Its the Costs, Stupid

In the last several posts on health care it is often pointed out that health insurance companies engage in dubious practices. For example, they’ll deny coverage for the most trivial of reasons. Many posting comments focus on this issue as well as others such as quality of care, the moral nature of providing health care, and so forth. While these are indeed problems with out health care functions here in this country my contention is that these are all side issues. The main issue is money.

For example, suppose we end the practice of denying people health care for pre-existing conditions. What would likely happen? The costs of health care and health insurance would probably rise. People with pre-existing conditions would have easier access to health care, and since they have pre-existing conditions health insurance premiums would have to rise and they’d also likely consume more resources driving up the costs of health care in general.

How about ending the practice of recission, what is the likely impact on health care costs? They would likely go up. People who would have otherwise had difficulty obtaining certain types of care would now have a much easier time. Hence they’d consume more resources driving up prices.

Then there is universal coverage. While it is unlikely that we’d obtain 100% coverage, we could probably get pretty close. But what would happen to costs? Again, people who don’t have easy access will have easy access and will in all likelihood consume more health care resources than they otherwise would. The most reasonable prediction is that costs would rise.

However, making all these changes is also desirable. Making sure that people with pre-existing conditions can obtain medical care that is not financially ruinous is a good thing. So is preventing the cancellation of an existing insurance contract for a ridiculous failure to report a minor health issue. But ending such practices alone will not improve the health care picture. In fact, it could very well make the picture bleaker by increasing the rate of increase in health care costs.

The big issue with health care is the costs. Both the magnitude and even more importantly the growth rate of health care costs are the primary reason for health care reform. I’ve described the health care issue as driving towards a cliff. Solving just these other issues is like saying you’ve adjusted the mirror, turned on the air conditioning, and tuned in a really great radio station. Sure they can be nice and helpful, but once you go sailing over the cliff they wont mean shit. Really.

Now ideally we’d like to control costs and maintain the current level of care or if possible improve it.[1] Addressing the costs issue should encompass both the demand side as well as the supply side of the issue.[2] Also, we can’t just look at other countries and implement that system and expect the same results. As Dave Schuler noted, Switzerland and the Swiss have a very different outlook on things than we do in the U.S. Part of the success there might hinge on that different outlook. Also, there is the size of the population. For example, Singapore has a pretty good health care system. It is also a tiny country with a miniscule population in comparison to the U.S. It is unreasonable to expect linear scaling if we were to move to the Singaporean model of health care…it might work, but the differences in size is pretty large making it a dubious proposition. Still, we should look at these systems that are doing better than the U.S. on the costs side of the issue. Maybe there are things that we can learn and implement here.

If the issue of costs and the rate of growth is not addressed, then none of the other stuff matters. We will eventually go right over the cliff and then all bets are off as to what will happen.
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[1]Improving care while contorlling costs will be very difficult, as the saying goes, “Faster, better, and cheaper–pick two.”
[2]Please do not read “supply side” to mean the macro economic policies that were popularized under Ronald Reagan. I’m talking about dealing with supply issues, the number of doctors, nurses, hospitals, drugs, etc.

FILED UNDER: Economics and Business, Government, Health, Health Care, US Politics, ,
Steve Verdon
About Steve Verdon
Steve has a B.A. in Economics from the University of California, Los Angeles and attended graduate school at The George Washington University, leaving school shortly before staring work on his dissertation when his first child was born. He works in the energy industry and prior to that worked at the Bureau of Labor Statistics in the Division of Price Index and Number Research. He joined the staff at OTB in November 2004.

Comments

  1. Gustopher says:

    Do you know when you really need access to affordable health care? Right after you’ve driven off a cliff.

  2. Tlaloc says:

    It’s beyond stupid that you believe the wealthiest nation on earth cannot provide decent health care for it’s citizens when any number of much poorer nations already do. In fact it’s borderline evil that you so trivialize people by putting industry profits above human health.

    I never wrote or implied any such thing at all.–SV

    Scratch that it’s not borderline at all. What you’ve said here is just evil and you should be ashamed of yourself. Unfortunately you’ve consistently demonstrated that in this matter you have no shame at all.

    If it is evil, then please explain why President Obama is in agreement, at least in his public statements that the costs are unsustainable and something has to be done to bring them in line?–SV

    When you say Faster, better, and cheaper—pick two” you conveniently leave out that you can make it cheaper by getting rid of the profit aspect. That’s an immediate savings. Added to that is the savings of getting rid of inefficient bureaucracies. You can pretend all you want that private companies are more efficient but in the real world we find that every other country with a single payer system pays far less and most of them do a far better job of providing care, particularly for those of us who think breadth of care is more important than your philosophy of “rich people get all they want, ^%$# the rest of you” and do not insult us by pretending your argument is anything but that. Everyone else gets better faster and cheaper all because they cut out the insurance company parasites. So should we.

    You are looking at this as if it is a pure market here in the U.S. A quick check with reality would disabuse you of this notion. We have a mixed system where the government is perhaps the single largest player. To quote Shia Labouf from Transformers, “Are you on drugs?”–SV

    Look I think libertarians are adorable. You guys have the cutest world view and the naivete that is required to maintain it is usually just so endearing I want to buy you all ponies. That said you guys are useful idiots at best to the people who actually run things and in matters like this you go beyond that to being, frankly, monsters who given a choice between their pet theories and human beings prefer to preserve the former and damn the latter.

    Now, shut the hell up, go figure out what is wrong with you that would let you become such a horrible human being, and let the rest of us fix this mess.

    Unfortunately for you, you don’t have any kind of administrator rights here at OTB, so no. Now you have a nice day Tlaloc.–SV

  3. Gustopher says:

    Everyone else gets better faster and cheaper all because they cut out the insurance company parasites. So should we.

    Actually, Switzerland has the parasites, and is doing quite well comparatively.

    Now, shut the hell up, go figure out what is wrong with you that would let you become such a horrible human being, and let the rest of us fix this mess.

    Pity your medicines are so expensive that you can no longer afford to take them.

  4. Gustopher says:

    One thing that would be helped by eliminating the pre-existing conditions, and merging small pools of the insured into larger pools, is that small business would have a better chance at predicting their health care costs next year, and whether they can afford to hire people now.

    The reality right now is that if one of eight employees gets a serious illness, renewal rates will skyrocket, and the small business will either have to cut back on benefits for everyone (forcing their employees to look for work elsewhere, most likely to lose the best ones), or illegally fire the ill employee and run the risk of a very costly lawsuit.

    Also, right now, anyone who has lived an eventful life cannot get individual insurance. Which means that they cannot start a business without access to insurance elsewhere (spouse, etc).

    Both of these hurt driving forces of our economy — small businesses and entrepreneurship.

  5. odograph says:

    FWIW, I much liked the Behavioral take:

    [T]he public’s skittishness about overhauling the system also reflects something else: the deep-seated psychological biases that make people resistant to change. Most of us, for instance, are prey to the so-called “endowment effect”: the mere fact that you own something leads you to overvalue it.

    Much more here

    What this suggests about health care is that, if people have insurance, most will value it highly, no matter how flawed the current system. And, in fact, more than seventy per cent of Americans say they’re satisfied with their current coverage. More strikingly, talk of changing the system may actually accentuate the endowment effect.

