased costs very strongly. At the same time, both the improvement in medical technology and skill, and the situation with liability insurance were increasing costs faster than inflation; this means that *eventually* the tax discount was eaten up.
As far as the notion that the Europeans have comparable health care to the US, this may well be true for some few things --- but increasingly, doctors in the UK are trying to get patients off life support more quickly, maternity wards are stacking moms in labor in waiting rooms so they don't get into the statistics, and old people with broken hips who would get a hip prelacement and be walking the next day in the US stay in bed for weeks because hip replacements are too expensive. Some number of those people die, of pneumonia or infection or any of the other things that happen to the bedridden elderly, but it doesn't appear statistically because there's no way to measure the effect of two years more relative health and happiness on an 86 year old grandma.
Having lived under several health care systems, US, Canadian, and German, and having known a fair lot of people whose treatment in, say, Canadian hospitals would not have been considered acceptable care --- would have made the doctor liable for malpractice --- in the US, I think the comparison should be taken with a grain of salt.
The basic paradigm shift which people raised Orthodox Friedmanite in the '70s and '80s are going to have to assimilate is that the past 25 years of deregulation and privatization have proven unambiguously that many kinds of government functions become more expensive and less efficient when farmed out to private enterprise. Not all, but many. These include military and policing functions, foreign aid (in my opinion), a lot of kinds of safety inspections, and health insurance.
The private sector produces cars, steel, resort hotels, hip-hop artists, and tongue studs more efficiently than the public sector. Food is a mixed public-private economy with massive farm price supports; handing it entirely over to the private sector is starting to look like a less obvious idea now that a lot of countries are suddenly facing shortages of basic staples again. Our health insurance system is also a mixed public-private system, but it's a stupid mixed public-private system, and the mixed public-private systems in Germany, the Netherlands, France, Sweden etc. do the job much better, insuring more people for more problems at far lower cost. So we should adopt one of those systems.
brooksfoe,
Mixner, walking into a subject that's as widely covered as this one and demanding to have all the specific evidence presented to you ad novum is ridiculous. You know perfectly well the US spends between 1.7 and 2 times as much per capita on health care as every other advanced industrial nation, and you appear to know our health outcomes aren't any better.
Yes, we've been over this before. Despite having had it explained to you over and over again, by a number of different people, you still don't seem to understand that average life expectancy, infant mortality rate, and other aggregate national health indicators are not the "outcome" of the health care system, but of a vast set of behavioral, cultural, political and environmental variables of which health care is just a small part. Differences between nations in just a few of these variables--diet and exercise patterns, for example--could easily account for the modest differences in life expectancy, etc. between industrialized nations. As I have pointed out repeatedly, there is overwhelming evidence that the services provided by a nation's "health care system" have only a small effect on aggregate morbidity and mortality statistics.
In order to compare the "outcomes" of different "health care systems," you need to look at data that actually measures the performance of those systems. The clearest example of such data that has been cited here is cancer survival rates. Cancer survival rates provide a direct measure of the performance of a health care system at diagnosing and treating cancer. And the data clearly indicates that the U.S. has some of the best cancer survival rates in the world, far better than those for Europe (although a few small individual countries in Europe approach the U.S.).
Scent,
Also, no one has posted a shred of evidence to validate the claim that other countries with better stats have 'healthier lifestyles', or a better gene pool or what have you.
The evidence has been cited repeatedly, but you continually ignore it.
Quote:
That's right: "shortfalls in medical care" account for only 10 percent of the variation of premature deaths. To illustrate the point, Longman cites a comparison between the U.S. and Costa Rica:
Having lived under several health care systems, US, Canadian, and German, and having known a fair lot of people whose treatment in, say, Canadian hospitals would not have been considered acceptable care --- would have made the doctor liable for malpractice --- in the US, I think the comparison should be taken with a grain of salt.
Anecdotal examples of poor care are literally worthless as argument. I could wallpaper my house with journalistic captures of misbegotten health care experiences in the US.
The difference between government rationing and current rationing is that our rationing allows good health care to rich people and dire medical emergencies, and that's it. The first of these is worse than any kind of rationing system I can think of, and the second is inherently more expensive than a system that rations based on, say, the severity of the long-term diagnosis.
If millions of Americans don't have access at all, this is really bad for the idea that we provide equal opportunity in America, even if those who have access get the best care in the world.
1. The idea that "millions of Americans don't have access at all" is utter nonsense. All Americans are guaranteed the right to emergency medical care by law, and there is a vast network of public and private clinics, doctors and other health care providers that provide primary health care services to the indigent and uninsured for free or for a nominal fee.
2. The idea that people living in countries with "universal health care" have access to equal or approximately equal levels of health care is also utter nonsense. In all countries, the wealthy have access to better health care than the middle-class, and the middle-class have access to better care than the poor. Canada, for example, has a "universal health care" system, yet the evidence indicates that its health-income gradient (the correlation between health and income) is comparable to that of the United States and may even be steeper.
Sigh. Mixner, this is not evidence. For this to be evidence, even provisionally(what is a 'premature death', for example? what are the metrics for determining the percentages?), you'd have to show that people in other countries are actually practicing those healthier life styles. No such evidence has been offered, in fact, I've pointed out(since you concede smoking can lead to bad health outcomes) that several countries with better health outcomes than the U.S. have much higher rates of smoking.
So let's see your 'evidence'[1]?
[1]Something more than a Washington Monthly article, which airily states that so-and-so said it, so it must be true.
Mixner,
My view is more supple than you seem to realize.
You're picking out things to quibble with, even though my argument is very broad, which is a little pedantic.
I don't mind that the rich have private options in countries with universal care. We can decide what we view to be a critical level of basic access, and give it to everyone, (in theory), like we do in public schools.
Universal access in public schools is a value we've adopted as a society, and it usually doesn't bother us that wealthier people can send their children to private schools.
And seriously, it's nice that we mandate emergency care, but by the time it gets to that point, if it's an illness, much preliminary and/or preventative care may have been missed.
And do you seriously think these neighborhood clinics come anywhere close to having the range of options available with insurance, or do you seriously think that overall, poorer people who have to rely on these clinics have care close to what people in Japan, Australia, etc have?
If you think they do, then I guess I don't want to keep talking to you, if you think they don't, then you can see that it's completely coherent to have a value system which says this is wrong and should be changed.
No access, in this context, can be seen as no access to the range of options available to people in other developed countries.
If you are simply saying that I was technically incorrect to use the term "no access," since people can go to the emergency room or a local ghetto or rural clinic, then score a point for you...
brooksfoe,
The basic paradigm shift which people raised Orthodox Friedmanite in the '70s and '80s are going to have to assimilate is that the past 25 years of deregulation and privatization have proven unambiguously that many kinds of government functions become more expensive and less efficient when farmed out to private enterprise. Not all, but many. These include military and policing functions, foreign aid (in my opinion), a lot of kinds of safety inspections, and health insurance.
What else? You say "many," but cite only four (4). And those four are rather bizarre. Who has suggested that the military and police are not legitimate responsibilities of government? Of course, we do use private enterprise to equip the military and the police. Is that what you object to? You seek to nationalize defense contractors like Boeing and Lockheed Martin, do you, rather than "farm out" the nation's defense needs to these private enterprises?
But let's get back to health care. Where is your "unambiguous proof" that "farming out" health care to private enterprise is less efficient and more expensive? And again, what kind of private enterprise are are you objecting to, exactly? As in defense, there are two basic divisions to health care: funding and delivery. In most countries, not just the U.S., health care delivery is provided almost entirely by the private sector (Britain is a rare exception), and in most countries, a significant amount of health care funding is also provided by the private sector. Which of these do you seek to provide through the government instead of the private sector? Health care delivery? Health care funding? Both?
If funding, do you seek to nationalize all health care funding (i.e., ban private health insurers and other private funding), or only some of it? How much?
Food is a mixed public-private economy with massive farm price supports; handing it entirely over to the private sector is starting to look like a less obvious idea now that a lot of countries are suddenly facing shortages of basic staples again.
Huh? It's government intervention that is causing much of these shortages. First-world governments provide massive subsidies to their farmers, raising prices and pricing farmers in the developing world out of the market. And government incentives to grow crops for biofuels (to fight global warming) has taken land away from food production, which has also contributed to rising food prices.
I was technically incorrect to use the term "no access," since people can go to the emergency room or a local ghetto or rural clinic, then score a point for you...
No, I'm not saying your statement was incorrect only in a technical or trivial sense. It's wrong in a major, substantive sense. There is a vast amount of health care readily available to the uninsured and poor through public and private agencies and programs. They don't have to rely on the ER, or drive hundreds of miles, or fill out endless paperwork, or jump through other hoops. The federal Community Health Centers program alone operates a network of hundreds of clinics and health centers that provide comprehensive health care services to millions of poor and uninsured people. Of course, in a nation of 300 million people, you will always be able to find individual horror stories (like Michael Moore's "which finger do you want to lose" example). But in general it is simply not true that the poor and uninsured cannot get health care, or can only get the most limited services.
