POLICY: Ezra Klein’s The Health of Nations

Now I’ve met Ezra I can stop calling him the young punk. He has written another excellent review of health care in universal coverage nations, including socialized medicine in the heart of America for our allegedly most treasured citizens.

It’s called The Health of Nations. Go read it.

It’s not entirely without flaws, almost all to do with the lack of good recent data that’s a problem with these comparisons and a need to conserve space. He skips over the UK’s private insurance system which enables the rich to trade up for elective surgery, and the recent increases in spending under Blair which have enable the Brits to buy spare capacity in private countries, (and ramped up GPs pay!). It would be nice to have Ezra do something similar on Japan and Holland (although Japan looks something like Germany plus a Canadian fee schedule, and Holland looks like an Enthoven-wet dream).

What’s also to some extent missing is the changes that have happened recently. Humphrey Taylor remarked to me on Sunday that Americans dont realize how much other systems are changing as ours essentially never does. The Brits have gone to 30% P4P in primary care; the Dutch to individually purchased insurance in a managed competition framework; the Danes and the New Zealanders have added rapid deployment of IT (100% EMR use in ambulatory care); whereas the Australians have added a private top up layer over their traditional socialized  medicine system; the Swiss have their individual mandate.

Of course all of these systems have their problems and all are changing; we’re stuck in 1991. And in fact the VA system, although it works very well it about to be hit with a wave of Iraq war vets who have real problems–and is unlikely to get the resources it needs to deal with them.

And although it goes without saying to those in the know, we should keep repeating that this is the only system that visits not only ill health on the unlucky but often financial disaster too.

13 replies »

  1. jd, I don’t know the German system, but I do know that the American system, in addition to having gigantic insurance industry waste, allows physicians to invest in highly profitable lab equipment and then order tests to their heart’s content. Does anyone know if this occurs in other systems. As Barry pointed out, in a McKenzie study, physicians that have a financial interest in the lab equipment are up to eight times more likely to order tests than are physicians without such investment.
    This isn’t the only elephant in the room, but it is a significant factor.

  2. John. Can you explain to us how much the Fraser data on waiting lists varies from the government data and why. I’ve accused you of cherry picking that in the past, but to be fair I haven’t looked in depth at that data and you have. I’ll happily publish your views here. After all it’s data not anecdote

  3. John Graham,
    If the German system seems to you so similar to the American system, then what do you think are the differences that produce expenses nearly twice as high per person? Why are we paying so much more and not getting better health outcomes?
    Here’s a suggestion: the national government sets the rates paid to providers in the German system. It’s kind of like the Managed Medicaid or Medicare Advantage programs, but for groups as well as individuals, and with even more direct government involvement on rate setting.

  4. The Dutch have it totally figure out going paperless. I implemented an EMR in my practice and the change has been dramatic. I found this eBook by EMR experts to be a huge help in setting it up.

  5. Here is an email I received from a friend:
    Ezra Klein (American Prospect) left out some important information on the NHS in the UK.  It’s the serious problem with queue-jumping which has plagued the NHS since almost the beginning.
    Because the NHS operates alongside a private insurance system which reimburses at a higher rate than the public service, many NHS  patients are forced to wait and wait and wait for service, while the privately insured get placed in the front of the queue, both for outpatient and hospital services.  When we lived in Wales, my oldest son used to bus from London over the Aberystwyth to see a doctor.  The queue jumping problem is severe only in urban areas.
    The same faultline exists in New Zealand and Australia.  I know so little about the French system I have no idea of the practical effect of the dual systems on French patients.
    Canadian developers of Canadian Medicare were aware of the unfair and undesirable impact of permitting duplicate private health insurance, so forbade physicians receiving Medicare reimbursements [from] also accepting private insurance reimbursements.
    A physician wishing to serve privately insured patients must “opt out” of the Canadian Medicare system. As of 31 March 2004, no doctors had opted out of the public plan in Alberta, Manitoba, New Brunswick, Newfoundland and Labrador, Nova Scotia, Prince Edward Island and Saskatchewan.  In comparison, 6 doctors had opted out in British Columbia, 129 in Ontario and 97 in Quebec.  For a number of reasons, the overwhelming number of Canadian physicians choose to remain in the Medicare system.
    If Mr. Klein were more knowledgeable about the weakness in the UK health service he might not have concluded that the U.S. adopt that reform model.

  6. As I read Mr. Klein’s description of Germany, I could have sworn he was talking about the U.S. Think about it: if you are free to join any sickness fund, isn’t that a lot more like using a voucher or a refundable tax credit, than “single payer”? (Voucher/tax credit being the “conservative free market” proposal to get rid of the deformed tax bias that currently exists.)
    The German management of selection bias, by making “healthy” sickness funds subsidise “sick” sickness funds sounds a little like the premium taxes that states levy on private insurers to subsidize their uncompensated care pools, or the non-specific “tax” caused by the cost-shift from Medicaid & Medicare to private insurers & hospitals.
    Also, U.S. insurers are not generally allowed to “cherry pick” as Mr. Klein alleges (which would be a good thing if it were allowed, but I’ll leave that for another day). Only in the still pretty tiny individual market (and not even there, for a few states) can health insurers freely underwrite.
    By the way, the Canadian waiting list data does not come from the American conservative media: It comes from Canadian doctors polled every year year by the Fraser Institute’s Calgary office.

  7. >>> “Our efforts on reform need to focus on freeing market forces to do what they do best – produce an efficient delivery model.”
    Yeah, maybe we need to turn the system over to Halliburton.
    Or, if we are smart, we’d recognize that the free market system is the cause of our 87% rise in health care costs since 2000. A look at our privatized Medicare system (Medicare Advantage), which is costing 12.5% more than Medicare itself, should tell us that private is not always cheaper than public. It is saddled with advertising and administrative costs that Medicare does not have to spend.

  8. We have two basic problems. Firstly, our care delivery system is hopelessly inefficient – primarily due to fragmentation. The “continuum of care” is actually a bunch of small to medium sized businesses working together in an ad hoc fashion. US healthcare has appropriately been described as “the world’s largest cottage industry”. You cannot legislate your way to efficiency – only a free market can do that. Our efforts on reform need to focus on freeing market forces to do what they do best – produce an efficient delivery model.
    The second problem is who is going to pay for the care of those that can’t afford to pay for it? Solve the efficiency problem and you positively impact the affordability problem however you do not solve it. The affordability problem is a social services issue and best left to our representatives in Washington.

  9. Yes, but Peter, we have the best politicians money can buy. That they are blocking meaningful health care reform on behalf of the insurance industry contributors is secondary to getting re-elected. What is still puzzling to me is that corporate CEOs haven’t caught on yet. They are usually quite intuitive.

  10. In what way is the WHO biased? Toward, oh, say, human beings instead of profits? People instead of things?
    What? Pray, tell us? Is it that it fails to worship at the alter of pharm profit margins? Is it that it neglects to pay the proper tribute to, say, mass-marketing of cheap, bad food to a chronically underpaid underclass? Does it neglect to see the wisdom of eternal economic hardship as a legitimate form of fatal duress? No?
    Which is it? Do shine upon us the wisdom of the market.

  11. As long as the U.S. runs its “democratic” system on bribes for politicians, rewards for party hacks and policy based on corporate profit protection, there will be no real change until crisis forces it.

  12. Actually, this is some of his old propaganda rehashed. And – you know that it can be safely ignored when you encounter the old trope about Canadian wait-times for surgery which ignores the long waits to see a specialist in order to get a diagnosis. Also, the reference to the biased and untrustworthy WHO rankings without any disclaimer show that young collectivist Klien is not to be taken seriously.