  6. Zelsdorf Ragshaft III says:

    You cannot reform health care without tort reform. And the lie that there are people out there without health care is just that a lie. Go to an emergency room at any hospital to see what I mean. What we have are people who do not have health care insurance. If insurance companies could compete across state lines it would lower costs. Can you get auto insurance for a preexisting condition. Go wreck your car then try to buy insurance to pay for the damage. Next, look up what the term insurance means. Use a dictionary. If you have a preexisting condition and did not have insurance, all you are doing is trying to get me to pay for your ills. If it is charitable, I may donate. Do not enlist government to steal my money to help you. I will fight to prevent that.

  7. PJens says:

    Mister Verdon, This is the best health care post I have read in quite a while. Thank you.

    It cuts right to the bottom line – costs. There are plenty of people to blame for the ever rising cost of health care and health insurance

    The question remains though: Who ought to pay?

  8. steve says:

    The issue of costs will have to be addressed eventually as costs continue to rise. As documented here (I think) and elsewhere, companies are dropping health care insurance. Individuals are having trouble finding insurance. It is heading to the point where only pretty well off people will be able to afford insurance and adequate health care. At some point it will also affect the “I have mine screw you” people (see prior post). Tort reform would be great, but it is just a start.

    Emergency rooms only perform emergent or urgent care. People without insurance do not get follow up. That spot on the CAT scan does not get followed up until they return with a bowel obstruction or they are coughing blood.

    I actually think we could make a big dent in costs, but it would take much more political will for risk than we have now. Cutting costs means you have to look at Medicare and that is political suicide in our system. The Greatest Generation are the Greatest Voters and the Greatest Deterrence to change.

    Steve

  9. brainy435 says:

    I work for a large company that makes MRI machines and equipment. We have tried for the whole 3 years Ive been there to drive down costs of doing business, drive up our reliability (both of which lowers costs to the medical facilities that use the equipment) and really focus on cheaper, more efficient solutions for those facilities. These practices would get us more money by increasing our market share, even at lower margins, would help business’ see more people in the same time with the same resources thus lower costs for consumers and has kept a number of jobs very safe even during the recession.
    In the same time period what has the wonderful government done? Shut us down for over 2 years due to paperwork issues, pushing back the efforts and delaying the savings to facilites and consumers alike.
    So regardless of what comrade Tlaloc says,capitalism is not evil and government is not the solution. As gene Wilder might say: “Strike that. Reverse it.”

  10. anjin-san says:

    The issue of costs will have to be addressed eventually as costs continue to rise.

    How much of these “costs” are made up crap? I recently turned 50 and had a colonoscopy. 12k for a routine procedure that takes 45 minutes. What a load of BS…

  11. anjin-san says:

    At some point it will also affect the “I have mine screw you” people

    Bingo. And these folks will change their tunes very quickly when they or someone they love is not getting decent care for a serious illness…

  12. brainy435 says:

    Addendum: Tlaloc also makes the traditional liberal stab at debate. In essence: Opponents are evil and should shut up and do what their betters say. Same argument Obama, Pelosi and Reid have been making.

  13. Gustopher says:

    I would really, really like to see an honest conservative, free market approach to controlling the costs of health care, that actually addresses the issues of universal coverage, pre-existing conditions, and all that.

    “I have mine, screw you” is a bit lacking, but all we have gotten from the Republican leadership is “I have mine, screw you”, “tort reform” and “death panels”.

    The private, free market health care system we have now is approaching a colossal failure. Where are the innovative ideas to save the parts of the system that work, and realign the parts that don’t work so they have the right incentives?

  14. TangoMan says:

    How much of these “costs” are made up crap? I recently turned 50 and had a colonoscopy. 12k for a routine procedure that takes 45 minutes. What a load of BS…

    What’s the problem? Some procedures are cash cows and others require huge subsidization. Here is an example of a hospital service which draws in subsidies from other sources, in this case government, but in other cases I’m sure that colonoscopy procedures and other insurable services provide another source for mining deep pockets:

    A recent patient survey indicated that 70 percent of the women who gave birth at Parkland in the first three months of 2006 were illegal immigrants. That’s 11,200 anchor babies born every year just in Dallas.

    According to the article, the hospital spent $70.7 million delivering 15,938 babies in 2004 but managed to end up with almost $8 million dollars in surplus funding. Medicaid kicked in $34.5 million, Dallas County taxpayers kicked in $31.3 million and the feds tossed in another $9.5 million. The average patient in Parkland maternity wards is 25 years old, married and giving birth to her second child. She is also an illegal immigrant.

    “Parkland Memorial Hospital has nine prenatal clinics. NINE The Dallas Morning News article followed a Hispanic woman who was a patient at one of the clinics and pregnant with her third child—her previous two were also born at Parkland. Her first two deliveries were free and the Mexican native was grateful because it would have cost $200 to have them in Mexico. This time, the hospital wants her to pay $10 per visit and $100 for the delivery but she was unsure if she could come up with the money. Not that it matters, the hospital won’t turn her away.

    Prices are determined by the willingness of consumers to pay a stated price. Prices have nothing to do with the cost basis of providing a good or service. Really, why do you care what your insurance company pays? Don’t get me wrong, I think it’s great and I wish that more patients were price conscious, but because of the massive disconnect between the consumers, the funders of health care and the providers of health care, there is hardly any price discipline in the health care sector. It is this lack of price discipline which allows cost shifting to take place and allows prices to diverge greatly from costs without fear of price wars from competitors who don’t engage in massive cross-subsidization in the procedures they offer.

  15. Tlaloc – removing the profit motive also means removing competition, and yet you think this is going to lower costs while improving accessibility? What is the color of the sky on your planet?

    Steve Verdon, I have heard your first note before as: Cost, Schedule, Quality — you can control two of them, but not all three. Same thing. The public is starting to notice that Obamacare is trying to promise improvements to all three. And ponies!

  16. Gustopher – TANSTAAFL.

  17. vech says:

    anjin-san makes a good point that needs further investigation. Will the colonoscopy he got cost the same as the one someone else gets across town? If not, why not? Who does the cost accounting for these places? Does anyone audit them? Do they use different cost accounting methodology, etc, etc. Does anyone assess hospital staff, direct care and non-direct care portions? Is final cost based on too large a staff, or too small a staff. In other words, do hospital associations (accreditation review groups) police themselves to ensure they are doing work that is efficient, effective, and economical? I had a procedure several months ago and left the hospital with medications I already had at home, for which I paid less than the hospital charged me. In addition to tort reform I would like to see an intermediary health care provider, such as a physicians assistant who would hopefully charge less for routine medical problems and screenings. I believe they must be employed by an M.D. now, but if they had their own practice for minor things, I would think their costs would be considerably less – except for that darn tort thing.

  18. TangoMan says:

    “I have mine, screw you” is a bit lacking, but all we have gotten from the Republican leadership is “I have mine, screw you”, “tort reform” and “death panels”.

    First off, if a man is drowning in a river and you see someone on the shore about to throw him an iron anchor, your efforts to stop that “life-saving initiative” are helpful in their own right.

    Secondly, there are conservative proposals to reform the system but frankly there are too many rent-seeking entities who actively work to preserve their rent-seeking arrangements and thus work to block efforts that undermine their privileged position. Tort reform is a good place to start. Once the lawyers are pissed off at their loss of privilege then they can be brought on board to support the attack on privilege held by the next rent-seeking group. Once two groups are on the outside, then they can aid in the efforts of giving the next remaining rent-seeking group a dose of the medicine that they’ve just been forced to swallow. Over time, as more groups are on the outside, without rent-seeking arrangements benefiting them, it becomes more difficult for the remaining groups to insulate themselves from reform. The point is that we need to start somewhere and trial lawyers and tort reform are the best place to start because trail lawyers are less sympathetic than doctors or hospitals or even drug companies.