And no, I'm not looking for things to quibble with. A lot of what you say is sensible and nuanced and I agree with it. But then occasionally you make these really stupid statements that suggest you've bought into the lies and propaganda of the far left ("If millions of Americans don't have access at all...").
scent,
Sigh. Mixner, this is not evidence. For this to be evidence, even provisionally(what is a 'premature death', for example? what are the metrics for determining the percentages?), you'd have to show that people in other countries are actually practicing those healthier life styles. No such evidence has been offered, in fact
Right, you just imagined reading the information I posted on the health-related lifestyle and behavioral differences between Costa Ricans and Americans, for example.
But in fact, the burden of evidence is yours, not ours. YOU are the one attributing health and lifespan differences between nations to differences between their health care systems, so it's up to YOU to provide evidence that health care differences are the cause rather than some other difference or set of differences, such as diet, exercise, smoking, pollution, crime rates, accident rates, drug use, climate, etc., etc. So where is your evidence for your proposition? Produce it.
Mixner,
Now it really does appear that we have a different understanding. You seem to be saying that most poor people, such that it qualifies as a general rule, have health care that amounts to more than just handing out aspirin, treating common colds, taking blood pressure, and giving medical advice.
In my case this type of care would include a prescription for Advair, which is very expensive without insurance, which would be very difficult for me to afford if I had kids, for example, and which is necessary for me to breath easily.
I also don't have to think very hard to think of people I know who have had children with serious illnesses.
You seem to be saying that these people would have options even without health insurance. That strikes me as something that even those on the far right don't believe, so even though you may be right, you must forgive me for finding this to be a counterintuitive claim, and it seem appropriate for you to provide some good evidence for this claim.
If this care amounts to more than treatments for the common cold or tests of blood pressure, and includes things like dialysis, prescription drugs somewhat comparable to those with insurance, and truly is as available (or even downright ubiquitous) as you say, then I will defer to you on the issue and change my mind.
Now it really does appear that we have a different understanding. You seem to be saying that most poor people, such that it qualifies as a general rule, have health care that amounts to more than just handing out aspirin, treating common colds, taking blood pressure, and giving medical advice.
Educate yourself. Here's a good place to start: Community Health Centers
And here's a description of the statutory minimum set of services that Community Health Centers must provide under federal law. Note, this is not a complete list of services typically provided, just the minimum required:
Mixner, first, read what I wrote: "our health outcomes aren't any better" than other countries'. They aren't. Name a single thing you would accept as a health outcome, and it's not significantly better in the US than in other advanced countries; in most cases it's worse. I didn't list a bunch of outcomes, you did. But go ahead and list 'em. They're no better in the US - with one exception, which we get to below.
Furthermore, while life expectancy isn't a good overall proxy for quality of the health care system, infant mortality is. It just is. There's no way to get low infant mortality stats besides having a good health care system. Compare infant mortality stats in, say, Cuba and Nigeria; Cuba has low infant mortality stats because its health system is better. Same deal with Vietnam vs. Indonesia, which is actually considerably richer. Is a lot of that antenatal maternal health stuff, rather than quality of postnatal care? Why yes it is -- which is why antenatal maternal health is part of a country's health care system, because it saves babies' lives. The US's antenatal maternal health system for low-income women is vastly inferior to that of France or Holland, which is part of why our infant mortality stats are worse.
Now, cancer survival rates are not the "clearest examples of" data on health care outcomes. They are just the one piece of data on which the US, for some types of cancers, clearly does better than many countries with universal health care. That's the only shred of evidence that there is an area in which US health care outperforms that of other rich countries; and it's not conclusive because the problem is that the US detects many kinds of cancers earlier than do other systems, so "survival rates" is partly an artifact of listing the date of diagnosis earlier.
The US doesn't have noticeably better health outcomes than other rich countries do. In many areas we're worse; in one area, that I know of, we're better. We do however spend twice as much as any other rich country on health care, and unlike them, we don't insure 1/7 of our population. That's the data set you have to work with to justify our system.
Who has suggested that the military and police are not legitimate responsibilities of government? - Mixner
No one. They have suggested, as I said, that the government's military and police functions could be performed more cheaply and better if much of it were contracted out to private corporations. Have you heard of Blackwater? KBR? It turns out that private contractors don't do this work cheaper and better. They do it more expensively and worse.
In most countries, not just the U.S., health care delivery is provided almost entirely by the private sector (Britain is a rare exception), and in most countries, a significant amount of health care funding is also provided by the private sector. Which of these do you seek to provide through the government instead of the private sector? Health care delivery? Health care funding? Both?
As I wrote, genius, "...a lot of kinds of safety inspections, and health insurance." "Health insurance" kind of sounds like funding, rather than delivery, don't it?
Read first. Then think. Then write.
In a similar thread some months ago, I posted references to several papers in public health journals that studied the correlation between infant mortality and income in New York City, London, Paris, and Tokyo. Every paper showed a strong correlation in New York but virtually no correlation in London, Paris, and Tokyo. I also cited a paper, the only one I could find, showing an example in the US in which there was no correlation between infant mortality and income level. This was on a US military base, in which the medical system is essentially the same as the National Health Plan in Great Britain. In our military Judy O'Grady and the colonel's lady are entitled to the same medical care.
To me, this suggests that the ability of expectant mothers to afford antenatal maternal health plays a strong role in infant mortality rate, no matter how the statistics are counted. I wonder what it suggests to Mixner (other than that I'm lying).
Mixner,
I mentioned that I was concerned about expensive prescription drugs, parents with seriously ill children, and how many of these types of centers there are.
While it looks like a very nice system, I don't see the information I was looking for. What I saw was nice, but it still seems like a far cry from the type of care that people get who have insurance. And you've got to believe that people in Japan and Australia have better options than this right?
I do see now how many of these centers there are Mixner, but if the services provided were supposed to make me feel better about universal access, they don't.
You may reply that this is just a value judgment, but that's what I've been getting at all along.
Universal access means access to the..."good life" of health coverage like those with good insurance here or those in Japan or Australia.
Once again, you may be technically right that it's not true to say that millions of Americans have "no" access, but these health centers were not the kind of access I was aiming for.
Once again, I don't see how expensive prescription drugs (like so many of them are) are covered or parents with seriously ill children would be served by these health centers as well as they would with the access that those with insurance have.
Re: Rationing, waiting lists, suffering, death, denial of drugs, tests and surgeries. That kind of thing.
Um, we have all these things too. Where have you been lately? You will wait weeks if not months for certain types of surgeries (my cousin waited three months for disk surgery on her back and was very nearly bedridden in that time). And go to any ER on a busy night for long, long waits. Nor am I aware that we Americans have founded Heaven on Earth, banishing suiffering and death from our midst. As for denials of drugs, have you checked out the fine print in your health policy? I have one of those gold-plated corporate plans but there are drugs not covered on that. Likewise all policies impose limits on procedures and tests.
Re: Show me your analysis proving that our health care system causes more suffering, death, lack of access to drugs, etc., than your favored alternative.
Visit a bankruptcy court. This is one sort of healthcare-related suffering you will not find in other countries. Again, let's not obfuscate the issue: universal healhcare has been shown repeatedly to provide adequete (adequete, not perfect) levels of care and are extremely popular. They are as such a superior product.
Re: Actually, there is plenty of evidence that Britain, Canada and France, for example (countries with health care systems dominated by public funding and strict regulation), are moving towards a greater role for private funding and deregulation. They haven't "gone over" to our system, but they're moving in that direction.
Britain, Canada and France all have very different systems, as unlike to each other as they are to ours. And saying they are moving toward our system is absurd. They are introducing some minor and perhaps mid-level reforms that very distantly resemble some features of ours. However, on the major issues-- universality and public funding-- hell will freeze over, the sun will rise in the west, pigs will fly and George Bush will enter into a gay marriage with Hugo Chavez before these would be abandoned.
Re: I think they probably have better health, in general, than America. Not because of better health care systems, but because their lifestyles and cultures are less conducive to unhealthy behaviors
It's just plain weird the way rightwingers reject any criticism of the US when leftists make it, but they happily run down their country when grasping at straws to deny a reality too much at odds with their ideology. But once again: lifestyle ills, from obesity to alcoholism, are universal. Some nations may do slightly better in one area, but worse in others (e.g., the French aren't as overweight as we are, but they smoke more). Overall though there isn't enough of a difference to matter. (Also, re: genetic diferrences -- most Americans have European ancestry so that dog doesn't hunt either.)
Re: but increasingly, doctors in the UK are trying to get patients off life support more quickly, maternity wards are stacking moms in labor in waiting rooms so they don't get into the statistics, and old people with broken hips who would get a hip prelacement and be walking the next day in the US stay in bed for weeks because hip replacements are too expensive.
The UK is not a good comparison: the NHS is extreme by world standards, and it resembles something you'd find in Soviet Russia rather than a first world democracy. No one is proposing anything remotely like the British NHS here, so this is a red herring.
