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POLICY: Health Care Problem? Check the New York Times Psyche

Hi, if you’ve wandered in from the Typepad blog of the day site, welcome!

Today the NYT lets its rational lefty business reporter Anna Bernasek make a rational if obvious and basic case for single payer health care, even though she quotes Vic Fuchs as if he was a leading opponent. He’s not—he’s just  a realist and he supports his own version of what the real opponents at Cato and Manhattan would call single payer.

The article is called Health Care Problem? Check the American Psyche. Of course  the real psyche that needs checking is that of whoever it is who controls (if anyone) what the NY Times writes about health care policy in its business pages. Last year they let several just appalling articles by Gina Kolata and David Leonhardt be published on health care spending—not to mention the odd op-ed by loony libertarians who think that the number of Nobel prizes for medicine awarded is a proxy for a good health care system.

And like a dog licking its own sore, they just could not stop.

Hopefully, with the debate getting real on health care, today’s article is a sign that the paper of record is beginning to be slightly less dense. And may even allow some rational voices to have a rational debate…

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25 replies »

  1. seeker,
    you said “This is not primarily very poor people; they have Medicaid.”
    But that’s not true. The fact is that about 2/3 of all the uninsured in the US today have incomes at or below 2X’s the federal poverty limit, and 98% of the uninsured are below 4X’s FPL. Being uninsured is very much a creature of poverty.
    It is also a creature of Medicaid’s failure to cover the poor – thus so many uninsured poor. Replacing Medicaid with another government program sounds a lot like what Nipsy Russell called running through hell in gasoline pants.

  2. It is so frustrating (to put it nicely) to read people fortunate enough to have no worries about their own healthcare talk about the wonders of a healthcare system that leaves 45 million people uninsured. This is not primarily very poor people; they have Medicaid.
    It is the working poor and an increasing number of people dumped on the individual market because their employers no longer offer coverage. Because of outrageous underwriting criteria and the exorbitant costs of individual policies, most people do not qualify for them or cannot afford them.
    Then to add insult, we are told that people who are frozen out of the “standard” US insurance system can just be happy with charity and limited (or no) ability to seek compensation for medical mistakes, something the writers seem not to be willing to give up for themselves.
    Finally, this second class kind of care is extended to a probable (I do not have statistics at hand) majority of the US population–those making up to $75k,
    What is wrong with this picture?

  3. “In talking about how Europeans view the U.S. healthcare system, he said that they love us clinically (excellent academic medical centers, top scientists and docs, state of the art technical capability, etc.) but they hate our financing mechanism and the fact that we have a significant number of uninsured.”
    I agree with this. I think as a society we need to figure out a way to offer a barebones HDHP that would allow more people to enter the risk pool at a reasonable monthly price. Hopefully the MA and MD plans will achieve this.
    “To that end, I would look most closely at end of life care (more use of living wills and advance directives), using specialized health courts to resolve medical malpractice disputes (could result in less defensive medicine), and more widespread use of electronic medical records, especially in hospitals, to reduce duplicate testing and adverse drug interactions.”
    These are all issues we need to be concentrating on. It would be nice to standardize a core EMR system that can be used universally.
    “Of course if you’re poor and don’t have insurance, then access to the best care in the world doesn’t do you much good, now does it?”
    Actually the poor are never denied care at the major medical centers. They can just walk into the ER and get care. If they need surgery or follow-up care from the ER, we need to go back to the old fashioned charity clinics and allow the chief residents at these centers more autonomy with limited liability to care for these patients. This combined with a mandatory low cost barebones HDHP for those with annual incomes b/w $20-75k should cover the vast majority of the uninsured.

  4. So what you’re saying pgbMD, there is no way to measure what country has the best medical care.
    You only believe the US is best, because “all the wealthy foreigners” (although you have since qualified that to mean mostly Middle Easterners) come here for care, because the US has the latest and greatest equipment, and if you’re rich and/or have insurance, you can get easy access to all that.
    That of course doesn’t mean US doctors have greater abilities, are more intelligent, or more caring now does it?
    Of course if you’re poor and don’t have insurance, then access to the best care in the world doesn’t do you much good, now does it?