    The private, free market health care system we have now is approaching a colossal failure. Where are the innovative ideas to save the parts of the system that work, and realign the parts that don’t work so they have the right incentives?

    If we had a true free market, then the barriers to entry for new providers, new insurers, new co-ops, new physicians, etc wouldn’t be so high and be protected by legislation. What we have is a very highly regulated market, which I suppose is better than a government provided service, but it’s certainly not a free market.

  19. Alex Knapp says:

    Charles,

    Tlaloc – removing the profit motive also means removing competition, and yet you think this is going to lower costs while improving accessibility? What is the color of the sky on your planet?

    Charles, this would be more believable to me if the evidence didn’t show that the United States pays, by a large margin, a greater percentage of its GDP on health care than any other industrialized nation without any significant difference in health care outcomes. The most socialist of them all–Britain’s National Health Service-has the lowest costs.

    I am generally in favor of free markets. I generally do not want government to be involved in most areas. But when I am confronted with the evidence, I cannot help but notice that most countries with more government involvement are better at having both lower costs and at least comparable, if not better, outcomes. This leads me to believe that general economic assumptions about the efficacy of markets may not actually apply to the provision of health care services.

  20. Mithras says:

    The invisible hand sometimes kills people. And the Right in America loves that. Even though every other rich country covers everyone, at lower cost, with better outcomes, conservatives would prefer market forces to sort out winners and losers, including sorting some people into early graves.

  21. anjin-san says:

    I am generally in favor of free markets. I generally do not want government to be involved in most areas. But when I am confronted with the evidence, I cannot help but notice that most countries with more government involvement are better at having both lower costs and at least comparable, if not better, outcomes.

    Roger that. Today I am an executive at a company that is profitable even in this crap economy. Very good insurance that I can afford. My wife gets 100% of her insurance covered at her job. We are pretty lucky. But experience tells me good times do not always last. I am 50, and the job market sucks. If things were to go south, It could get ugly pretty fast.

    We need a better system. Period. I am very tired for the “America can’t get it done” crowd on the right. We can do better.

  22. anjin-san says:

    If we had a true free market

    Well, Bush pretty much give corporations a green light to do whatever we wanted. Our economy damn near collapsed last September. Sorry but the “free market will fix everything” line is kind of a joke…

  23. peterh says:

    anjin san says:
    “And these folks will change their tunes very quickly when they or someone they love is not getting decent care for a serious illness…”

    I somewhat doubt it…..those folks tend to vote against their interests in a way that was once aptly put: they cling to guns or religion or antipathy…….

  24. TangoMan says:

    But when I am confronted with the evidence, I cannot help but notice that most countries with more government involvement are better at having both lower costs and at least comparable, if not better, outcomes.

    Please, spare this act of yours, where you posture as being a fellow who is moved by evidence. Your reliance on “evidence” is quite shallow, in that you cling to “evidence” which supports your view and discount evidence which contradicts your view.

    However, let’s work with this evidence your favor. Here is Andorra, which has the world’s 2nd highest life expectancy at birth, 82.51 years, which compares to the US 78.11 years. If we’re to be influenced by evidence then we should consider the Andorran model of funding:

    Healthcare in Andorra is provided to all employed persons and their families by the government-run social security system, CASS (Caixa Andorrana de Seguretat Social), which is funded by employer and employee contributions in respect of salaries.[14] The cost of healthcare is covered by CASS at rates of 75% for out-patient expenses such as medicines and hospital visits, 90% for hospitalisation, and 100% for work-related accidents. The remainder of the costs may be covered by private health insurance.

    Healthcare is funded by a tax on earnings and it only reimburses for partial service with the patient being responsible for the remainder. So, in Anjin-san’s $12,000 colonoscopy example he’d have needed to come up with a $3,000 co-pay for his procedure. You see, that co-pay would have been totally worth it, because the evidence is that the Andorran health care model leads to longer life expectancy than that seen in America.

    Hey, you can’t argue with “evidence,” now can you?

  25. TangoMan says:

    Well, Bush pretty much give corporations a green light to do whatever we wanted. Our economy damn near collapsed last September.

    Your model of causality is best described as “There is many a slip betwixt cup and lip.” In other words, it’s pretty much worthless and it’s a shame that you view the world through such simplistic lenses.

  26. TangoMan says:

    But when I am confronted with the evidence, I cannot help but notice that most countries with more government involvement are better at having both lower costs and at least comparable, if not better, outcomes.

    Actually, the evidence doesn’t support this statement. There are more countries with government involved healthcare that have lower life expectancies than the US than there are countries with government involved healthcare with greater life expectancies than the US. You’re reaching your conclusion by focusing on a minority of countries and ignoring the majority which don’t fit your ideological view.

    Throwing away contrary evidence doesn’t lend support to your claim that you arrive at your positions by examining evidence.

  27. Alex Knapp says:

    Healthcare is funded by a tax on earnings and it only reimburses for partial service with the patient being responsible for the remainder. So, in Anjin-san’s $12,000 colonoscopy example he’d have needed to come up with a $3,000 co-pay for his procedure. You see, that co-pay would have been totally worth it, because the evidence is that the Andorran health care model leads to longer life expectancy than that seen in America.

    Hey, you can’t argue with “evidence,” now can you?

    Given that you’re allowed to supplement with private insurance, that looks a lot like other European models, and so seems like a sweet deal to me, especially considering that they have achieved lower overall costs per head than the U.S.

  28. Alex Knapp says:

    Actually, the evidence doesn’t support this statement. There are more countries with government involved healthcare that have lower life expectancies than the US than there are countries with government involved healthcare with greater life expectancies than the US. You’re reaching your conclusion by focusing on a minority of countries and ignoring the majority which don’t fit your ideological view.

    No, I’m ignoring the ones where per capita GDP, infrastructure, government stability, and other significant issues prevent them from being worthwhile comparisons to the United States. The U.S., U.K., Canada, Japan, New Zealand, and most of western Europe are close enough to the United States in baseline economic measures to make comparisons useful. Comparing U.S. life expectancies to say, Russia or Angola is silly because there are other overriding factors that make comparison meaningless.

  29. TangoMan says:

    The U.S., U.K., Canada, Japan, New Zealand, and most of western Europe are close enough to the United States in baseline economic measures to make comparisons useful. Comparing U.S. life expectancies to say, Russia or Angola is silly because there are other overriding factors that make comparison meaningless.

    What do baseline economic measures mean with regards to health outcomes? What “other overriding factors” are in play with Russia that are not in play with Iceland?

  30. Alex Knapp says:

    TangoMan,

    If you honestly believe that Russia and the United States are comparable enough in terms of GDP, infrastrucutre, and ability of the government to provide basic services to meaningfully determine how level of government affects health outcomes, then this is clearly going to be a fruitless discussion.

    And for the record, my ideology would dictate that markets would provide health care better and at a lower cost than government. But the data suggests otherwise.

  31. TangoMan says:

    If you honestly believe that Russia and the United States are comparable enough in terms of GDP, infrastrucutre, and ability of the government to provide basic services to meaningfully determine how level of government affects health outcomes, then this is clearly going to be a fruitless discussion.

    Life expectancy in Mexico (76.06 years) and Libya (77.26 years) and Albania (77.96 years) and Denmark (78.3 years) and Bosnia and Herzegovina (78.5 years) and Jordan (78.87 years) and Finland (78.97) years.