Re: you still don't seem to understand that average life expectancy, infant mortality rate, and other aggregate national health indicators are not the "outcome" of the health care system
OK, let's grant that for the sake of argument. That being the case though, why not move to a universal system? It won't affect those factors for good or ill, and we'll have a more just and more efficient system. Again, what's not to like?
Re: The clearest example of such data that has been cited here is cancer survival rates.
These stats, as cited by the Right, are deeply cooked and marinated with taurine byproduct. No one ever defines what they mean by "survival". Does that mean that the cancer is successfully treated and the patient dies eventually, cancer-free, of other causes? Does it jsut mean a terminal cancer is diagnosed sooner and the patient really doesn't live any longer (in the absolute sense) than he would elsewhere? Does it merely mean that the terminal phase is prologed in the US, so that we are morel ikley to spend datys or weeks longer about the business of dying? These "cancer survival stats" can mean so many diffrerent things that they are meaningless.
Infant mortality stats are really, really complicated.
To start: there is a huge difference between black and white infant mortality rates in the United States--a difference that persists even when you control for income, education, prenatal care, family support, and everything else the researchers could think of. Black women are not only vastly more likely to have premature babies, but also more likely to have early preemies. That drives a very strong correlation between income and infant mortality, because unfortunately, in our country race is correlated with income. It also raises our infant mortality rate generally--when over 10% of your population has a 2x-3x higher risk of early premature birth, your infant mortality statistics shoot up fast.
Free or reduced cost prenatal care is pretty easily available to basically any woman who says she needs it--that's something that pretty much everyone to the left of the minarchists has long agreed on. There may be differences in our social system for pushing women into pre-natal care, but access to adequate healthcare services during pregnancy and birth is not driving infant mortality rates. Post-natal care for newborns is similarly obtainable, as anyone who's ever gotten their healthcare at a Medicaid mill can attest--the place is postered wall to wall with advertisements in four languages for pregnancy and infant care programs.
Meanwhile, the United States leads the world in declaring low-weight babies infant mortalities rather than stillborns. If its chest ever expands to take in oxygen, and its over 400g, we call it a baby. Even other developed countries would call many of those a stillbirth, and developing countries put the threshhold much higher still, because a country like Cuba doesn't have the resources to care for very early preemies. Or at least, that's the theory, because as far as I can tell all of the Cuban infant mortality data, and all the other data on the magic of their health care system, comes from the Cuban government, which clearly enjoys bragging to foreigners about the magic of its health care system, and just as clearly is not above a little information control. So who knows what relationship it bears to reality?
Yes, and this type of statistical magic also emanates quite profusely from the German health care system as well. I suppose a major benefit from our coming romp with socialized medicine is that all the squabbling will cease as a central authority under a strong federal bureaucracy takes over, with close monitoring of speech to make sure malfeasance and negligence are more effectively hidden.
Of course we can all rest assured that the medical malpractice lawsuit industry will gladly give up their business once their allies in the Democratic Party tell them to. It's the party that tells the labor unions and trial lawyers what to do, not the other way around.
/snarktasm
Without quantitative data, Megan's post about the different methods used to define infant mortality settles nothing. If some study from a reputable source tells me that the US infant mortality rate would be the same or lower as in western Europe if infant mortality was defined in the same way, I'll concede the point. If not, I won't. The same goes with regard to the effect of life style on life expectancy. Americans weigh more than Europeans, but they smoke more. Which effect wins? And finally, is Megan really contending that universal medical coverage in the US would not improve the health of our poorer brothers and sisters?
Oops, I meant to say that Americans weigh more than Europeans but Europeans smoke more. Which effect wins?
"Nevermind the fact that the US doesn't even have the highest longevity. Instead someone who cleary doesn't even understand econ 101 is going to attempt to chide posters for not understanding econ 101. It is called ECONOMIES OF SCALE."-freddiemac
Freddiemac clearly doesn't understand that--as others have made abundantly clear above--longeivty is the result of a lot of things like diet, genes, exercise in addition to health care. If he had ever studied much econometrics, he'd realize that one has to include all the relevant variables to determine ceteris paribus effects.
He also doesn't understand that when one is making an calim--it doesn't suffice to simply assert something, one has to actually provide some kind of argument. Asserting that "economies of scale" will make nationalized health care more efficient than a private system doesn't make it so. He probably thinks that "economies of scale" should make the LA public schools better and more efficient than the competing private schools. The fact that the evidence proves that to be incorrect should come as no deterrent to someone who prefers fantasy to evidence.
Moreover, it seems quite dishonest to pretend that those of us who resist a socialist system think the current system is just dandy. The current American system needs reform. There is waste and in some cases we are not getting good value for our money. There is no one quick fix that will solve the problem but a whole series of market-oriented reforms are necessary. One of these is (as McCain proposes) to remove the asymmetry between employer provided insurance and insurance purchased by the individual.
It is also dishonest to pretend that those of us who resist government control of our health care do not care about the poor. I strongly believe that poor people ought to receive a subsidy for their health care. I just don't think affluent people should recieve one.
Personally, I don't need government help and don't want it. I would be happy if--in health care--the government would just leave me alone. Some people here seem so addicted to their utpoian socialist visions, though, that not all the evidence in the world about filthy British hospitals and older people left to die untreated will punture their delusions. Nor do they care that cncer treatment is clearly inferior nder the NHS. Nor yet do they seem to care that government "care" woud mean a substantial loss of freedom.
No, "Workers of the world unite," they blithely cry. Because government efficiency has been so manifest at the Post Office, at the INS and in the public schools. And who can forget the wonderful efficiency on display in the Soviet Union in an earlier age? Reflecting on all of that, it's hard to believe that anyone would be skeptical of claims that govenrment monopoly would bring enormous economies of scale, right?
Gimein is a little bit disingenuous here. The 2.3 trillion in national health spending is not entirely insured by just the 5 health insurers covered in his article. The correct comparison would be the ratio of the total medical spending of the policy holders of these five companies to the profits of these five companies. This correct ratio should be a bit larger than the one that he gave us.
"What you're claiming, then, is that the government presently has a budget surplus more than sufficient to begin covering a national healthcare scheme, or at least some sort of national health insurance/indemnity scheme."
Nothing I wrote could possibly be interpreted that way.
That could not even possibly be passed off as an honest misinterpretaion of what I wrote.
What I wrote stated that because the IRS is already collecting bills for the government, they can collect bills for government run healthcare more cheaply, at marginal cost rather than the unit cost that a private insurer must pay. How you could possibly twist that into what you claimed I said is a matter for psychiatrists or possibly theologians.
I looked up some numbers, I was way off about the percentage of healthcare costs in the last month of life. I remembered hearing it from an alleged expert, but it just ain't so.
rwe, Clinton's plan calls for requiring people who do not receive medical insurance as a job-related benefit to purchase it privately, with a subsidy (based on income) provided by the government. Obama's plan is similar but more restrictive in that it affects only the children of those who don't get insurance through their employers. I do not consider either plan to be socialized medicine.
I also don't understand your contempt for the British health system.
The UK has had several Conservative governments since the National Health Plan was brought in by Labour in the 40's. None of these governments, including Mrs. Thatcher's, has tried to privatize British medicine. Why do you think the Conservatives stick to a system you feel is so awful? Is Great Britain a dictatorship? Why don't the British go for our wonderful system? I'm interested in your answers.
"Dunno about healthier eating. As I understand it, the Japanese diet is very high in sodium"
While high blood pressure relates to health problems, and high sodium intake raises blood pressure, there is no known relation between high sodium intake and any health problems. It is an odd, counter-intuitive result, but it has been studied quite a bit.
Stan, just as a preface, I got a little carried away in my post above. Freddiemac irritated me, but that's not the sort of tone I usually take.
As for Britain, I think Mrs. Thatcher would have liked to privatize the health care system, but it was not politically feasible to do so. It is much easier to get into a socialist system than to get out of it. Why do the British not want to privatize? I think they are under the impression that the only alternative to a government system is complete laissez-faire, in which the poor just persish without treatment. There would also be enormous transitional costs. They might be able to move to a better system in time, but their medical system might experience a painful period of chaos as they attempted to make the transition. That gives us all the more reason to be wary of socializing medicine.
Now, I have a special distaste for the NHS because I saw it up close. I have had relatives treated under it. One was clearly allowed to die without treatment because treating her would have been expensive. Another was taken off of a drug his doctor considered important because it was expensive.
And I got the strong impression from my time in Britain that these were not isolated cases, that Britain holds costs down by rationing care. Numerous studies of waiting times in Canada, for instance, shows that rationing is pervasive there as well.
It still strkes me as a macabre calculus for the government to be deciding that someone doesn't deserve treatment--someone who has a small but finite chance of survival, and someone whose treatment will be pricey.
Again though, I think reasonable people ought to be able to disagree respectfully. So I shall endeavour to maintain a more moderate and respectful tone than I had above. That was a momentary lapse.