  5. I would like to make several points..
    First, while I unfortunately cannot remember where I read it, I recall an interview with a leading healthcare academic. In talking about how Europeans view the U.S. healthcare system, he said that they love us clinically (excellent academic medical centers, top scientists and docs, state of the art technical capability, etc.) but they hate our financing mechanism and the fact that we have a significant number of uninsured.
    With respect to the health of the uninsured, since most uninsured are also poor, it is hard to know how much of their poor health is due to not having health insurance and how much is caused by the fact that they are poor. Perhaps it would be useful to attempt to compare the health of a sample of poor people insured by Medicaid with a group of poor uninsured people who make a little too much money to qualify for Medicaid.
    Regarding why our costs are so high in the U.S., I think administrative costs are a factor but not as significant as most people think. The Lewin Group analysis of the Wyden plan, for example, projects relatively modest savings from lower administrative costs resulting from moving people into large groups and eliminating medical underwriting. My main candidates are (1) doctors, hospitals and other providers (including drug companies) charge more here. I would like to see some apples to apples comparisons showing the cost (at Medicare rates) of, say, a CABG or a DES in the U.S. vs Canada, UK, France or Germany and also how many are performed per 100,000 population. (2) There may be material differences in our approaches to end of life care. Even if other countries (aside from the UK) don’t explicitly ration care, there may be a very different consensus among doctors as to what constitutes good, sound medical practice overseas vs here. Surgical interventions for frail elderly people may be much less likely overseas because the costs, risks, and potential impact on quality of life make the procedure not worth doing whereas we might do it just because we can, and the family wants everything done to prolong the life of their loved one. Even within our own country, there are large differences in practice patterns. Medicare, for example, spends approximately 2.5-3.0 times more per beneficiary in Miami than in Minneapolis with no difference in outcomes. Yet CMS has done precious little to reduce that variance in practice patterns between the best practicers and the high utilizers. (3) Other countries such as Canada engage in implicit rationing. This means deliberately restricting the supply of hospital beds, MRI machines, etc. by requiring a government issued Certificate of Need for new facilities to be put in place. The effect is to increase wait times for non-emergency procedures. While this probably does save money on balance, disease could easily progress while you’re waiting for your MRI, CAT scan, colonoscopy or whatever.
    The biggest problem with our system, in my view, centers on the cost and availability of insurance and the lock in effect of forcing some people with significant medical issues to stay in a job that may be less than satisfactory just because they need the insurance coverage and can’t easily replace it if they change jobs. While good price and quality transparency tools would be helpful at the margin to make providers more price competitive, I think we need to work hardest at safely finding ways to reduce healthcare utilization. To that end, I would look most closely at end of life care (more use of living wills and advance directives), using specialized health courts to resolve medical malpractice disputes (could result in less defensive medicine), and more widespread use of electronic medical records, especially in hospitals, to reduce duplicate testing and adverse drug interactions.

  6. “Hey! I’m not the one making the claims. Why should I be making an effort to prove you right or wrong. That usually falls under the purview of the person making the claims.”
    I will try to get some hard data on this. Anecdotally, I just got off the phone with a friend of mine and he relayed to me that a partner of his (a world-renowned urologic surgeon) just recently treated a French patient who paid in cash to reconstruct a complex urologic injury. The US is fortunate to have some of the world’s finest surgeons who have through innovation advanced the science of medicine. Not to say, of course, that Europe does not have its own fair share, but if lined up next to each other we have the lion’s share of top physicians and scientists in the world.
    “The larger point in the health care system debate (international version) is this – we pay more for health care, but our health is in most cases not as good as others who pay less.”
    Again, you cannot use a population’s “health” to gauge a healthcare system. More useful measures would be specific disease-to-treatment outcomes comparing patients with similar co-morbidities and severity of disease. For instance, I know that French intensive care unit mortality is nearly 15% higher when compared to the US. Maybe this is due to a more pervasive use of advanced directives, stricter management of end of life care, or just poor medicine. I do not know.
    In terms of cost, we do pay more in this country for healthcare in order to have an abundance of the latest technology and no wait times. When comparing government spending as a proportion of GDP for healthcare, the US is lower than Canada, France and Germany. The spending in the US system mushrooms when we add in the private spending. However, I believe, in a free society, private spending cannot be limited or outlawed. At the same time though we do need to fix the uninsured problem and hopefully the MA and MD plans may be the solution.

  7. Not knowing Mr. Browning, I’m somewhat confused as to his point. It appears he is trying to drag Matthew into a debate about infant mortality rates and the relation of same to health care systems (and I assume the nature of those systems).
    I’ve noted the differences in outcomes and costs at my blog a time or two. While I don’t know that there is a tight correlation between the two, there is certainly ample evidence from around the world and up in Hanover NH that more costs does not equal better outcomes. And, the studies from RAND and others clearly indicate that the health of our uninsured population is not as good as those of us with insurance.
    The larger point in the health care system debate (international version) is this – we pay more for health care, but our health is in most cases not as good as others who pay less.
    So, why are we paying more?

