Since Barack Obama has declared that obtaining universal healthcare coverage is one of the core elements of his program to rescue the economy (I believe he is quite disingenuous in this, but no matter, universal healthcare is on the way) it is important that we all understand some of the premises of the debate. Some widely held basic assumptions are simply not true. For example, there is no problem of access to healthcare. Anyone can obtain healthcare regardless of their ability to pay. Emergency rooms are legally obligated to treat all who enter their doors and there are clinics in most cities that will offer treatment at reduced fees or for no cost to those who are too poor to afford insurance. Admittedly the care is problematic, with limitations on some elective care and some medications, but no one is denied care in this country when they need it.
There are limits to healthcare insurance, of course; not everyone has insurance and we will see the numbers of uninsured mentioned time and again as reason for universal healthcare (though rarely with any caveats about the number of uninsured who are here illegally or how many are uninsured by choice.) Ultimately whether or not we insure the uninsured is a major issue not because suddenly people without healthcare with have it available but because for some people, cheap healthcare will become more available. From my experience working with Medicaid patients in a clinic I can assure you that this will not achieve any cost savings as time goes on. The idea that preventive care saves money is a myth; preventive care costs money. A patient with Diabetes and Heart Disease who is kept alive long enough to develop the complications of those diseases is a patient who will cost the system a small fortune; the most inexpensive patients with such illnesses are those who never obtain treatment, don't tkae care of themselves, have deleterious lifestyles, and die young. I am not suggesting our policy should be to deny care (something we do not now do) but simply pointing out that preventive care actually ends up costing much more money than the alternative.
With that preamble in mind, here is another argument, and its factual basis, that you will see in favor of the coming healthcare revolution, courtesy of Joe Conason:
The questions our healthcare debate ignores
Why do we spend so much more on healthcare, per capita, than other developed countries? Why do we achieve worse outcomes on several important measures than countries that spend far less? Why do we spend up to twice as much per person as countries that provide universal coverage while leaving as many as 50 million Americans without insurance? [Emphasis mine - SW]
The salience of those questions has grown over the past several decades, ever since President Truman first sought to create a universal health benefit program that resembled systems in Europe. Last month, the Paris-based Organization for Economic Cooperation and Development issued the latest in a long series of reports on our wasteful and cruel practices that ought to awaken a sense of national embarrassment. This highly topical study carried a deceptively bland title: "Healthcare Reform in the United States." Naturally, the mainstream media and punditry ignored its findings (although OECD reports promoting free trade often receive wide coverage).
Since I do not spend as much time scanning the MSM as I suppose Joe Conason does, it is hard for me to comment on whether or not the findings of the report have been ignored; I tend to think not, since I have heard just such comments made in many different fora, that we spend more on healthcare for lesser results, that our infant mortality rates are higher, and that life expectancy lags countries that have universal health care. These findings may be accurate but without some basic facts, understanding and interpreting the data is problematic. Since you will likely be hearing a great deal about this, some elaboration is in order. Here is the opening of "Healthcare Reform in the United States" that Joe Conason quotes. (All page numbers are for the pdf; all emphases, unless otherwise indicated, are mine.)
(p. 5) The US health-care system has many attractive features: in particular, most of the population has access to high standards of medical care, which are being continuously enhanced through cutting edge technological innovation. Nevertheless, the overall health status of the US population, as reflected in variables such as life expectancy and potential years of life lost, appears to rank among the lower third of OECD countries, despite much higher health expenditure per capita than in any other country. While many factors other than the performance of the health-care system affect health, the US health-care system can make a greater contribution to improving the health status of the US population without increasing expenditure, including by expanding access to health care. According to the 2008 Economic Report of the President, there are “substantial opportunities for reforms that would reduce costs, increase access, enhance quality, and improve the health of Americans”. Seizing these opportunities would thus contribute to achievement of the main objectives of the US Department of Health and Human Services (since 1990), namely: to reduce and ultimately eliminate health inequalities among various segments of the US population, including those among gender, ethnic, socioeconomic and geographic groups; and to increase life expectancy and quality of life among Americans of all ages.
The first thing to notice is the obvious contradiction in their opening paragraph. There is simply no way to maintain "access to high standards of medical care" and "continuously enhanc(ing) ... cutting edge technological innovation" and "expanding access to health care" all the while "without increasing expenditure(s)". Anyone who tells you otherwise is trying to sell you snake oil; if you believe these claims are true you are simply mathematically illiterate and should not take part in the discussion. However, there is more and, in many ways, it is even worse. There are three important points that the report emphasizes, with multiple official looking charts and graphs, to support their contention that the United States spends more and gets lesser outcomes:
(p. 7) Population health status is falling behind that in other developed countries
Population health status reflects performance of the health-care system amongst other factors. On the criteria of life expectancy, infant mortality and amenable mortality, for which we have reasonably reliable cross-country data, health status in the United States does not compare favourably with that in most other OECD countries. Other contributions of the health-care system to health status, such as quality of life associated with the reduction of symptoms and improved functional status are also important, as is the absence of waiting lists for elective surgery. Unfortunately, reliable data are not available to make cross-country comparisons on these aspects of health status, which could very well show the United States in a more favourable light.
Consider life expectancy:
(p. 8) It should ... be noted that these comparisons do not adjust for country-specific changes in demographic composition and differences in life style, which may also help to explain the pattern.