No, that is not 'evidence', that is a popular article, with ill-defined terms and no citing. What is 'premature death'? What do they mean when they 10% to type of health care? No studies cited. How about something from JAMA, or the AMA or WHO?
Further, YOU are the one who asserted the different outcomes were due to something else besides type of health care, that in fact those other things predominated. If you want to say that the Japanese populace has a 'healthier lifestyle', you're going to have to define what that means, and you're going to actually have to back that up. Since I've already posted stats on smoking incidence being much, much higher in Japan, I'd say you have your work cut out for you.
I might add at this point that since you believe that 3x=y, does not necessarily mean that 6x=2y (you said it 'depends on the study' as I recall), so I'm not even trying to refute your nonsense that is just being reposted from the last go-round; I'm just pointing out the futility of anyone trying to change your mind, and the degree to which you will utter patent nonsense.
Props, Njorl, on the acknowledged misrememberance. I tend to mangle numerical memories quite badly myself, so I can't throw stones from my glass house. Whatever the correct ratio is, it still raises as many questions as it answers I think.
Y'know, all of this was quite thoroughly debeunked on the last go-around. This is from just this February:
As I pointed out last time, if you look at the second line in the mortality tables, life expectancy from one year, this eliminates any variation one might expect from infant mortality. If you look at life expectancy past the 'dangerous years' to eliminate violent crime and accidents, say from 30 years on, you still get higher life expectancies.
I notice that most of the same people here were posting the last time, yet somehow, these facts just went down the memory-hole.
Why is that, I wonder ;-)
ScentOfViolets: How do people 65 and over fare? At that point, our Medicare system is in full swing, presumably leveling the playing field between Americans and Canooks. And what are the breakdowns in terms of gender, race, and income groups? Statistics are all well and good, but they still don't answer the question of causality.
As the famous quote has it, politicians use statistics like a drunk uses a lamppost: for support rather than illumination.
SoV,
Your analysis shows that life-expectancy differences are not due to infant mortality, but it does not show that infant mortality differences are not due to differential reporting.
That said, as often as I have seen it asserted that the US counts infant mortality differently, I have not found an authoritative source to back this up. Anyone got one?
Sigh. The time for you to have made those observations, MarkG, is _before_ they were provided. Why didn't you say something earlier, when people were talking about variable infant mortality definitions as being a significant source of disrcrepency?
And why aren't you asking the people who claim it's all about the 'lifestyle' to actually back up this assertion with some data?
To the contrary, they do. This is a misunderstood idea, and used to great effect sometimes by people who really should know better. Now, it's true that correlation does not imply causality. But in the other direction, causality certainly implies a correlation. So it follows that a _lack_ of correlation implies a _lack_ of causality.
Sigh. I was responding to the claim that variations in life expectancy were at least in part because of variations in the differences in the way infant mortality statistics are reported. It says so in the post.
I'll say it again, that's definitely not the case.
I checked the life expectancies at age 65 for the US and the UK.
In 2000, they were virtually identical: about 16 for men, and 19 for women.
SoV, have you talked to a doctor about your respiratory problems? You even sigh when I agree with you.
I'm not saying you did something wrong, I'm just asking if you (or anyone else) has any more information to hand. Infant mortality is an important metric apart from its influence on life expectancies.
I dunno. Sheer middle-age perniciousness. Or the desire to make the world safe for peace, justice, and the American way. I forget.
brooksfoe,
Mixner, first, read what I wrote: "our health outcomes aren't any better" than other countries'. They aren't.
What, excactly, do you mean by "health OUTCOMES?" "Outcomes" of WHAT? Average life expectancy and infant mortality rate are health indicators. As I have explained to you over and over again, these health indicators are the "outcome" of a huge set of variables that influence health. They don't tell you anything meaningful about the performance of a nation's health care system. What part of this isn't clear to you?
Furthermore, while life expectancy isn't a good overall proxy for quality of the health care system, infant mortality is. It just is.
No it isn't. Again, you just don't know what you're talking about. A nation could have the best health care system in the world, and still have average rates of infant mortality due to other factors like a high rate of drug and alcohol use by pregnant women, or a broad definition of "infant mortality" to encompass deaths that other countries would classify as stillbirths. Both of those examples apply to the U.S.. We've been over this repeatedly.
Now, cancer survival rates are not the "clearest examples of" data on health care outcomes.
They're the clearest ones I have seen anyone mention on this blog. What clearer examples of "health care outcomes" (and again, health CARE outcomes, not merely health indicators) than cancer survival rates can you provide us with?
They are just the one piece of data on which the US, for some types of cancers, clearly does better than many countries with universal health care.
Not just "some" types of cancer. Most types of cancer. And the difference is not small, it is substantial. If you get cancer, you are significantly more likely to be dead in five years if you live in Europe than in you live in the United States, because the health care system in the United States is simply much better at diagnosing and treating cancer.
I'll bite. How is this:
agreeing with me?
Is this just a statistical artifact from independent evnets, that the probability of A given B is the same as the probability of A (not given B)?
SOV,
I'll bite, too.
First, you cite Megan talking about differential reporting of infant mortality -- note that she is not talking about how this impacts life expectancy calculations at all -- and say "this was throuroughly debunked" by showing that infant mortality is not affecting life expectancy calculations.
Which is not at all what the text you quoted was talking about. This sort of makes your "debunking" less persuasive, as you were completely non-responsive to the text you quoted to debunk.
Then Rob Lyman responds to your post by saying that the facts you cited do show what you say they do but that they don't actually say anything about the text you say your were debunking: that is, the claim that infant mortality rates cannot be used to compare health systems (like between the U.S. and Cuba, as Michael Moore did) because of different reporting standards.
He didn't explicitly ask if you had information on that in his original reply but he did in the follow-up.
So I guess, in a nutshell, the way this:
is in agreement with your post saying that infant mortality doesn't affect life-expectancy differences is because he says "You're right" in almost as many words.
Perhaps your confusion is because you thought you were debunking comparisons of infant mortality but were in fact arguing a different point entirely.
In an earlier post I asked if any scientific studies had been made showing that the relatively high infant mortality rate in the US is a result of the method used here to define infant mortality. I also asked if any scientific studies had been made showing that the difference between American life expectancy and the life expectancies in countries with universal medical insurance is due to life style rather than health care. By "scientific studies", I meant refereed papers appearing in scholarly journals.
I have not seen any responses. Mixner, where are you?
I tend more towards the sociobiological explanation to explain the US infant mortality rate. I think the differential statistics idea is interesting, but like Rob, I've yet to find an authoritative source.
I don't think this is proof by any means, but here's probably where a lot of this started.
The following text comes from a 1992 CBO report on infant mortality (link below):
These measures still do not provide an entirely valid basis for
comparison, however, because they only include fetal deaths of 28 weeks or
more gestational age, which is the minimum gestational age required for fetal
death reporting in many industrial countries. Consequently, if births below
28 weeks gestational age are classified as fetal deaths, they will not be
included in either the infant mortality statistics or the alternative mortality
measures. Limited data from Japan, Norway, and the United States—the only
three ICE countries for which data on fetal deaths below 28 weeks gestational
age are available-suggest that births from 20 to 27 weeks gestational age are
more likely to be classified as live births in the United States than in the
other two countries.
The relevant data in the CBO paper comes from:
Robert Hartford, "The International Collaborative Effort on Perinatal and Infant
Mortality-Overview and Major Results," paper, International Working Congress on
Problems of Infant Mortality in Europe, sponsored by the Union of National European
Paediatric Societies and Associations, Dusseldorf, Germany, October 18, 1991
http://www.cbo.gov/ftpdocs/62xx/doc6219/doc05b.pdf
About Costa Rica having such an abysmal health care system: that's not what WHO says. Here's a list (I've tried posting several times now, but I'm not getting through, so I'm not giving the link.)
Look at the relative positions of Costa Rica and the U.S. :-) Just goes to show you don't need to lot of money to get quality.
Stan, most people on that side of the isle don't do scholarship. The one coherent reason I could get was that it was "too hard, and not appropriate for a blog".
Bob, you're right. I made a mistake. My apologies, Rob. Just goes to show what happens when you go by what you assume, rather than what you see.
Oh, no apology necessary.
Stan,
I also asked if any scientific studies had been made showing that the difference between American life expectancy and the life expectancies in countries with universal medical insurance is due to life style rather than health care.
I haven't said the difference is due to lifestyle. I said we don't know what the difference is due to. "Lifestyle" differences are one possible contributor.
If you agree with me that we don't know the cause of the "difference between American life expectancy and the life expectancies in countries with universal medical insurance," great.
If, on the other hand, you're asserting that the difference in life expectancy is due to differences between health care systems, then you need to present evidence to support that claim.
SoV,
That WHO 2000 study is littered with problems. In the report, and the data tables, you will see the US is ranked #1 in 'Responsiveness' or (combination of patient satisfaction and how well the system acts). However, in order to get result more in tune with what they want, they made actual performance and satisfaction worth 1/8 of the final score, equals to responsiveness distribution (RD).