    Now, you were writing something about government abilities as measured by GDP and infrastructure being determinative of health outcomes, so I’m curious what advantages in GDP and infrastructure Bosnia and Jordan have that are lacking in Denmark. I’m trying to understand your process of evidence evaluation in support of your decision making.

  32. Gustopher says:

    First off, if a man is drowning in a river and you see someone on the shore about to throw him an iron anchor, your efforts to stop that “life-saving initiative” are helpful in their own right.

    If you have two people on the shore debating whether to throw an iron anchor or a stone anchor, might it not make sense to chime in and point out an alternative?

    Now, I don’t think that the various plans being crafted by the Democrats are worse than useless, but the Republicans profess to believe so — isn’t it imperative that they offer a possibility of their own, to avoid the inevitable iron or stone anchor?

    The Democrats have the votes to pass something, and unless the Republicans come up with something compelling, the Democrats will pass a Democratic something.

  33. Gustopher says:

    And for the record, my ideology would dictate that markets would provide health care better and at a lower cost than government. But the data suggests otherwise.

    The data suggests that a government run system could provide better, lower cost health care than the current system, not that a free market system couldn’t do even better.

    When you start looking at the costs, you will quickly notice weird things like medicines in the US being four or five times as expensive as the same medicines in Canada, despite Canada being about as close to the US as possible demographically, economically, and geographically. The pharmaceutical companies will trot out the old standby of recouping costs for development, but that simply begs the question of why is the US subsidizing the development of drugs for everyone else on Earth?

    And, until things like that are addressed, there’s no way we can control health care costs.

    But there are free market and big government ways of addressing these issues — we could import drugs from Canada (free market) or set price controls via Medicare or a public plan (big government).

    And every step of the way, we have the same dilemma.

    And for the record, my ideology would dictate that markets would provide health care better and at a lower cost than government. But the data suggests otherwise.

    I’m a lefty, my ideology would dictate a single payer system, but I’m pragmatic enough to be open to a different solution if it can get the same results. I’m deeply disappointed that the right hasn’t even tried.

    I’m sure that there is a more free-markety solution, which might require ripping down some of the current regulation, and adding entirely different regulation aimed at ensuring that the insurance company’s profit motive is more in line with good public policy.

  34. sam says:

    @Tangoman

    [B]ecause of the massive disconnect between the consumers, the funders of health care and the providers of health care, there is hardly any price discipline in the health care sector. It is this lack of price discipline which allows cost shifting to take place and allows prices to diverge greatly from costs without fear of price wars from competitors who don’t engage in massive cross-subsidization in the procedures they offer.

    I suppose that this goes to your plea for more price transparancy. But just how is that to be achieved? My, admittedly quick, intuition is that the major players would mightly resist the move to transparancy.

    On costs. This issue was directly brought home to me yesterday. I received two letters from my insurance company….When last we visited sam, the dreary saga of his funky ankle continued apace (ahem).

    The first letter simple detailed the costs of my last foot doctor’s visit, minus my deductible for the visit. The insurance company was telling me that I wasn’t to be charged, etc. So far, so good–I mean, that bill looked fine to me in terms of cost (of basic visit). It was the second letter that stopped me in my tracks, so to speak.

    I’ve been wearing a certain kind of ankle brace, and usually when I see my doctor (about every 6 months), I get a new one (they wear out quickly with the kind of use I put them to). My doctor recommended a new kind of brace, more durable, better suited to the kinds of things I do. Cool, I’ll take it. He goes and gets it; we put it on (no problem); he hands me a brochure; and out the door I go. Elapsed time for the fitting, about 5 minutes. Bill, according to the second letter: $450.00. Jesus! I looked the brace up on the web, cost $100. Now, what I’m supposing is that his helping me put the brace on fell under the rubric, Fitting a Prosthetic Device (or some such), and that the doctors’s group had negotiated a flat fee for this kind of procedure. But, damn, $450 for a five-minute task. My insurance covered it, but I’m still shocked at the cost. You’d think that the insurance company and the doctors could be a little more fine-grained in the way the categorize procedures. I guess not, though.

  35. Alex Knapp says:

    TangoMan,

    For one, I’m not using life expectancy as a measure of health care outcomes. (But if you are using them, did you notice that of the countries you listed, the one with the MOST private health care expenditure and LEAST government involvement in health care–Mexico–has the lowest life expectancy?)

    That’s primarily because there’s too many variables outside of the health care system that are determinants of life expectancy. (For example, Mexico is engaged in a virtual civil war with drug cartels.)

  36. Phil Smith says:

    Alex, if you’re not using life expectancy, what outcomes are you using? You aren’t using survivability rates or wait times. What is left?

  37. Alex Knapp says:

    You aren’t using survivability rates or wait times.

    Who said I’m not? But they’re not as important as infant mortality and potential years of life lost. The latter is, I think, the most important measure of health care outcomes.

  38. Phil Smith says:

    Who said I’m not?

    The data says you’re not. US cancer survivability (e.g.) is simply the best in the world. Our wait times are far lower than most. So those can’t be the metrics you’re using to say we’re average to below average on “outcomes”.

    But I’m curious about this potential years of life lost. Please be so kind as to point me to a good study on this.

  39. anjin-san says:

    it’s a shame that you view the world through such simplistic lenses.

    Actually, my world view is fairly complex. But my time is limited, as is my need to impress the other kids in the class with how bright I am. I got over that in the 8th grade. Perhaps someday you will too 🙂

  40. Alex Knapp says:

    Phil,

    US cancer survivability (e.g.) is simply the best in the world.

    France and Japan both have comparable cancer survival rates to the United States and surpass it on some cancers.

    http://www.webmd.com/cancer/news/20080716/cancer-survival-rates-vary-by-country

    Our wait times are far lower than most.

    Also false:

    http://www.medicalnewstoday.com/articles/76295.php

    http://www.commonwealthfund.org/Content/Performance-Snapshots/International-Comparisons/International-Comparison–Access—Timeliness.aspx

    So those can’t be the metrics you’re using to say we’re average to below average on “outcomes”.

    Yes, I can. That’s what the data shows.

  41. Phil Smith says:

    I’d like to see some more granularity on those cancer rates, as I know that you’re twice as likely to die from breast or prostate cancer in the UK as in the US, but I’ll settle for modifying my statement to “among the very best”, which your link supports. And we just kick the shit out of the UK on breast and prostate cancer.

    Your link on wait times shows a mixed bag. I suppose I was thinking of the wait to see a specialist, where our wait times are substantially better than anyone except Germany, and statistically equal to them. I will admit that I’m very surprised to see that anyone had a 6 day wait in the US to see a doctor at all, much less 23%. I would really like to see the question asked, as anyone with access to an emergency room can see a doctor. It’s one of the things driving our costs. I’m skeptical on that number.

  42. Alex Knapp says:

    I’d like to see some more granularity on those cancer rates, as I know that you’re twice as likely to die from breast or prostate cancer in the UK as in the US, but I’ll settle for modifying my statement to “among the very best”, which your link supports. And we just kick the shit out of the UK on breast and prostate cancer.

    We definitely beat the UK, but France and Japan are right up there with signficantly less cost.

    Your link on wait times shows a mixed bag. I suppose I was thinking of the wait to see a specialist, where our wait times are substantially better than anyone except Germany, and statistically equal to them.

    And yet, Germany has substantially lower costs than the US.

    And our primary care wait times SUCK. And the study mentions that this is one of the reason why Americans go to ERs instead. Additionally, look at those links and check the sheer number of people who forego care because of cost concerns. It’s horrible.

