[ExI] Health care in the USA

[Max More]

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!" 
<http://www.reason.com/news/show/29303.html>

Also:
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 they’ve 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?"
http://www.reason.com/news/show/116488.html


On waiting:

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:
http://content.healthaffairs.org/cgi/content/full/23/3/119

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 26–57 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
Go
). 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.

And:
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.
<http://www.reason.com/news/show/29303.html>

Max


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Max More, Ph.D.
Strategic Philosopher
Extropy Institute Founder
www.maxmore.com
max at maxmore.com
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