RD does not take into account absolute levels of care, which favors countries with poorer care, since it will be more evenly distributed (banning healthcare above first aid would top out this metric). We're also tied for 3rd there anyway.
Responsiveness is also weighted at half that of "Financial Fairness" a metric that basically just pushed socialized medicine higher, without regard for actual healthcare outcomes.
Disability-adjusted life expectancy is also ranked at 25%, and while this is a rough indicator of health, there are many factors (accidental deaths, violence, racial demographics, lifestyle) which can move this number. Since on the high we we're talking 1-4 years between the US and the highest countries.
The other quarter is DALE distribution, which can be even more skewed by the factors above.
The numbers were weighted in such away to push certain countries up, certain ones down and to weight non-healthcare issues above healthcare ones.
Mixner, to me there's a prima facie case that better health care, particularly preventive care, increases longevity and decreases infant mortality. The suggestion you're making, that better health care DOESN'T increase longevity and decrease infant mortality, strikes me as so absurd that it requires some form of factual backing. And if, mirabile dictu, your suggestion about lifestyle being the main determinant of longevity is true, why do you bother going to the doctor?
Stan,
In an earlier post I asked if any scientific studies had been made showing that the relatively high infant mortality rate in the US is a result of the method used here to define infant mortality.
http://www.ncbi.nlm.nih.gov/pubmed/11862950 Registration artifacts in international comparisons of infant mortality
http://www.cmaj.ca/cgi/content/full/163/5/497
Comparing international infant mortality rates
http://ije.oxfordjournals.org/cgi/content/abstract/24/3/583?ijkey=89d07bf879aaf455f35072d957365525b3ab5ac3&keytype2=tf_ipsecsha
International Rankings of Infant Mortality and the United States' Vital Statistics Natality Data Collecting System—Failure and Success
http://www.cbo.gov/doc.cfm?index=6219&type=0
Factors Contributing to the Infant Mortality Ranking of the United States
http://www.popline.org/docs/0859/230426.html
Problems in the international comparison of infant mortality figures
And you know the intent behind the ratings . . . how? Would you care to also speculate as to why anyone would want to do such a thing?
stan,
Mixner, to me there's a prima facie case that better health care, particularly preventive care, increases longevity and decreases infant mortality.
Then there's a prima facie case that a better diet, more exercise, less crime, less drug use, lower pollution, less gun violence, stricter health and safety laws, and a million other things also increase longevity and decrease infant mortality. But you cannot jump to the conclusion that international differences in longevity and infant mortality are due to any of those variables any more than you can jump to the conclusion that they're due to health care. You need evidence. Do you have any?
The suggestion you're making, that better health care DOESN'T increase longevity and decrease infant mortality,
I never suggested any such thing. There is evidence that health care generally has only a small effect on aggregate morbidity and mortality rates, but not that it has no effect at all.
SoV,
The only reason I can see for weighting "Financial Fairness" twice as much as "Responsiveness" is to game the results. You are no longer measuring the effectiveness of the health system, but how it compares to the model one you desire.
Their intention is irrelevant here, that data is pretty useless in that discussion. From their report we are #1 in responsiveness, 3rd in responsiveness distribution, meaning we get better care, higher satisfaction and the same distribution of that care across society as France, Canada and the UK (but at a higher level).
Devaluing those numbers by factors barely if at all related to actual healthcare (DALE, Financial Fairness) is an exercise in sophistry, and does nothing to tell us how that system treats patients.
Iow, you have no idea why, and haven't bothered to research why that measure is used or weighted the way it is, but you'll speculate perjoratively anyway.
brooksfoe,
As I wrote, genius, "...a lot of kinds of safety inspections, and health insurance." "Health insurance" kind of sounds like funding, rather than delivery, don't it?
But why not health care delivery too? After all, the drug companies and MRI manufacturers and nursing agencies and pharmacies are making profits "off the backs of the sick" just like for-profit private insurers are. And why not other kinds of insurance (home insurance, life insurance, auto insurance, disability insurance, mortgage insurance, credit card insurance, etc., etc.)? Why only health insurance? Do you have a principle or standard to justify your bizarre grouping of health insurance as a function of government, like defense and criminal justice, rather than as a function of markets, like pretty much every other kind of good and service we consume? I know I've asked you this question before, but you've never given me a clear answer.
scent,
Look at the relative positions of Costa Rica and the U.S. :-) Just goes to show you don't need to lot of money to get quality.
skullberg has pretty much covered this, but just to reinforce the point, the only actual health measure used in those rankings is DALE, and DALE is influenced by a vast range of variables in addition to health care. You cannot draw any meaningful conclusions about the "quality" of health care from these rankings. It's a political document, not a medical one.
Stan, most people on that side of the isle don't do scholarship.
Oh, the irony.
Likewise, you have no clue why they are weighted that way, yet you speculate positively. I've shown you why I reject those numbers because 75% of their scores aren't based on healthcare, but on factors related more to economics, demographics and lifestyle as well as other things.
This is not a measure of world health systems effectiveness, this is a measure of world societal structure as compared to the WHO's ideal. If you can find persuasive reasoning as to why they chose to rate actual healthcare interactions 1/6 as much as those other factors, I will listen.
No. You're the one claiming that the relatively poor stats despite the high costs of health-care are because of 'lifestyle choices'. So prove it. Put up or shut up. Don't try to pretend you haven't done so:
And in fact, the way we pragmatists argue is thusly: health care costs are rising much faster than inflation, health care in the U.S. is just about as expensive as it gets anywhere in the first world anyway, and outcomes for the U.S. system don't appear to be any better, in fact, in many cases worse for all that is spent. So why should we continue with the present system?
And various speculations have been offered. But very little evidence to back up those speculations. If you want to claim that it's because other countries have 'healthier lifestyles', fine. But be prepared to offer some actual evidence for this hypothesis. You know, the evidence you claimed was 'overwhelming'.
scent,
As I pointed out last time, if you look at the second line in the mortality tables, life expectancy from one year, this eliminates any variation one might expect from infant mortality.
So what? That observation doesn't "debunk" the point that international comparisons of infant mortality rates are distorted by differences in definitions and recording practices. It doesn't say anything at all about such comparisons. It simply shows that there are international differences in life expectancies for age groups other than infants. Your claim that this "debunks" the infant mortality point is nonsense.
Mixner, I'd like to acknowledge the hard work you did in finding your references on the difficulties of comparing infant mortality rates in different countries. You've shown me that the US may not be worse than other countries in terms of infant mortality. This isn't saying much considering our wealth as a country and our large per capita medical expenditures, but it's something.
In your research, you missed this paper:
http://www.ajph.org/cgi/content/abstract/95/1/86
Its main conclusion is "In stark contrast to Tokyo, Paris, and London, the association of income and infant mortality rate was strongly evident in Manhattan."
To me, this suggests that access to medical care decreases the infant mortality rate. Apparently, to you it doesn't.
You also missed this one:
http://www.cbo.gov/doc.cfm?index=6219
This showed that correcting for differences in definitions regarding extremely premature births did improve the US's ranking slightly, but only slightly -from #22 in the world to #19 (for the years studied by the paper).
I return to a previous point. You seem to be an extreme lifestyle faddist in your approach to wellness. After all, if diet, exercise, and smoking are more important than medical care in causing a long and healthy old age, why waste time and money on medical care? I think this is the point you're making. I hope this works for you. Live long and prosper.
Sigh. No, I am not 'speculating positively'. I am giving a cite, a cite, moreover, which I would have thought to be nonpartisan and respected. End of story.
YOU are the one who is speculating. YOU are the one claiming that there has to be some sort of nefarious reason for the attributes selected and the weightings given. YOU are the one saying, 'I don't see why they use this, so it must not be useful'(argumentum ad ignorantiam.)
So why don't you actually do some research? Why don't you look up why WHO included this. Given that one of the objections to the U.S. system is it's inordinate costs for the given outcomes, to argue that economic indicators don't figure into rating a health care system strikes me as absurd.
It seem as if you want to ignore costs and questions of access(by which measure the U.S. fares badly) and concentrate on certain types of outcomes, outcomes which I suspect deal more with the high-end techno-glitz, where the U.S. does pretty good.
That's not a good rating system, imho.
scent,
You're the one claiming that the relatively poor stats despite the high costs of health-care are because of 'lifestyle choices'.
I didn't claim any such thing. We don't know what the causes are, but differences in "lifestyle" are a likely contributor, and may be the primary cause. Apparently, you think there are no significant differences in health-related behaviors (diet, exercise, smoking, drug use, crime, etc.) between different nations, a belief so implausible it's laughable.
and outcomes for the U.S. system don't appear to be any better,
On the contrary, the only "health care system outcome" for which evidence has been provided--cancer survival rates--indicates that the U.S. health care system is significantly better than European ones at diagnosing and treating the disease.