  43. Bill W says:

    Gustopher, with about 2 seconds of googling I found the link to the Republican bill they are pushing as an alternative. “Empowering Patients First Act”, and some other news results from at least 2 months ago. The Republicans ARE suggesting alternatives (no judgment call here on how good they are though) but they have no realistic shot of implementing any of them. The Democrats control all they need in government at the moment and their versions are going to be the dominant theme of discussion.

  44. Phil Smith says:

    There’s no denying that our costs are high, per capita or % of GDP. You just can’t make the claim that our outcomes are bad. The data doesn’t support it. But the current proposals aren’t going to reduce costs.

    What you’ve convinced me of is that we need to study Germany’s system and see what can be done to replicate it. Canada and the UK, no.

  45. Steve Verdon says:

    Tlaloc,

    Just curious is English your first language? And exactly which post are you responding too? Because if its mine your reading comprehension sucks. It it isn’t my post let me know and I’ll delete your comment.

    Oh, and calm down, I don’t think that throbbing vein in your forehead is a good thing, just some free advice.

  46. Alex Knapp says:

    Phil,

    I don’t think that we have the worst health care outcomes, but we don’t have the best. (Our PYLL measures are wretched) and given that we spend twice as much per capita as the OECD average, we don’t seem to be getting any bang for our buck.

    I think that taking the best policies from France/Germany/Denmark is the way to go, too.

  47. Steve Verdon says:

    Alex,

    You’re problem is that you are ignoring the institutional frame works involved.

    Well, that’s your first problem. Your second one is that you are only counting the dollar costs and ignoring other costs such as waiting times for treatment for example. The UK has lower costs, but often times people go untreated in the UK that would be treated here (I recall and article where smokers were denied a type of care because of being smokers).

    Sill, that being said, looking at countries like France and others that are as close to the U.S. in terms of size, population make up, etc. is probably a good starting point. That wont be enough as we’ll still be heading towards that cliffs edge.

    But call me a horrible human being for noting that. Right Tlaloc?

  48. sam says:

    And our primary care wait times SUCK. And the study mentions that this is one of the reason why Americans go to ERs instead.

    I cannot get to see my primary physician in any time under 4-6 weeks. We’re told that if we need urgent or emergency care, to go to the ER–which now will cost us $250 for the visit (works out, I figure, to about $50-60 an hour for the waiting in the ER),

  49. Phil Smith says:

    I’d like to see PYLL measures adjusted for homicide and traffic accidents. You just can’t pin those two issues on the health care system. You must have missed JJ’s post on a related topic.

  50. Phil Smith says:

    I cannot get to see my primary physician in any time under 4-6 weeks.

    Is there a reason why you can’t get a new doc?

  51. Steve Verdon says:

    Alex,

    I find this link of yours a bit suspicious. Not too long ago I noted that in the UK some people were waiting up to 16 weeks or more for treatment due to costs. Of course, I would imagine that such people who are waiting aren’t “sicker”, but then again how is that defined.

    Also, just as a point of information the Chairmen of the Commonwealth Fund is a Democratic supporter. So is director Benjamin Chu, William Brody, James Mongan, and Robert Pozen (although he does appear to have supported some Republicans). I’m a bit less persuaded by that information and would be curious about the definitions behind the table and even some of the actual data.

  52. Alex Knapp says:

    Steve,

    You’re problem is that you are ignoring the institutional frame works involved.

    French and German institutional frameworks aren’t that dissimilar from our own.

    Your second one is that you are only counting the dollar costs and ignoring other costs such as waiting times for treatment for example.

    As I already linked above, the U.S. has pretty terrible waiting times, especially for primary care.

    but often times people go untreated in the UK that would be treated here (I recall and article where smokers were denied a type of care because of being smokers).

    While I wouldn’t want to adopt the NHS, it’s worth pointing out that here in the United States, more people go untreated for primary care:

    “U.S. patients were more likely than patients in the other five countries [Australia, Germany, United Kingdom, Canada, and New Zealand] to report not filling a prescription, not visiting a doctor when sick, and/or not getting a test or follow-up care recommended by a doctor because of cost in the past two years …

    U.S. patients were more likely than patients in four other countries (except Australia) to report that it was very difficult to get care on nights, weekends, or holidays without going to the emergency department

    …The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.

    Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.”

  53. TangoMan says:

    But, damn, $450 for a five-minute task. My insurance covered it, but I’m still shocked at the cost.

    You view that $450 as a true cost, by which I mean that you equate it to what it would take to earn that money and what alternatives could achieved with that money. The insurance company simply looks on that cost as a transaction, by which I mean they collect the money, as a premium, from the employer, pool it with other premiums, and then pay it out as a benefit. As an intermediary if they fall short they can simply raise the premiums to make up the shortfalls. They don’t have the same price sensitivity that you do, much like Lockheed and the Department of Defense aren’t as price sensitive as an individual consumer when shopping for toilet seats.

  54. Alex Knapp says:

    Phil,

    I’d like to see PYLL measures adjusted for homicide and traffic accidents. You just can’t pin those two issues on the health care system. You must have missed JJ’s post on a related topic.

    It’s already built into the metric, because the comparison is age of death vs. expected life expectancy for that nation.

    So if someone dies at age 60 in the U.S., that 19.1 PYLL, but in Denmark, that’s 19.3 PYLL.

  55. Alex Knapp says:

    Steve,

    Re: the Commonwealth Fund link, if you look at the charts you’ll see that the absolutely wretched performance of the NHS is reflected in wait times for specialist care and elective surgery. But you’ll also note that while the U.S. is pretty good there, Germany is even better.

  56. Steve Verdon says:

    French and German institutional frameworks aren’t that dissimilar from our own.

    I would beg to differ. In France insurance is provided via non-profit health funds. Also, the government picks up the tab for fair amount of the costs. Also, doctors are paid quite a bit less. I’m thinking one thing is not like the other.

    As I already linked above, the U.S. has pretty terrible waiting times, especially for primary care.

    I’m skeptical of the links you’ve provided. I’d like to see more than that and something more comprehensive. I know that in parts of the UK wait times for months for some health issues were in the months not that long ago.

    “U.S. patients were more likely than patients in the other five countries [Australia, Germany, United Kingdom, Canada, and New Zealand] to report not filling a prescription, not visiting a doctor when sick, and/or not getting a test or follow-up care recommended by a doctor because of cost in the past two years …

    Why? Is it their choice or was it due to policy–i.e. mandatory. The two are not the same.

    U.S. patients were more likely than patients in four other countries (except Australia) to report that it was very difficult to get care on nights, weekends, or holidays without going to the emergency department

    Yes moving away from emergency rooms would be good, but then we run into that institutional problem–more doctors and nurses. Why don’t we have them here? Private insurers? I doubt it. Government? Hmmm, think we might have a winner.

    …The percentage of U.S. patients who waited six days or more for a doctor appointment when sick was not significantly different from the rate in Canada (23% v. 36%), the worst-performing country.

    I would think that 13% is likely significant.

    Only 47 percent of U.S. patients were able to see a doctor on the same or next day when sick, versus 61 percent to 81 percent of patients in the four better-performing nations.”

    I’m skeptical if they are including the UK given what I know has been going on there over the years. I’m becoming even less impressed with the Commonwealth Fund.

    For example, the abstract of the first citation at your link,

    This article reports on a comparative survey of sicker adults in Australia, Canada, New Zealand, the United Kingdom, and the United States. The study finds that despite differences among the health care systems, large proportions of citizens across the five countries report dissatisfaction with their health care system and serious problems including medical and medication errors, faulty patient-physician communication, and poor care coordination. The most crucial policy implication of these findings is that a focus on a small population of intensive health system users could have the potential to both control costs and improve care.