  8. Hey! I’m not the one making the claims. Why should I be making an effort to prove you right or wrong. That usually falls under the purview of the person making the claims.
    And, as far as using infant mortality and life expectancy as a measure of the quality of health care, I really wasn’t attempting do that.
    What I wanted to know was, if we can’t use measures such as those, what exactly do we use to measure the quality of US health care?
    Obviously you know, because you have already stated that US health care is the best in the world.
    I am just curious on what basis you made that determination? VIP wards?

  9. “You’re just spouting propaganda by those who have a vested interest in making people believe US health care is the greatest in the world.”
    Wow, this is the first time I have been called a propagandist. I will take that as a compliment! You obviously have a very limited fund of knowledge when it comes to American medical centers. Just go to Hopkins, The Mayo Clinic, etc and ask about the VIP wards. Unfortunately, I am not privy to the VIP data, but I am sure others here that are on the admin side of the house may be able to shed light upon it and exonerate me. I am just going off my experience during surgical training while “in-house”. As far as your international buddies via the internet, we’ll just have to take your word on that one.
    And please, stop going back to the debunked infant mortality and life expectancy data, even the honorable Mr Holt has resigned that their use is limited at best. “There is only a limited connection between a nation’s health care system and its health outcomes measures. (Mr. Holt)”
    Again, does it make sense that the Canadians have far better healthcare for their dogs and cats than for themselves??
    “A Short Course in Brain Surgery” http://www.onthefencefilms.com

  10. Sorry pgbMD, but you did say “all the wealthy foreigners” and the “vast majority of foreign dignitaries”, come to the US for care.
    Still all we have is your word for it. I have never seen any stats for that, nor would you or could you name even one that has come here.
    You’re just spouting propaganda by those who have a vested interest in making people believe US health care is the greatest in the world.
    I’ll repeat what I have said on other blogs, I am in daily contact with many people from all over the world, including Italy, France, Germany, as well as people from Japan, China, Australia and New Zealand, and even one person from Egypt, just to name a few, with similar disease to me, and I have never heard any person complain about the care they receive, nor would any of them trade their system of health care for that in the US.
    And Mr Browning if we can’t use infant mortality or life expectancy to compare health care systems, just what do we use?
    Cost? The number of people who don’t have easy access to care? The US sure wins on both those counts!

  11. Since Mr. Holt has been unable to refrain from personal insults, this will be my final post.
    Nevertheless, now that Mr. Holt has deigned to offer a quick lesson in health econ 101 offering a veiled repudiation of the New York Time’s article linking life expectancy averages and government control of health care systems, I’m hoping that he will now cease using life expectancy and infant mortality rate differentials – which have nearly nothing to do with the quality of a health care system – in his propaganda.
    I’m not betting on it.

  12. “So what you are saying, is that those foreigners who do come to the US for health care, aren’t actually from Europe, as most people claim who think the American health care system is the greatest in the world, but rather are from the Middle East.”
    I guess you have difficulty reading my posts.
    I said, “but there were several royal names that came from Europe as well”. You then interpret it as, “those foreigners who do come to the US for health care, aren’t actually from Europe”. Please stop misquoting me. Still, however, the US healthcare system is the best in the world.
    I find it comical that the Canadians have far better healthcare for their dogs and cats than for themselves. Sadly, since the 1970’s, we have been slowly drifting in that direction as well with the ever-increasing government regulation and intervention that has strangled our healthcare system.

  13. I will say this only once, and for Mr Browning that may not be enough. Nothing in the piece that these comments refers to has anything to do with the Canadian health care system. I am not a proponent of adopting that system in America, although it would be better than what we have now.
    There is only a limited connection between a nation’s health care system and its health outcomes measures. That’s health economics 101 and what Mr Browning is talking about in these comments I do not know.
    However, it is abundantly clear from voluminous peer-reviewed research from real academics (like Rheindhart and Anderson) not ignorant software millionaires, that the American health care system delivers roughly the same services as those in other countries, at a much much higher cost. And that poorer people in the US have a much much worse experience with their health care system than do poorer people in other developed countries. I guess that doesn’t matter to millionaires.
    Less than a week ago I wrote this piece that showed that Canada isn’t all bad. I was suggesting that in the hands of the Canada-bashers the converse stories would be used as evidence of the evils of the Canadian system. It’s called humor. Something Mr Browning presumably doesn’t understand.
    Mr Browning has said the most ridiculous things about me and several other bloggers (not all of whom I agree with) on his mostly unread site, and sent several ridiculous and insulting emails to me and others.
    There are some intelligent rational Canada bashers out there–who I will talk with and discuss. Mr Browning is not one of them.