And this is why people dismiss you as a kook, Mixner. You've claimed this many times, not just on this thread, but elsewhere. I've quoted you, you know, where you said 'the evidence was overwhelming'.
And there you go again. No, I don't know if there are 'significant differences'. You, otoh, are claiming there definitely are. Let's see your 'proof', that the 'Japanese lifestyle choices' are healthier - healthier in spite of the fact that I've published WHO data that shows they are much heavier smokers than their American counterparts. Or is WHO ideologically suspect now?
What you are doing, in short, is trying to have it both ways, trying to claim that there are significant extraneous factors that tip the balance in favor of the U.S., without actually having to do any work in defending those claims. And quite transparently at that.
stan,
You've shown me that the US may not be worse than other countries in terms of infant mortality. This isn't saying much considering our wealth as a country and our large per capita medical expenditures, but it's something.
We don't really know how our true IMR compares to those other nations, because of the problems described in the papers I cited, and others. It might be much better, it might be much worse, it might be somewhere in the middle. We just don't have the data.
Also, it simply does not follow that because we spend much more per capita on health care than other countries, we should expect our true IMR to be significantly better. As I explained before, our true IMR might be average even if our health care system is much better than those of other countries at treating sick infants. Variables such as the rate of drug and alcohol use by pregnant women, the percentage of pregnancies that are multiples (a common outcome of fertility treatments), the percentage of pregnancies that occur in middle-aged women, the percentage of pregnancies to poor women, the percentage of pregnancies to single women, and so on, are likely to influence IMR independently of the quality of health care received by pregnant women and their babies.
scent,
And this is why people dismiss you as a kook, Mixner.
Statements like this is why people dismiss you as a drooling moron, Scent.
What you are doing, in short, is trying to have it both ways, trying to claim that there are significant extraneous factors that tip the balance in favor of the U.S., without actually having to do any work in defending those claims.
Since I am not making any definitive assertion about the actual causes of the differences in life expectancy between the U.S. and any other nation, I have no "claim to defend." We simply don't know what the causes are. But plausible contributors include lifestyle-related behaviors such as diet and exercise.
You have offered not one shred of evidence to support the belief that the difference in average life expectancy between the U.S. and other nations is due to differences between their health care systems. The only evidence that has been cited of the influence of the health care system on mortality is cancer survival rates, and that evidence strongly supports the conclusion that the U.S. health care system is superior.
stan,
You seem to be an extreme lifestyle faddist in your approach to wellness.
You really need to get a grip. I point out the utterly banal and non-controversial fact that lifestyle (diet, exercise, smoking, drug use, etc.) is very important to health, and that makes me an "extreme lifestyle faddist," does it? Pretty much any doctor would give you the same advice: follow a healthy diet, exercise moderately, don't smoke or do drugs, drink only in moderation, etc. Are they "extreme lifestyle faddists," too? This isn't exactly rocket science.
After all, if diet, exercise, and smoking are more important than medical care in causing a long and healthy old age, why waste time and money on medical care?
Another bizarre question. Just because lifestyle is very important to health obviously doesn't mean that medical care is never important. If you get cancer or fall off a roof medical care is obviously important regardless of how healthy your lifestyle is otherwise.
Sigh. Mixner, I've _quoted_ you saying this is the case. I did it right up there, and you said the 'evidence was overwhelming'. That's a quote. From you. Here, I'll quote them again:
Moving on, would you agree that Scandinavia, Japan, and Australia have rates of health and access to health care on par with ours?
I think they probably have better health, in general, than America. Not because of better health care systems, but because their lifestyles and cultures are less conducive to unhealthy behaviors (obesity, smoking, drugs, crime, stress, lack of physical exercise, etc.)
And that's why people say you're a kook - you're very big on this sort of denial.
Further, the onus is on _you_ to prove that its 'lifestyle differences' - in fact its logically impossible for me to prove its _not_ 'lifestyle differences' or some other factor (More evidence of kookery). I've shown that Japan has a much higher incidence of smoking. Looking at the WHO Global Infobase, we see the U.S. has a Physical Inactivity Index for both sexes over 20 of about 25%. For Japan, the comparable figure is 72%! For heavy drinking: The U.S. 5%, Japan 4% (binge drinking in Japan cuts across a larger age group: 6%, no info available for U.S.)
Iow, on some very significant 'lifestyle choices', Japan's populace makes comparable to much worse lifestyle choices. But there's bound to be some characteristic where Japan scores significantly better than the U.S., say consumption of fish oil for fatty acids, at which point you would say, "So now prove that it's not the lifestyle choice of consuming fish oil. You haven't _proven_ that it doesn't more than make up for the other deficiencies."
That's why the burden of proof is on you to show that 'lifestyle choices' make the bigger difference, and in Japan's favor, not on me to show that they don't. That, and the fact that you've already made the assertion several times.
Scent,
Sigh. Mixner, I've _quoted_ you saying this is the case.
Sigh. Double sigh. Sigh sigh sigh. No you haven't.
Further, the onus is on _you_ to prove that its 'lifestyle differences' -
You really are a drooling moron. I tell you repeatedly that we don't know what it is, and in response you keep telling me I need to "prove" it's "lifestyle differences." What part of WE DON'T KNOW isn't clear to you?
Still waiting for your evidence that health care system differences account for any part of the difference in average life expectancy between the U.S. and other nations.
I've shown that Japan has a much higher incidence of smoking.
You keep repeating this thing about Japan and smoking, but I have no idea what point you think you're making. Are you under the impression that someone has claimed Japan has a lower rate of smoking? They haven't.
I'm pointing out, kook, that the 'lifestyle choices' I've been looking up for Japan are _less_healthy_ than their American counterparts. Choices like smoking more than twice as much per capita, exposing more people to second-hand smoke, etc.
And this is where I cut you off again, after - chuckle - quoting you saying that you think it's all about 'lifestyle choices':
Note, btw, kook, that you claimed smoking was a significant 'lifestyle choice', but then say 'You keep repeating this thing about Japan and smoking, but I have no idea what point you think you're making.'
Or maybe not a kook. Just plain old-fashioned dishonest. Just like last time, feh.
I'm pointing out, kook, that the 'lifestyle choices' I've been looking up for Japan are _less_healthy_ than their American counterparts.
Well done, drooling moron. Now produce some actual evidence to substantiate those assertions, and also evidence regarding all the other differences between Japan and the U.S. in health-related behavioral, cultural and environmental variables, so that you can control for the effects of those variables on life expectancy and isolate the effects of the health care system.
After you've done that, try googling for some actual research and expert opinion on the causes of Japanese longevity.
SOV,
If you bothered to check instead of playing your stupid games you'd see that most experts believe that the main reason the Japanese live so long is their DIET. Last I checked diet was a mainly a matter of lifestyle/culture/environment, not health care.
kwf,
Oh, don't confuse him. I'm sure he thinks he's now "debunked" the research on the causes of Japanese longevity. Just like he "debunked" the research on international IMR comparisons. He's nothing if not delusional.
scentofviolets
"I've been looking up for Japan are _less_healthy_ than their American counterparts. Choices like smoking more than twice as much per capita, exposing more people to second-hand smoke, etc."
But you're just comparing current smoking rates. What about the rates 20, 30, 40 years ago? We know that the smoking rate in America was much higher in the past. What's happened to the rate in Japan? Smoking often takes decades to produce serious health problems, so the current rate doesn't tell you much. And what about the number of cigarettes? Maybe American smokers average many more cigarettes than Japanese smokers. To make a useful comparison you would need to compare something like the share of the population who are current or former smokers, or the average number of years of smoking per capita, or something like that.
A nation could have the best health care system in the world, and still have average rates of infant mortality due to other factors like a high rate of drug and alcohol use by pregnant women, or a broad definition of "infant mortality" to encompass deaths that other countries would classify as stillbirths.
I suppose all kinds of things could be true, but in the real world, drug and alcohol abuse is not higher in the US than in, say, the UK. Any time the US comes out behind on some stat, those with an interest in protecting the system will hunt for some reason why our stats aren't comparable to foreign stats because those nasty foreigners can't be trusted. But the question really isn't whether the US has dramatically worse infant mortality rates than Western Europe, Taiwan or Japan. The question is whether we have dramatically better rates, to justify having expenditures that are 1.7 to 2 times as high as theirs. And we don't.
But why not health care delivery too? - Mixner
Assuming you're not stupid, you know perfectly well by now what the distinction between health insurance and health delivery is. So give it up. Most reformers don't want to eliminate or sharply restrict private health care; they want to eliminate or sharply regulate private health insurance. There are problems with health care delivery in the US, but they're problems of overtreatment and excess expense, to which the main solution is reform of how bills are paid -- i.e. reform of the insurance industry. Mostly, the health care system isn't broken. It's the health insurance and payment system that's broken, and it creates most of the problems in the health care system.
Why only health insurance?