Even minimal contemplation would alert one to the fact that if there are no adjustments made for differences in demographics or life style, all assumed causes for discrepancies are merely guesses; correlation does not imply causation, especially when we know that diet, exercise, and life style are far more important for life expectancy than access to healthcare.
How about infant mortality?
(p. 11) A factor to bear in mind when interpreting these mortality rates is that part of the international variation may be attributable to differences amongst countries in registering practices of premature infants (whether they are reported as live births or foetal deaths) (OECD, 2007). In the United States, as well as in Canada, Japan, and the Nordic countries, very premature babies with relatively low odds of survival are registered as live births, a practice that increases mortality rates compared with countries that do not register them as live births. Nevertheless, infant mortality has also declined more in all of the countries with the same registration practices as the United States, and has fallen to much lower levels than in the United States. Even if there were uniform reporting standards of infant mortality across countries, a second
limitation to using it as an indicator for health outcomes is the potential effect of certain interventions on the likelihood of a live birth. It is conceivable that additional health care provided in the second or third trimester causes a pregnancy that would almost assuredly be a stillborn to become a pregnancy with an improved chance of a live birth but also an above-average likelihood of dying within the first year. These interventions increase health care expenditures and result in the birth of more low-weight-and very low-weight babies, with significantly greater health problems. It is not clear whether or not this factor
helps to explain the apparent smaller decline and higher rates of infant mortality in the United States than in other countries. In addition to the above caveats, there may be other factors, including the mother’s behaviour (e.g., smoking) and demographic factors (e.g., teen births), that are changing over time and contribute to the observed pattern of infant mortality that are independent of health-care system efficacy.
NB. I don't know about Japan or Norway, but the shortage of NICU beds in Canad has caused many women with high risk pregnancies to venture across the border to the United States to deliver their babies; the Canadian insurance plans pays for the healthcare but the statistics belong to American hospitals.
Note as well, that without controlling for maternal behavior, infant mortality rates across cultures and demographic groups is at best an exercise in informed guess work. Furthermore, premature babies, kept alive in American hospitals with "cutting edge technological innovation" cost a small fortune and will have outcomes that raise our infant mortality rates.
Finally, to the argument that we are lagging in reducing "amenable mortality":
(p. 11) The United States also appears to be lagging other countries in reducing “amenable mortality” – deaths from certain causes that should not occur in the presence of timely and effective health care. Nolte and McKee (2008) examine recent trends in deaths from treatable conditions and find that while the United States was comparable to other OECD countries in 1997-1998, it ranked near the bottom in 2002-2003. The authors note, however, several potential data and measurement issues when comparing aggregate data across countries, including differences in interpretation regarding the concept of amenable mortality and reporting issues relating to conversion to the ICD-106 system. The authors also find large regional differences in amenable mortality. They estimate that if all states achieved levels seen in the best-performing state, about 90 000 premature deaths could be avoided annually, compared with 101 000 if the United States were to achieve levels of amenable mortality seen in the three top-performing countries. They also note that US underperformance on this measure has coincided with an increase in the uninsured population.
Once again if you are comparing populations that are different from each other and/or defining your terms differently, comparisons become meaningless.
This report has already been cited by bloggers I respect and some with whom I disagree about most things. c3 at Stubborn Facts quotes approvingly from the report:
So we already spend far more than any other country and yet we can’t provide basic coverage for 1 in 7 of our citizens and though our health has improved over the years it hasn’t improved as much as other countries who have spent much less.
I would submit that our wealth, freedoms, and refusal to overtly ration healthcare lead us to have higher mortality rates but also allow us to have the most innovative system in the world and to have a system, expensive and inefficient as it often is, that will allow us to maximize life for most Americans. We keep alive infants who would die (or be allowed to die) elsewhere and keep alive our parents and grandparents well past the days when countries with government run healthcare have determined such care is no longer cost effective.
Universal healthcare, as much as it makes a wonderful sounding slogan, will have significant opportunity costs associated:
2009, Not 1992 [Regina Herzlinger]
When Obama gets it enacted, most historians will revere him as the president who finally dragged barbaric Americans into the modern world. But some may note that the Obama system worsened results for the sick and killed the promising genomic industry, in which the U.S. currently enjoys a world-wide lead. These are the inevitable results of the Obama administration’s push for a statist health-insurance market that contains an underpriced Medicare as an option. The phony pricing for Medicare will draw vast numbers of enrollees, over 100 million in one estimate, and create a virtual single-payer health-insurance system. This system would control costs by rationing health care to the sick, especially when it comes to powerful, expensive new drugs. The U.K., for example, ranks last among the biggest economies in Europe in its uptake of cancer drugs and has the dreadful survival rates to prove it. If the U.S., which is by far the largest market for such drugs and the largest source of capital for their development, becomes a single-payer system, we can kiss this industry good-bye.
In addition, without the United States essentially subsidizing healthcare in other countries (by absorbing the cost of R & D for example) their healthcare costs will increase and their outcomes will worsen, count on it.
Finally, I would add one more (hidden) danger from the kind of system the Democrats are likely to give us. If you have private insurance and the insurer denies you access to an expensive new treatment as unproven or not cost effective, you have recourse. You can complain to your state's commissioner of health (or perhaps the insurance department); if that fails you can contact your Congressman or even mobilize your local TV station to shame the insurer. Once the government bureaucrats run the system, when they deny care (out of design or simply incompetence) you will have no recourse; that is how government bureaucracies operate.
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