    Sounds more reasonable. I guess the U.S. could still rank last everywhere, but given the ideological bent the Board of Directos have I’m a bit concerned about datamining here.

    people who are waiting aren’t “sicker”, but then again how is that defined.

    D’oh it was there at the link and its self-reported. Color me unimpressed.

    And Alex, it isn’t quite true to say then that U.S. waiting times are horrible. In some regards they are, in others they aren’t.

  57. Alex Knapp says:

    Steve,

    I would beg to differ. In France insurance is provided via non-profit health funds. Also, the government picks up the tab for fair amount of the costs. Also, doctors are paid quite a bit less. I’m thinking one thing is not like the other.

    Oops–I think we’re talking past one another. I was thinking structure of government institutions generally, not health care institutions specificially.

    I’m skeptical of the links you’ve provided. I’d like to see more than that and something more comprehensive. I know that in parts of the UK wait times for months for some health issues were in the months not that long ago.

    Yeah, but you don’t have any critcism of the methodology. And I would add that my links SUPPORT the claim that for specialist care and elective surgery, the UK sucks and has the longest wait times. However, Germany produces comparable results to the US. Again, I’m not suggesting we adopt the NHS model.

    Why? Is it their choice or was it due to policy–i.e. mandatory. The two are not the same.

    It’s U.S. policy to put most health care expenses on the backs of consumers, so if that policy results in higher costs for consumers to the point that they don’t receive further care, that’s a significant data point.

    Yes moving away from emergency rooms would be good, but then we run into that institutional problem–more doctors and nurses. Why don’t we have them here? Private insurers? I doubt it. Government? Hmmm, think we might have a winner.

    New Zealand has fewer doctors per capita than the United States and yet only 13% reported this problem compared to 39% in the U.S.

    I would think that 13% is likely significant.

    I’m inclined to agree, but only 3% of New Zealanders had this problem, again despite having fewer doctors per capita than the United States.

    I’m skeptical if they are including the UK given what I know has been going on there over the years. I’m becoming even less impressed with the Commonwealth Fund.

    Once again, the Commonwealth Fund link I provided pointed out that the UK is the WORST among the five when it comes to wait times for specialists or elective surgeries. That eliminates your reasoning for disputing the data.

  58. Alex Knapp says:

    Steve,

    And Alex, it isn’t quite true to say then that U.S. waiting times are horrible. In some regards they are, in others they aren’t.

    Two things: 1) I consider, on a societal level, access to primary care to be a superior consideration. I can see where others might weigh that differently and that’s totally fair.

    2) However, when you consider that 51% of the U.S. survey respondents reported not pursuing follow-up care because of cost, I have to wonder how many of those people didn’t go see a specialist because of cost, or chose not to have an elective surgery performed because of cost. Because that’s going to skew waiting times, isn’t it? Just a hypothesis there, no data, but it’s something to think about.

  59. TangoMan says:

    they’re not as important as infant mortality and potential years of life lost. The latter is, I think, the most important measure of health care outcomes.

    Here is a life expectancy by age calculator using UN Data.

    Life Expectancy at Age 65, 2003:

    Austria = 16.4
    Belgium = 15.9
    Canada = 17.4
    Denmark = 15.6
    Finland = 16.3
    France = 17.0
    Germany = 16.2
    Greece = 16.7
    Ireland = 15.9
    Netherlands = 15.9
    Norway = 16.8
    Portugal = 15.7
    Spain = 16.8
    United Kingdom = 16.4
    United States = 16.8

    In the US the data can be broken down by race:

    White man at age 65: 17.2 years
    Black man at age 65: 15.3 years

    Take this latter figure and apply it as a control factor in the UN calculations to arrive at a MORE ACCURATE comparison. Even without controlling for population variances we see that the US is surpassed only by France and Canada. How is it possible that Americans, a people that encompasses both blacks and whites, at age 65, have more years of life ahead of them than do the Austrians, Germans, Belgians, Danes, Irish, Dutch, British and Portuguese? Also, within the EU why do the neighboring countries of Portugal and Spain have such a difference in expected life after age 65, a difference of 1.1 years when both nations have socialized medical systems that you claim are superior to the American model?

  60. Alex Knapp says:

    TangoMan,

    How is it possible that Americans, a people that encompasses both blacks and whites, at age 65, have more years of life ahead of them than do the Austrians, Germans, Belgians, Danes, Irish, Dutch, British and Portuguese? Also, within the EU why do the neighboring countries of Portugal and Spain have such a difference in expected life after age 65, a difference of 1.1 years when both nations have socialized medical systems that you claim are superior to the American model?

    At age 65, virtually every American gets their health care from Medicare, a government-run, single payer health care system…

  61. TangoMan says:

    At age 65, virtually every American gets their health care from Medicare, a government-run, single payer health care system…

    But your model would have it that they’ve entered into their retirement years having accumulated many ailments from having suffered from sub-optimal care preceding their retirement whereas the Europeans have been cradled in the sweet nurturing arms of their government from the moment they were born.

  62. Alex Knapp says:

    TangoMan,

    See, this is why I have insisted throughout this comment chain that life expectancy is a lousy health care outcome metric compared to access to care and PYLL, because otherwise we get into all sorts of data wankery about factors in life expectancy.

    For example, 15.4% of American adults are daily smokers. Compare that to 19.6% for Portugal and 26.4% for Spain and there are those who might argue that there’s the culprit for the life expectancy differences right there.

    Okay, but despite this point, the fact remains that it’s difficult to evaluate the life expectancy at 65 metric due to the simple fact that at 65, the average American is receiving his health care from a single payer system.

    But my overwhleming point is that all the available data shows that the United States spends SIGNIFICANTLY more money per capita on health than any other industrialized nation. And yet it does not produce significantly better health outcomes. France, Germany and Japan seem to do the best, even though they have much more government controls than the U.S. does. Why not examine their policies for what works the best?

  63. TangoMan says:

    Male Life expectancy at various ages, Year 2000:

    Age 30-34:
    Austria = 46.6
    Belgium = 46.0
    Canada = 47.9
    Denmark = 45.9
    Finland = 45.4
    France = 46.8
    Germany = 46.3
    Ireland = 45.5
    Netherlands = 46.6
    United Kingdom = 46.7
    United States = 46.0

    Age 40-44:
    Austria = 37.1
    Belgium = 36.6
    Canada = 38.4
    Denmark = 36.4
    Finland = 36.1
    France = 37.4
    Germany = 36.7
    Ireland = 36.0
    Netherlands = 37.0
    United Kingdom = 37.2
    United States = 36.7

    Age 50-54:
    Austria = 28.0
    Belgium = 27.6
    Canada = 29.2
    Denmark = 27.4
    Finland = 27.3
    France = 28.7
    Germany = 27.8
    Ireland = 26.8
    Netherlands = 27.7
    United Kingdom = 27.8
    United States = 27.9

    At age 30, when many Americans chose not to insure their health and thus stay away from professional health maintenance we see that, even with our higher levels of homicide and traffic accidents, that the mean expected years of life for males are still greater than what the men of Denmark, Finland and Ireland can expect to live and we’re in the same league as Germany and Belgium.

    At age 40, when middle age maladies start to arise we see that our men still have more life left in them that the men of Belgium, Denmark, Finland and Ireland, and we’re comparable to men in Germany, Austria and the Netherlands.