  14. Sorry pgbMD, I wasn’t suggesting the reason you were commenting was that you were pathetically lonely, after all I was commenting as well. It was simply an observation.
    So what you are saying, is that those foreigners who do come to the US for health care, aren’t actually from Europe, as most people claim who think the American health care system is the greatest in the world, but rather are from the Middle East.
    So based on your statement, I can only assume that all those wealthy Europeans must prefer the inferior health care systems in their own countries.
    Umh! I wonder what that tells us about US health care?
    Oh, I know, US health care is better than what you can get in Egypt, and Saudi Arabia.
    Now that’s something to brag about. NOT!!!!

  15. Everyone should see Stuart Browning’s movie “A Short Course in Brain Surgery” at http://www.onthefencefilms.com. A very disheartening look inside the Canadian healthcare system through the eyes of a patient diagnosed with a brain tumor. This is not what the main stream media and politicians pushing a single payer system want us to see.
    I guess single payer “advocates” here in the US have no problem with Canadian patients waiting over 8 months for brain surgery to remove a tumor? Not wanting to wait 8 months, the patient was forced to have his MRI in Buffalo, NY and then he booked his surgery in the US the next week. Unfortunately, these same healthcare “advocates” want something similar here in the US…

  16. Notice that Mr. Holt never attempts to actually defend his assertions.
    Once again, Mr. Holt are you really giving credit to the Canadian health care system for the 2.4 years of additional life expectancy that Canadians experience? If that’s what you’re asserting here, then please confirm this for the other readers.
    I’m betting you won’t take the bait.

  17. Frankly to be insulted by someone of the academic integrity of Mr Browning is quite an honor.
    I would though be surprised if the software that made him his fortune cost twice as much as that of his competitors and yet delivered no measurably superior results. On the other hand, perhaps I wouldn’t be that surprised.

  18. “Where is the information about “all the wealthy Europeans” coming to the US for treatment? Are there government statistics that keep track of this?”
    If you read my post carefully, I said wealthy foreigners not Europeans. From my experience during surgical training, most of them come from the Middle East and Asia, but there were several royal names that came from Europe as well. No stats though. The data would be hard to gather since most of these super wealthy individuals stay on the VIP wards, want to remain anon, and pay in cash.
    This was my first New Years without a sip of EtOH since I have 14 month old twin girls. Thus my reason for posting was not as sinister or pathetically lonely as you may have suggested! 😉

  19. Oh, I should point out Matthew, it doesn’t do much good to post an article that requires a paid subscription to the NY Times to read.
    Not everyone can read it, including myself!

  20. What’s more disturbing than the fact that Matthew posted 2 new posts on New Years eve, and that 3 people were up up New Years day commenting is the fact that I am actually reading and commenting also on New Years day. The only saving grace is I am watching the Rose Parade.
    Anyways to my point.
    Where is the information about “all the wealthy Europeans” coming to the US for treatment? Are there government statistics that keep track of this?
    And can you name maybe 5 wealthy Europeans who have come for health care in the US, say in the past 5 years, and what they were treated for?
    Inquiring minds want to know!

  21. Don’t expect a correction from Mr. Holt. Expect instead additional nonsense about WHO rankings and how the healthy majority in Canada prefer their “free” system. And when those threadbare non-arguments fail, he’ll begin hurling the “racist” epithet or calling people “looney” as substitutes for rational discourse.
    I hope all who read here are at least keyed in to Mr. Holt’s essential motivation: it’s *NOT* health. I’ll let others deduce what it might be.

  22. With respected to infant mortality statistics, there are significant differences among countries in how they define a live birth as illustrated here. There are also many factors that affect life expectancy besides the quality and availability of healthcare as pgbMD stated. Genetics may also play a role. In Japan, for example, their diet may contribute to the longer life expectancy of their people, but their diet evolved, at least partly, as a function of what foods were most available to an island nation (fish) and what could be grown most affordably (rice), especially when the country was poor.
    I find it frustrating that advocates of government run healthcare keep pointing to infant mortality and life expectancy statistics as evidence of other countries doing a better job in providing healthcare to their citizens at far less cost than we do. It would be a shame if public policy driven were driven by such shoddy analysis.

  23. Which country has the best healthcare? Where do all the wealthy foreigners go for care? The US! Of course France and Germany do well too, but still the vast majority of foreign dignitaries come to the US for care.
    People confuse the quality of a healthcare system and it’s doctors with the quality of the health of a nation. They are not the same. The quality of the health of a nation depends on far more factors other than the quality of the healthcare system such as: smoking, low-birth weight babies (drug abuse by the mother, smoking, etc), obesity, murder rates, alcohol consumption, racial diversity, fast food, inactivity/sedentary lifestyle, etc.

  24. Loony libertarians? How about out-and-out liars such as yourself who continue to sell the myth that life expectancy and infant mortality rates have much of anything to do at all with the quality of a health care system?
    Do you spread this propaganda merely because it is convincing to many who won’t take just a few moments to actually think?
    Shameful.

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