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1. Eric, only death and taxes, but since I see no counterexamples, I’m willing to try it. Remember Stein’s Law and it’s clear that US healthcare will change to control costs. I cannot convince you of my gut feel (remember the gut has more nerve endings than the head), but it seems blindingly obvious to me that adding universal coverage is cheap especially when you consider that government administration is often more cost effective. Of course, I’m guessing you’re of the opinion that we have too few doctors where I think we have way too many so we don’t even agree about starting points.

2. Matthew, I agree with your conclusion at the end of our article that there is little or no connection between the healthcare system and the health of the people, but people who lack health insurance are likely to suffer worse health outcomes than the adequately insured.
   That said, there are a lot of complexities in attempting to compare health status and outcomes among people from different countries and culture, even after controlling for ethnicity and socioeconomic status.
   The U.S., for example, has a population at least five times that of the most populous Western European country and about ten times Canada’s. Our land area is vastly larger than any Western European nation. While Canada also covers a vast land area, much of its population lives in three metro areas — Montreal, Toronto, and Vancouver.
   There are significant regional differences in the U.S. in the types of foods that are popular and prevalent in the typical diet, some of which are healthier than others. In New York City, where many people don’t have cars, I’ve read that there is less obseity because people walk more out of necessity. In areas with a nice climate during much of the year, like California, there is more opportunity to pursue outdoor activities and the implicit beneficial exercise that goes with them. In regions where farming and ranching are the dominant economic activity, above average amounts of physical activity go with the occupation and lifestyle. Conversely, people who work in underground coal mines, for example, probably have worse health outcomes and shorter life expectancies due to the inherently dangerous nature of the job.
   I also wonder in a large country like ours, how many people are hurt in accidents on highways, in workplaces, or from sports and other recreational activities vs other countries and how much of our healthcare spending relates to medical care required to treat people hurt in those accidents.
   Finally, significant differences in tax burdens probably create differences among Americans, Europeans and Canadians in how they value and make the tradeoff between work vs leisure. In Europe, people, on average, have more vacation days than Americans. To the extent that some medical conditions are exacerbated by stress, this can also be a contributing factor to both health expenses and outcomes.
   Regarding out of pocket financial exposure, I certainly agree that the peace of mind that comes from knowing that insurance will be there, at least to cover the costs related to a catastrophic event, is worth a lot. For smaller employers who may be able to afford to offer employees a high deductible plan but not a more comprehensive plan, the high deductible plan is certainly a heck of a lot better than nothing.

3. Matthew- best thing you have written in quite some time! I fear this may put you at pretty serious odds with many of your political compadres, however.
   elliotg cannot claim with any degree of certainty that national healthcare in the us will decrease costs. Peter is simply not honest when he refers to the ‘so called free enterprise model’ with regards to the us healthcare sysetm. 50% of the spending comes from the government- it is not a free market.
   Doctors do not promote junk food, bad diets, and sedentary lifestyles (or smoking)… all things over which people actually have free choice to modify.

4. I think that might be a good point elliottg. Economics is a zero sum game. Last year we spent $6000 extra in out of pocket expenses for healthcare, none of it tax deductible. That money went to one industry and did not go to any other sector in the economy, including the government sector. Americans are deluded when they rely on a so called free enterprise model to solve all their problems all the time. It usually means someone is benefiting from their loss. Promoting the feeding of junk food to children, high fat/high sugar diets and no exercise, while the food industry gets massive subsidies, along with industry resistance to pollution controls, and the health industry gets rich from the outcomes. Just doesn’t seem to be working very well.

5. I think that you failed to consider something when you stated that there was not a link between universal access and health outcomes. Universal access drives down expenditures on healthcare. Sure I’m willing to spend an outrageous amount of someone else’s money on my health whether it be 3rd party insurer or govt., but when everyone gets the same baseline then resources exhaust too fast so rationing is instituted (the good kind – standards and EBM). The second effect is that the money is freed up and the cost/benefit analysis for public health/welfare initiatives becomes easier. So maybe Canadians have better health because they have more money to spend on welfare, public housing, etc. Maybe the existence of universal healthcare fosters more of a we’re all in this together culture that’s willing to spend on those things.
   It would be interesting to map income inequality to healthcare outcomes for different countries or maybe even different states.