    At age 50, long before eligibility for Medicare kicks in, we see that American men will outlive the Belgians, Danes, Finns, Germans, Irish, Dutch and British. In fact, at age 50 the only men who will outlive the Americans are the Austrians, Canadians, and French.

    Now you were arguing something about longevity being tied to Medicare or socialized medicine.

  64. TangoMan says:

    But my overwhleming point is that all the available data shows that the United States spends SIGNIFICANTLY more money per capita on health than any other industrialized nation. And yet it does not produce significantly better health outcomes.

    Absolutely correct. The relationship between health spending and life expectancy is pretty weak. This is why you see Libya and Albania having higher life expectancy than Denmark, even though the Danes far outspend these two poor countries and have a far more socialized health care delivery system which serves a greater proportion of the citizenry and gives them greater depth of care.

    Levels of health spending correspond better to metrics like life satisfaction. Suffering is eased while life extension isn’t materially affected. This is what is accounting for our exorbitant level of spending, alongside rent-seeking rackets that are protected from price competition. Defensive medicine doesn’t produce life extension nor does it lessen patient suffering. The ratio of general practitioners to specialists is lower in the US than many other nations, which means that problems that could be solved at a lower cost at the general practitioner level are billed at a higher specialist rate.

    To truly understand international comparisons anyone who gets into the analysis must correct for a host of factors before they start comparing outcomes. Pulling an Ezra Klein and concluding that health outcomes are the result of financing methods is being simplistic.

  65. Alex Knapp says:

    TangoMan,

    Once again, I don’t think longevity is the relevant metric. However, I find it interesting that you cherry picked to only compare males, and you used 2000 numbers even though 2006 numbers were avaiable.

    Despite this, the data you used appear to indicate the superiority of the French model, n’est-ce pas?

  66. TangoMan says:

    For example, 15.4% of American adults are daily smokers. Compare that to 19.6% for Portugal and 26.4% for Spain and there are those who might argue that there’s the culprit for the life expectancy differences right there.

    Smoking doesn’t have an immediate health impact, it’s a time bomb, a lagging effect, so looking at the current proportion of smokers can aid you in predicting the future but it tells you absolutely nothing about the present. To understand the present, in terms of smoking effects, you need to look at the past, and when you look at the past you see that the US had the world’s highest rate of cigarette consumption up until the mid-80s.

  67. TangoMan says:

    Older data sets have less incomplete entries. You’re free to present the data for females.

    Despite this, the data you used appear to indicate the superiority of the French model, n’est-ce pas?

    The superiority of the French people, yes, the French model, maybe. Apply the French model to the people of Nigeria and if we get the same result that we see in France then the French model might have something going for it.

  68. Alex Knapp says:

    TangoMan,

    Levels of health spending correspond better to metrics like life satisfaction.

    Cool. Then lets use DALY, instead. DALY doesn’t just calculate longevity–it calculates the average number of years that a person can expect to live in “full health” by taking into account years lived in less than full health due to disease and/or injury.

    The United States is 24th. You can see that Libya and Albania don’t fare well–103 and 108, respectively, but that Japan, Australia, France, Sweden and Spain, “socialists” all, are in the top five.

  69. TangoMan says:

    DALY (Disability-adjusted life years) is a product of a statistical manipulation. It’s like arguing that one can measure the happiness of a child’s life by concocting a metric which factors in distance to school, school grades, number of friends, number of siblings, number of times the parents buy the child new shoes, etc. DALY is not a metric that is properly validated, and that’s why it’s a controversial metric.

    Further, it’s improper to compare Japan to the US unless one controls for population variance. The same goes with Sweden and the US. You have to compare like to like, in order to understand the common feature of the comparison.

  70. Alex Knapp says:

    Further, it’s improper to compare Japan to the US unless one controls for population variance. The same goes with Sweden and the US. You have to compare like to like, in order to understand the common feature of the comparison.

    You mean break things down in the US by Irish, Scots, Swedish, German, Polish, Slovak, Japanese, Chinese, Ugandan, Kenyan, El Salvadoran, Mexican, Korean, French, Belgian, etc?

    Seems silly.

  71. TangoMan says:

    You mean break things down in the US by Irish, Scots, Swedish, German, Polish, Slovak, Japanese, Chinese, Ugandan, Kenyan, El Salvadoran, Mexican, Korean, French, Belgian, etc?

    Seems silly.

    If you honestly want to understand the effects of health care delivery, then yes, that’s what you do. Here is one study that undertakes such a detailed examination:

    The researchers used figures from the US Census Bureau and the National Center for Health Statistics to calculate mortality (death) rates for the years 1982—2001. They took note of the county of residence and of the race of all the people who died during that period of time. This enabled them to calculate the mortality rates for all 8,221 “race-county units” (all of the individuals of a given race in a given county). They experimented with different ways of combining the race-counties into a small and manageable number of groups. They eventually settled on the idea of there being “eight Americas,” defined on the basis of race-county, population density, income, and homicide rate. Each group contains millions or tens of millions of people. For each of the eight groups the researchers estimated life expectancy, the risk of mortality from specific diseases, the proportion of people who had health insurance, and people’s routine encounters with health-care services. (The researchers also created maps of life expectancies for the US counties.) They describe their eight Americas as follows: Asians, northland low-income rural whites, Middle America, low-income whites in Appalachia and the Mississippi Valley, western Native Americans, black Middle America, low-income southern rural blacks, and high-risk urban blacks.

    Many striking differences in life expectancy were found between the eight groups. For example, in 2001, the life expectancy gap between the 3.4 million high-risk urban black males and the 5.6 million Asian females was nearly 21 years. Within the sexes, the life expectancy gap between the best-off and the worst-off groups was 15.4 years for males (Asians versus high-risk urban blacks) and 12.8 years for females (Asians versus low-income rural blacks in the South). The causes of death that were mainly responsible for these variations were various chronic diseases and injury. The gaps between best-off and worst-off were similar in 2001 to what they were in 1987.

    As you delve into the data and start controlling for known and measurable factors you start to see, for instance, that the life expectancy at birth for a male child born in Utah, Colorado, or Minnesota exceeds the life expectancy at birth of a male child born in the Canadian provinces of Nova Scotia, New Brunswick, Quebec, Manitoba, and Saskatchewan. Further, the life expectancy at birth of a male child born in New Hampshire, Idaho, Washington, California, Vermont, North Dakota, Iowa, Massachusetts, Connecticut, Nebraska, Oregon, Rhode Island, Wisconsin, New York, Maine, and South Dakota exceed the life expectancy of a male child born in Newfoundland and Prince Edward Island.

  72. Alex Knapp says:

    What I mean is, it seems silly from a policy perspective. Compare wait times, cancer survivor rates, access to primary care, DALY, Life Expectancy, whatever–you’ll see that the U.S. isn’t getting any kind of decent ROI on its high health care expenditures. The French model seems to consistently produce better or comparable outcomes for significantly lower costs. From a policy perspective, I think it would be wise for the U.S. to examine the French model and adopt what makes sense given our institutions.

  73. TangoMan says:

    My point with the last comment was that we shouldn’t be seeing such variance in life expectancies if the key determinant is the nation’s medical system. Medical care provided in P.E.I. is little different from the medical care provided in neighboring Quebec or Nova Scotia. Similarly, medical care provided in Minnesota is little different from the medical care provided in North Dakota. Why is there such variance with the Canadian system and the American system? You posit that the variance between Canada and the US is because of the different methods we chose to finance the system. If that’s the case then why are the metrics from so many states better than the metrics from Newfoundland and PEI?