You can't keep asking people to reprise their entire argument in full, Mixner. It's just ridiculous. You have to treat the things that have already been spoken as spoken.
But this is just exactly why - as I explained - the burden of proof is on those who go with the 'lifestyle choices' theory. I can produce stat after stat after stat, and someone can still say that factor X wasn't considered, and that I have to prove that factor X doesn't more than make up for all of the other deleterious comparisons. 'You cross-compared the effects of a rice diet, you say, and found that the difference was neglegible? But you didn't take into account the effect that the rice grown in the U.S. was grown under different soil and water conditions. Until you account for that, you can't say for sure. Oh, you did account for that? Really? Rice in Japan is grown at a higher altitude above sea level than that in the U.S., did you account for that? If not, then you still can't say for sure . . .' Iow, it's very, very difficult to prove a negative. Which is why the burden of proof is on the other side.[1]
So, no, given that health outcomes are worse in the U.S., even though more money is spent, the burden of proof is on others to explain why the outcomes are worse if it's not the fault of the health care system.
[1]In fact, this is a standard ploy for those who got nothin' - try to put the burden of proof as much as possible on the other guy, and then claim that 'they are not convinced', that something else has to be done:
See. Btw, as I stated, when I produced those stats about smoking, drinking, and physical inactivity, my source is the WHO GlobalInfobase. Apparently I've got a quota of links that operate across posts, so that if I post more than four or five total, the next post with a link won't go through. So google on 'Who GlobalInfobase' for some informative stats. If you can't find it, I will use up part of my quota and post the link.
I did some research, how else do you think I found the weightings and definitions. Their reasoning is unpersuasive, and thus their overall rankings are unpersuasive.
That's quite the straw man, according to the WHO report the US is #1 in overall Responsiveness, the actual measure of the healthcare system and patient satisfaction. The US is also tied for 3rd in Responsiveness Distribution, how well that system performs across society. I wouldn't call that "far[ing] badly." That looks like top end stuff.
If we want to have a financial argument, fine we can have that. But presenting our system as 37th best, when it's actual performance is by their rankings is the best, doesn't do service to that end. We are at the tops in both service and access.
Saying we could get the same / better performance for less money is fine argument if you have data, but according to this report, our service will fall if we move towards a Canadian, French or UK style system as they provide lower service then we do now with no better relative distribution of that service. Now, that may be acceptable, but that should be the discussion.
We most definitely could move up in the WHO rankings by socializing and eliminating private rooms, end of life care and new drugs. I don't think that would make our healthcare system any better though.
Skullberg's posts have been especially good on this thread. He makes a persuasive argument against the WHO rankings.
Nevertheless, even if one accepts those rankings, the lesson is not what some have been claiming. France is #1 while the UK and Canada come in at 18 and 30 respectively.
Yet, in health care, France allows a much broader scope for the market than the UK and Canada. This means that those who posit a simple relationship--more government control brings better health care--cannot rely on the WHO rankings as evidence.
By 'did some research' you mean, 'clicked on link/cite I provided. I also see that you've gone from 'how else would you explain the rankings, unless they wanted them to come out a certain way', to 'their reasoning is unpersuasive'.
He does, eh? Where are those links he's used to his research? What do you see, other than bald assertion? Is this like your branding of broad swaths of people 'unpratriotic' for not wearing flag pins?
Yet, in health care, France allows a much broader scope for the market than the UK and Canada. This means that those who posit a simple relationship--more government control brings better health care--cannot rely on the WHO rankings as evidence.
Yes, just like I can say 'there are those' who oppose health care reform simply because it's less of a free market approach. 'There are those' who oppose it because it takes money away from the private sector. The 'there are those' - on your side of the fence who oppose it because they think people who can afford the health care they need should die.
Can we retire the 'there are those' empty assertions?
I think most people are merely being pragmatic, and using simple pragmatic diagnostics to identify a possible problem.
How it's solved, I don't particularly care, as long as the outcome is a better health care system.
So please take your insinuations elsewhere, Mr. I-get-to-decide-who's-a-patriot.
SoV,
What link/cite did you provide with regards to the WHO rankings. You want where I looked up, here you go:
WHO PDF here: Here
see "Box 2.4 Weighting the achievements that go into overall attainment"
CATO Critique: Here
Another Critique: Here
I had other but I can't find them now. The report is unpersuasive in stating any measure of healthcare performance.
Once again, according to the WHO, we are tops in System performance and satisfaction and equity of that system. You are the one proposing we change our system to be more like the ones performing worse.
I admitted their intentions, however obvious I believe them to be, are irrelevant. The numbers themselves discredit the report for any use other than headlines.
SoV, would you point me to the place where I called anyone unpatriotic for not wearing a flag lapel pin? If you can find it, I'll gladly rescind it. Otherwise please stop making the accusation. I myself have never worn a flag lapel pin, so it would be a little strange for me to attack someone else for not wearing one.
As for health care, if your argument is that we ought to take a close look at the French medical system and see what we can draw from it to improve our own, then I agree with you. I thought there were some people here (Stan, for instance) who wanted to import the Canadian or British system--which the French deride as socialized medicine.
Stan seems like a gentleman, though, so I wasn't attacking him personally for his pro-NHS views, which I believe are mistaken.
One thing I certainly prefer about the French system is that it offers much better protection against frivolous malpractice suits. So, anyway, it certainly has never been my argument that the US system needs no reform.
And as for Skullberg, I thought he was right to point out that there is some arbitrariness in the weightings used by the WHO rankings. That doesn't mean the rankings are useless, just that the relative weights ascribed to various factors are not sacrosanct. A different institution might well have given a greater weight to "Responsiveness" and put the US much higher.
That said, I do think there is good reason to doubt that we are always getting good value for our money. There are clearly lots of unnecessary tests and procedures performed, for example. I would very much like to see incentives adjusted to reduce the amount of waste.
"I thought there were some people here (Stan, for instance) who wanted to import the Canadian or British system--which the French deride as socialized medicine."
rwe, the Canadian system is not the same as the British system. The Canadian system is like the French. In the system used by Canada and France, medical care is provided by individual practioners and the insurance is provided by the government. This is similar to Medicare in the US. In the British system and in the system used in Spain, all medical care is provided by the government. The closest American equivalents are the medical systems used by the armed forces and the VA.
I don't favor either approach. I favor the systems used in the Netherlands, Germany, Switzerland, Japan, Singapore, Israel, lots of other countries, and the Commonwealth of Massachusetts. In these systems you are required to buy health insurance if (and only if) your employer doesn't provide it, and you receive a subsidy based on your income. To me, this reform would be the most conservative way of achieving universal coverage. To others, including Megan, I'm afraid, it's creeping socialism.
Stan, my impression was that the French system is quite different from the Canadian system. In particular, the French have managed to avoid the long waiting times that plague the Canadian system (and which is one of its most unattractive features). So if we were looking for an inspiration for reform, I would much rather look at France than at either Canada or Britain (which evidently you dont see as models either).
I'm also suspicious of proposals for sweeping changes. There are some respects in which American health care really is the best, as reflected in cancer survival rates, for example. The United States has significantly better cancer survival rates than Canada and dramatically better survival rates than Britain. Look here and here for example.
Of European countries, France has the highest survival rate, which again makes it appealing to me (as someone who with numerous family members who've had cancer). As the Times reports:
So rather than any radical reforms that might compromise the virtues of the American system, I would like to see more modest reforms that would fix some of the problems in our system without sacrificing its merits. One reform would be to remove the tax asymmetry between employer provided insurance and insurance purchased by the individual. Another would be to have some sort of government catastrophic health insurance, as in France.
I think these sorts of piecmeal reforms hold than more radical proposals. As economist Bill Easterly says, "Just say no to the big plan."
That last part should read:
I think these sorts of piecemeal reforms hold more promise than more radical proposals. As economist Bill Easterly says, "Just say no to the big plan."
rwe, we may be the last survivors in this thread. Re the French and Canadian systems, I think there are three differences: the French system is national and the Canadian system is handled by the provinces, leading to different degrees of coverage in different parts of Canada, in the French system individuals are expected to take out private insurance policies to cover things the basic policy doesn't, like private or semi-private hospital rooms, while the Canadians seem to discourage private coverage (I think), and the French system is always well funded and the Canadian system isn't.
I favor a Dutch-type system because it can achieve universal coverage, which I think is vitally needed, but it does so with the least possible disruption to the present state of affairs.
Alright Stan. I'm content to let the conversation end there (for now, anyway, I'm sure this topic will come up again). Please post links to any interesting articles you've read on the Dutch system.
I've enjoyed the exchange, and since SoV tells me I have jurisdiction in these matters, let me declare you officially a patriot.
rwe and Stan: as a coda, if the health care discussion in the US as a whole comes down to a Stan-and-rwe-style debate between left and right over whether we should move towards a French-style system or a Dutch-style one, I for one will consider my faith in the viability of open political discussion to be completely renewed.
