[ExI] Health care in the USA
max at maxmore.com
Sun Jun 28 05:15:08 UTC 2009
Since I'm going to partially defend the US health
care system here against some exaggerated
criticisms, I want first to emphasize that I am
NOT a fan of the existing system. I regard it as
overly expensive, and badly distorted by huge
government intervention and massive regulation. A
move toward a true market-based, consumer-driven
system could do much better. (Although I'm not
yet very familiar with it, the Swiss system seems
to be a good step in the right direction.)
Among the problems of the existing US health care
system: It costs hundreds of billions more than
it seems that it should, given outcomes -- even
adjusting for the greater wealth of the country;
insurance costs far more than it should due to
the third-party payment system (itself the result
of tax and regulation policy); hospitals are far
too expensive and much more care could be done
outside them; medical errors are far too high
(true of all countries); and so on.
The relentless criticism of the US system should
not be allowed to obscure the real ways in which
it leads the world. Parts of the system are world
class, including its best hospitals. The US has
been the leader in medical innovation. Waiting
times are lower (for the insured and others who
can pay)--see below. Cutting-edge drugs and
treatments are available earlier. According to
Robert Goldberg of the Manhattan Institute's
Center for Medical Progress, the pharmaceutical
and biotechnology industries of the USA has
developed more cancer drugs than all those in
Europe, Canada, and Japan combined.
Pharmaceutical R&D has increasingly been focused
in the United States due to price controls
elsewhere. Goldberg points out that it is in the
US that 75 percent of all new drugs are
discovered and first used. (Examples being coated
stents for treating narrowing heart arteries and
LASIK surgery for correcting vision problems.) I
would argue that these remarkable results are due
to the private aspects of the system.
James Hughes wrote:
>So we pay for the most expensive health care in
>the world, to serve the smallest proportion of
>our population, for the poorest health outcomes,
The worst outcomes in the world? Really?
>Also, the rationalized queueing in Canada
>compares quite favorably to the over-utlization
>of tests and procedures by specialist-heavy, for-profit medicine in the US.
If you agree that there is a much heavier user
(or "over-use") of tests in the USA, I think you
should also grant that the higher incidence of
diseases that contribute to the apparently
relatively poor health showing of the USA is
partly or largely due to greater detection. In
fact, there are numerous cases of apparently
sudden spikes in the incidence of diseases (in
many countries) when new tests become available.
"Advocates of a single-payer system often cite
the lower medical costs of the completely
nationalized health care systems in Canada and
Britain, which spend less than 9.6 percent and
7.7 percent of their GDPs on health care,
respectively. Despite the lower spending, the
average life expectancy at birth is 79.8 years in
Canada and 78.2 years in Britain, higher than
America's 77.1. What explains the differential?
As University of Iowa health economist Robert
Ohsfeldt notes in the fall 2003 issue of The
Independent Review, if higher U.S. accident and
homicide rates are taken into account, our life
expectancy numbers match those of Britain. The
difference is also partly due to a slightly
higher infant mortality rate in the U.S.: 6.8 per
1,000 live births, compared to Canada's 4.9 and
Britain's 5.3 rate per 1,000. (That seems largely
related to racial disparities -- the white U.S.
infant mortality rate in 2000 was 5.7 and the
black infant mortality was 14.4.)"
(From "Mandatory Health Insurance Now!"
Looking at some specific disease data, one finds
again that there is not really much difference
between Americans and Britons. What could be
going on? The indispensable science reporter Gina
Kolata over at the New York Times makes the point
that at least part of the answer is that
Americans spend a lot of that extra money on a
wide array of medical tests These include PSA
tests for prostate cancer; mammograms for breast
cancer; 64 slice CT scanners for coronary artery
disease; and a regular battery of blood tests to
carefully monitor cholesterol and insulin levels.
Doctors tell people that they are suffering from
metabolic syndrome which until a few years ago
would have just meant they should lose some weight.
In the JAMA study about twice as many Americans
said that theyve had cancer than Britons, but
the cancer incidence rates are not all that
different. Part of answer to the paradox of sick
Americans versus healthy Britons is that by
resorting to more testing and more aggressive
doctoring we Americans get diagnosed with
something more frequently. Kolata ends with a
wonderful anecdote in which a doctor-in-training
was asked by his professor to define a well
person. The resident thought for a moment. A well
person, he said, is someone who has not been
completely worked up. The JAMA study likely
reflects the fact that America and Americans have
been a lot more completely worked up than the British have.
"Are Yanks Sicker Than Brits?"
I agree with James that it's not unreasonable --
at least on one measure -- to include in waiting
times the inability of some uninsured to get any
treatment at all (remembering that, for
emergencies, the uninsured DO get treatment --
contrary to the common myth I used to hear
frequently in the UK). However, your estimate
goes way too far, as you include ALL the
uninsured as being on an infinite wait. This just
isn't right. Note that about one third of
Americans without health insurance have incomes
over $50,000. Many or all of them can get medical
procedures, with the usual very short US wait
times. You don't HAVE to have insurance to get
treatment, you just have to pay up when you need it.
>Absolutely. In fact, international surveys have
>found that if you "Was there a time in the last
>year when you had to wait to get a necessary
>procedure, either because you were on a waiting
>list or because you could not afford it?" *twice
>as many Americans* had to wait for procedures as
>compared to any other industrial country.
James, you cite this source for the claim:
I didn't see anything in that source that
supports what you said? Am I missing something?
What I did find there suggests the opposite:
"This paper reports on a 2003 comparative survey
of hospital executives in Australia, Canada, New
Zealand, the United Kingdom, and the United
States. Reflecting higher spending levels, U.S.
hospitals as a group stand out for generally more
positive ratings of facilities and finances and short or no waiting times.:
"The current survey asked respondents about
waiting times in their own facility. Except in
the United States, sizable shares reported long
waits in their hospitals for elective admissions.
Waits of six months or more for elective
surgeries were reported to occur "very often" or
"often" by 2657 percent of executives in the
four non-U.S. countries; only 1 percent of U.S. hospitals reported this,:
"Breast biopsy and hip replacement. Hospital
executives were asked for their perceptions of
waiting times for breast biopsy and hip replacement (Exhibit 3
). For both, U.S. executives reported by far the
shortest waiting times, followed by Australia."
It's true that waiting times in U.S. emergency
rooms (i.e. time to see a doctor) as increased
over the last decade from 22 minutes to 30
minutes (but 15 minutes in nonurban hospitals).
Unlike in the UK, there's no additional wait
outside in the ambulance. According to the
Guardian, the government has aimed for waits of
no longer than four hours. When this failed to be
met, British hospitals worked around it by
keeping people unofficially waiting in ambulances
outside -- a practice called "patient stacking".
Apparently, people with broken limbs or breathing
problems could find themselves waiting in ambulances for up to five hours.
The U.S. looks much better than countries with
nationalized health care when you consider
waiting times for tests and treatments. Ohsfeldt
reports, for example, that in 1997 the mean
waiting time for magnetic resonance imaging (MRI)
of the head was 150 days in Canada, compared to
three days in the U.S. In 1998 the U.S. had 16
MRI machines per million citizens, compared to
3.4 in the U.K. and 1.7 in Canada. Such delays
have a serious impact on quality of care: A
patient has to wait longer for a good diagnosis,
increasing the probability that his treatment
will not prevent a lasting disability.
Max More, Ph.D.
Extropy Institute Founder
max at maxmore.com
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