  74. TangoMan says:

    What I mean is, it seems silly from a policy perspective.

    I disagree. If you can’t properly identify and model the question that you’re studying then every answer to the posed and incomplete question will be wrong when applied to the real-life scenario.

    Think of it this way – why is China manufacturing so many goods for export compared to the US? Be sure not to factor in employee wages, work conditions, pollution control expenses and taxation levels. Now go about and construct a model and see how valid the results of that model are. Good luck in coming to a true understanding of the China manufacturing phenomenon. If you actually implement the findings of such a circumscribed study then you will, I predict, see the policy lead to failed results.

  75. Alex Knapp says:

    TangoMan,

    Ah, I get your point now. But that study only represents life expectancy, right? What about cancer survivability, wait times, DALY, etc? I’m guessing there’s not a lot of research on a state by state/province by province level–I’ve never seen any. So national data’s probably as good as it gets.

  76. TangoMan says:

    Ah, I get your point now. But that study only represents life expectancy, right? What about cancer survivability, wait times, DALY, etc? I’m guessing there’s not a lot of research on a state by state/province by province level–I’ve never seen any. So national data’s probably as good as it gets.

    This one study looks at life expectancy. Keep in mind that this is only one study and also keep in mind that they’re not using proprietary data sets, they’re using data for the US Census and the National Center for Health Statistics.

    If you, or any other interested party, wants to truly understand the health effects that arise from different financing models then you need to study a situation where you compare ONLY the effects that arise from different financing models. When you, or others, do that, then I, the skeptic, will pay heed to the results. What I, the skeptic, will not do is believe you when you refer to studies which completely ignore confounding factors that I, in blog comments, can bring into discussion and demonstrate that these confounding factors are in play.

    All evidence is not of the same quality. There is solid evidence that withstands replication efforts and is a valid representation of the studied phenomena and then there is weak evidence which is easily picked apart.

    We can certainly construct general metrics which are comprised of a series of minor metrics, but each component must be valid, in that it accurately measures what it purports to measure, so this means that when we compare breast cancer survival rates we control for population variance in race and estrogen receptor status, for both factors impact on survival rates. And so on. Then, once we are comparing like to like, we can understand the influence on health outcomes that different financing schemes produce.

    As it stands now, in terms of life expectancy we see that American results, when compared to international peers, get better as one gets older. That’s interesting in itself. Considering the medical intervention rises as we get older, it would seem that causes of death that are not medically centered have a greater role in American society than in European society. Why are 30 year old American men more likely to die than 30 year old French men? Why does the gap grow smaller as men get older? Why are our rates better than those of Danish men? I think that the preferred answer, methods of financing medical care, is too simple and too simplistic an answer.

  77. Alex Knapp says:

    I think that the preferred answer, methods of financing medical care, is too simple and too simplistic an answer.

    Which is why I have, time and time again in this threat, rejected mere life expectancy as a valid measure of health outcomes…

  78. TangoMan says:

    Which is why I have, time and time again in this threat, rejected mere life expectancy as a valid measure of health outcomes…

    To argue under generalities, like health outcomes, but not provide specific comparative data that accounts for confounds, doesn’t really advance your argument. I’ve been providing data on life expectancies and demonstrating the weak correlation between method of health care financing and life expectancy outcomes.

    You say that you’ve adopted your position through careful analysis of the evidence. Cite the evidence then. Referencing buzz-speak like DALY (Disability-adjusted life years) isn’t really providing evidence.

    Just so we’re clear, I understand your thesis as being that socializing medical costs will improve life outcomes as measured by factors A, B, C, etc. If that’s an accurate assessment of your position, then show us the evidence that led you to reach your conclusion.

  79. Alex Knapp says:

    TangoMan,

    Just so we’re clear, I understand your thesis as being that socializing medical costs will improve life outcomes as measured by factors A, B, C, etc.

    My thesis is that other industrialized nations produce comparable or better health care outcomes at substantially lower costs than the United States. Given that those nations socialize the cost of health care substantially more than the United States, my contention is that it is possible for the United States to socialize the cost of health care without sacrificing health care outcomes and perhaps even improving them while at the same time lowering cost.

    I’m not going to reproduce all of my links regarding health care outcomes in one comment. They’re in this thread. PLYY, DALY, Wait Times, Cancer Survivability and Access to Primary Care as compared to costs are the data points that I’ve already presented. I suppose life expectancy also supports this on the “comparable” level, but there are too many odd things about life expectancy for me to consider it very dispositive.

    From the data presented, I would argue that the United States should adopt a health care model similar to that of France.

  80. TangoMan says:

    I’m not going to reproduce all of my links regarding health care outcomes in one comment. They’re in this thread.

    You’re seriously basing your decision on the evidence that you’ve presented in this thread? Frankly, you may as well be basing your position on the findings of a tarot reading.

    France and Japan both have comparable cancer survival rates to the United States and surpass it on some cancers.

    From your link they even make note of the following:

    A racial gap in survival was evident, with white patients more likely than blacks to survive, especially breast cancer. “The comparison is confirmed right across the USA, in all 16 states,” Coleman says of the racial gap.

    For the study, the researchers estimated relative survival, adjusting for such factors as wide differences in death rates from country to country and for age.

    Doesn’t it strike you as odd that the researchers make note of the racial disparity and then they simply ignore it? They control for factors like age in order to derive their international comparisons, but they ignore race. Tell my why their study is an accurate assessment of the situation.

    As for colon cancer in Japan, I already hit on this topic in another thread:

    Data from the current study suggest that survival among Asians is less affected by SES or treatment disparities, and may be because of biologic factors.

    Again, no attempt made to control for a very powerful causal factor.

    Phil: Our wait times are far lower than most.

    Alex: Also false:

    I would be ashamed of myself for quoting what amounts to a evidence-free press statement from the Physicians for a National Health Program. Here is a refereed academic study which compares sick adults in 5 nations – Table 7 of details their findings on wait times. There’s too much data buried in the table so a short summary doesn’t do it justice. The data is there and it shows that Phil is correct.

    Alex, what you’re doing sure looks like a hunt for evidence that only supports your emotional or ideological preference. So long as someone claims something that you favor you cling to that statement as evidence but you don’t evaluate the quality of the evidence. In short, the evidence you’ve cited doesn’t withstand challenges and therefore doesn’t support your position. Now, if you hold a position based on evidence and then the evidence is undermined, you should have no compunction against abandoning your stated position.

  81. dutchmarbel says:

    As I stated earlier: in the Netherlands 18.36% of the deaths in 2008 where younger than 65. In the USA 27.4% of deaths in 2006 where younger than 65.

    @tangoman: you claim that ” when you look at the past you see that the US had the world’s highest rate of cigarette consumption up until the mid-80s” and link to a book that can’t be read online. So I googled a bit, and looked for the statistics of my own country, the UK and the US. I haven’t looked up stats for other countries, since the first two allready contradicted your statement.

    Of the US population 42.4% smoked in 1965 and it declined since (37.4% in 1970, 33.2% in 1980, 25.5% in 1990).

    In the Netherlands, the rate of daily smokers among adults has fallen from 43%
    in 1980 to 29% in 2007

    In the UK The prevalence of cigarette smoking decreased substantially in the 1970s and early 1980s, from 45 per cent of all men and women aged 16 and over in 1974 to 35 per cent in 1982.

  82. TangoMan says:

    I haven’t looked up stats for other countries, since the first two allready contradicted your statement.

    You’re using 3 different sources, likely compiled using 3 different methodologies, so, in other words, your conclusion has no sound basis.