I've spent the last 8 years with intermittent experience of the Dutch system -- both kids were born there -- and have had a lot of French doctors abroad (West Africa, mostly), and I really can't say I have a preference. Anecdotally it seems to me French health care may be better, but the French have a cultural advantage when it comes to service industries (the Dutch have a tendency to think pain is something you should shut up and cope with) so I'm not sure which works better for the US.
Two discussions of Dutch medical system:
http://tinyurl.com/3afy9h
http://tinyurl.com/5pogrf
Opening paragraph of a Wall Street Journal article on Dutch system:
http://tinyurl.com/5va7vs
The French public health care system is bankrupt. It's been running a deficit every year for the past 22 years. Cuts in services, or increases in taxes and fees, or both, are inevitable. See this piece for an overview. In 2004, a report on France's health care system commissioned by the French government concluded that the system would "collapse" within 15 years without "fundamental" reform. In response to this report, the government instituted some changes to reduce access and shift costs on to patients, but as the CMAJ piece notes these modest reforms don't go nearly far enough.
As for the Dutch system, like the U.S. system it is built around private, for-profit health insurance which brooksfoe claims has been "unambiguously proven" to be "more expensive and less efficicent" than public health insurance. Not only has brooksfoe failed to produce this "unambiguous proof" (or even anything remotely resembling serious evidence) but if he seriously believes his own rhetoric he should obviously oppose the private-insurance-based Dutch system also.
And this highlights the basic dishonesty and stupidity I see over and over again from critics of the U.S. health care system.
- Absurd, unsubstantiated empirical claims, e.g., brooksfoe's "unambiguously proven" nonsense.
- Argument by anecdote or irrelevant statistics ("My neighbor's friend's second cousin couldn't get health insurance because of pre-existing conditions!" "Country X has a lower infant mortality rate than we do!")
- Ignoring the strengths of the U.S. system. Ignoring the weaknesses of the health care systems in other countries. No attempt at any kind of comprehensive, balanced, impartial comparison.
The fact that in decades of debate no one has been able produce a clear, evidence-based case that is persuasive either to the American people or to medical professionals, health economists, and other communities of experts that the health care models of other countries (Britain, Canada, France, whatever) are clearly superior to the U.S. model strongly suggests that they are not. Different models have different strengths and weaknesses.
Mixner, you're misinformed. Here are three url's showing substantial support by doctors for universal medical coverage:
http://tinyurl.com/4zb2yc
http://www.pnhp.org/
http://tinyurl.com/45kkla
Here's one poll (among many) showing support by the US public for universal medical coverage:
http://www.angus-reid.com/polls/view/15715
I spent many years in academia, and I can tell you that ignoring evidence that undercuts your own position is not the path to fame and fortune.
You're also misinterpreting my post. I favor a Dutch type system for the US because it causes the least disruption to the present system and at the time has the ability to get everybody insured.
Do you oppose this type of system? If so, why?
Finally, I'd like to point out that even Mitt Romney, a guy well to the right of Czar Nicholas II, supported the kind of reform I favor when he was back in Massachusetts. Are you arguing that he was wrong, and that we should stick with the status quo?
stan,
Mixner, you're misinformed. Here are three url's showing substantial support by doctors for universal medical coverage:
No, I'm not misinformed. I really wish you would read what I write more carefully, and then I wouldn't have to waste so much time correcting your misrepresentations and nonsequiturs. I did not say there isn't "substantial" support among American doctors for "universal medical coverage." I said American doctors (actually, "medical professionals") have not been persuaded there is a clearly superior alternative to the U.S. health care model. As your very first link points out, for example:
I see no evidence that a consensus, or even a bare majority, of American doctors support adoption of the French model, the Dutch model, the Canadian model, or any other alternative model. The AMA does support expansion of health coverage through mechanisms like tax incentives and insurance regulations.
Here's one poll (among many) showing support by the US public for universal medical coverage
Polls have repeatedly found that a majority of Americans favor "universal medical coverage" in the abstract. But the answer they give to a brief poll question is very different to what they actually support when a real-world "universal medical coverage" proposal is presented to them and its potential problems and downsides are exposed and debated through the political process. All attempts to enact actual "universal medical coverage" have failed. Remember HillaryCare? This also includes state ballot propositions for "universal medical coverage" in Oregon and California that were overwhelmingly rejected by popular vote. If "universal medical coverage" is rejected by the voters by a 2-to-1 margin in two of the bluest states the country, it's hard to take seriously the claim that it has strong popular support.
Having said that, I think it's plausible that we will eventually have some kind of "universal medical coverage." But it probably won't be the kind of comprehensive, full-service coverage that you seek. Indeed, we already do have a certain kind of "universal medical coverage". See my earlier posts about the Community Health Centers program, which provides a wide range of health care services to Americans regardless of their insurance status or ability to pay.
Mixner, you're misinformed. Here are three url's showing substantial support by doctors for universal medical coverage:
http://tinyurl.com/4zb2yc
http://www.pnhp.org/
http://tinyurl.com/45kkla
Here's one poll (among many) showing support by the US public for universal medical coverage:
http://www.angus-reid.com/polls/view/15715
I spent many years in academia, and I can tell you that ignoring evidence that undercuts your own position is not the path to fame and fortune.
You're also misinterpreting my post. I favor a Dutch type system for the US because it causes the least disruption to the present system and at the time has the ability to get everybody insured.
Do you oppose this type of system? If so, why?
Finally, I'd like to point out that even Mitt Romney, a guy well to the right of Czar Nicholas II, supported the kind of reform I favor when he was back in Massachusetts. Are you arguing that he was wrong, and that we should stick with the status quo?
Stan, you just posted the same thing twice. I responded to it the first time you posted it. See above.
FYI to those who favor the French health care model, and other models dominated by public funding: One big reason why American doctors are unlikely to support adoption of these models is because they would stand to lose a huge amount of income. American doctors make around three times as much as their French counterparts. Some of this is offset by lower educational and insurance costs in France, but there's little doubt the incomes of American doctors would decline dramatically if health care funding in this country were to be shifted substantially further from for-profit private insurance to non-profit public insurance.
Ditto for nurses, pharmacists and other medical professionals. American nurses already earn far more than their European counterparts, but there's still a nursing shortage in this country. Reducing nurses's pay would likely exacerbate this problem.
Mixner:
Three issues. First, there is obviously something preventing the entire nursing staff of, say, the Netherlands (who speak fluent English) from emigrating to the US for the higher salaries here. That something is in large part all-embracing public and job-related benefits. Just try figuring out how Europeans survive, and take vacations and buy cars and iPhones, on salaries that seem meager by American standards; you'll start to see how this works.
Second, what that means is that doctors' salaries would not be able to fall as far as French doctors' salaries in the US if we adopted a French-style system, because people, including doctors, in the US need to earn more money. However, nobody is claiming that the US will cut its health expenditures by 40%, down to French levels, through health care reforms. The claim is that we can slow the growth in health care expenditures and eventually pay, oh, just 30% more than the French rather than 70% more, while getting better results. Most of the predicted savings come from reduced admin costs, not lower doctors' salaries. By forcing all of their private insurers to adopt a single common payment system, the French have eliminated a huge amount of waste.
Third, your claim that doctors will oppose a French-style system because it will cost them income is purely an observational one about political interests. It has no moral weight. In fact, doctors in the US make too much money; their position in a thoroughly non-free-market system, which insurance-driven health care inevitably is, allows them to suck far too much money out of the system. In a pure free-market fee-for-services medical economy with no publicly funded, mandated or regulated health insurance, there would be fewer doctors and most would make much less money. Of course, many Americans' health would also be far worse. We have a system with substantial regulation where end-users of health care mostly do not pay for services, and that system brings us vast public benefits. But the purpose of the system should not be to make doctors extremely rich. So it's important to keep in mind that while doctors might oppose a French-style system due to self-interest, doctors profit hugely from the current 40% public, heavily regulated and subsidized medical system, and we as health consumers should decide which system we want based on the merits, even if it stands the risk of making doctors slightly less rich.
As for the Dutch system, like the U.S. system it is built around private, for-profit health insurance which brooksfoe claims has been "unambiguously proven" to be "more expensive and less efficicent" than public health insurance.
The main difference between the Dutch and US systems is that the Dutch system has community rating, which eliminates the cream-skimming problem. Both systems are mixed public-private systems. In the Dutch system, government shapes the market more rationally by preventing private insurers from making money in ways that harm public health and increase the country's overall health expenditures. That way competition is directed towards productive areas: insurance companies compete to be more efficient and offer better plans, rather than competing to find the healthiest customers and shift costs onto everyone else, which is how it works in the US.
Here is how US health care costs are spent (2006 numbers):
$600 billion: Hospitals
$400 billion: Doctors
$200 billion: Prescription drugs
$150 billion: Insurance companies
http://www.consumerreports.org/health/doctors-hospitals/health-care-security/who-is-to-blame-for-high-costs/health-care-security-costs.htm
The truth is that US doctors and nurses are paid at roughly twice the OECD average.