Michael Moore's Sicko (or why Orac should relent and go see this movie)

I grew up in the UK, and when I first moved here it simply boggled my mind that health care was run as a for-profit business. It was crystal clear that this was absolutely *not* the way it should be, for all the reasons you have stated so eloquently. Since then, the situation has only become worse - which to me is no surprise at all.

Now, I do understand that the UK system is not perfect (Maggie had a lot to do with that), but at least you won't go bankrupt or lose your home just because you are sick.

My brother lives in Canada, and he and his wife constantly bitch about the Canadian health care system. At least, they did until they learned from me what I pay for "insurance" each month (and that's just my share - my employer pays the bulk).

I concluded long ago that the American public is so utterly brainwashed that they truly believe this is "the greatest nation on earth" and that their health care system is "the best in the world". It's going to take something truly momentous to change things here, but perhaps this film might be a first move in that direction. If only all those voters would see what big business has done to them, perhaps there really would be a change, although it's going to be a hard and painful path because there are so many intertwined and entrenched interests in maintaining the status quo.

I've lived in a system with public health care and I've lived with American-style HMO care. I can safely say that American-style HMO care sucks.

That said, many people who live with the public system have never known anything else, and complain about it. They hear about people traveling to the U.S. for elective procedures and paying out of pocket and having the procedure the next day and they think that is the norm. (I mean seriously, if you have enough money to pay for your care with cash, you'll get the best care in the world in the U.S.) *Many* people that live in countries with public health care would switch it for the American system. That said, they have no idea what they're saying. Their ignorance leads them to assume that the grass is greener on the other side.

Again, having lived many years in American and a country with public health care, I can safely say that American-style health care is vastly inferior (unless you have the resources to pay cash). And when people ask the question, "But do you want the government to be in charge of your healthcare?" I always answer "Hell, yes!".

And when people ask the question, "But do you want the government to be in charge of your healthcare?" I always answer "Hell, yes!".

Is that what you really want? That would be just as bad as what we've got right now.

What you want is a government that is in charge of covering the costs... you want doctors in charge of your heath care. Petty bureaucrats can do terrible things to individuals, be they in insurance companies or be they in governments.

This question should be faced head on, and rejected as not the right question to ask. Admitting that it is the right question to ask, even with the answer of "yes," yields a lot of ground to those who see socialized medicine as putting medical decisions in the hand of government.

-Rob

Rob, You make an excellent point. I am American but have been living in Montreal, Canada, for 3 years. My wife is an ER nurse and has worked in a major trauma center in the US and here in Montreal. I think we have a pretty good grasp of both systems. The current American system is clearly a failure on many levels detailed above. One of the major failures of the Canadian system is bureaucracy in the government that fails to get the right drugs on formulary and fails to keep up with technology. There is no question that the Canadian system is fair to all, but everyone ends up with mediocre care (on a daily basis) when they clearly have the potential to offer the best possible care to everyone. To the credit of the government (federal and provencial) there is much motivation to achieve this goal and there is a movement to increase the visibility of doctors, nurses and researchers in the decision making process on the level of bureaucracy. I should add that I had a major spinal injury while in Montreal. I recieved fast, professional and quality care that lasted over more than a year including surgery and therapy to get me up and moving again. I have paid virtually nothing and now, more than 1.5 years out, I am more or less normal again. I shudder to think what would have happened to our finances (and my career -- I'm a postdoc and make next to nothing) if I would have had the same injury in the US.

My opinion is that the US has a major opportunity to create a system that can be fair to all and offer first class care across the board. The question is, I suppose, if people will be willing to pay more taxes. I, for one, have never understood the problem in that regard because the higher taxes even out in not having to pay insurance premiums plus the extra charges that always come with a doctor's office or hospital visit.

I was in Havana in 1992 and the elevator attendant at my hotel received a checkup at work from a doctor.
Question: Couldn't you, or any doctor, work without managed healthcare clients? Couldn't you run your office and only take patients who pay out of pocket and do pro bono work or deeply discount your fees for those who couldn't afford certain things? I'm just curious? And I have this impression that this does happen in the really small towns of America. Does the small-town doctor still exist?

Rob-- The problem is, the system we have right now does not work. To use 'Do you want the government in charge of medicine? They might mess it up!' as an excuse to keep using a system that does not work is lazy and morally unacceptable.
Personally, I am in favor of universal health care. But I dont care what plan someone has for the health care crisis in the US as long as we're trying something.
This inaction-- this "I hate insurance, but god dont change the system till I retire" attitude from physicians-- is infuriating, to say the least. Every damn one of us is an illness, an accident, away from medical bankruptcy.

Im disappointed he did the Republicans/Democrats thing. Well, I mean I do blame our lack of universal health care on Republicans, but the ones in Trumans do-nothing Congress. Not the 80's-90's Republicans.

Robin: Even if you only offered services to patients who could afford to pay cash, you would still need the malpractice insurance. But because you limited yourself to only those who can pay out of pocket, unless you could charge exorbitant rates, you wouldn't be able to cover your insurance costs, never mind paying rent on a shoebox.

Josiah: That is what I suspected, but thanks for your input. Any other thoughts on the small-town doctor thing?

Robin,
That is essentially what my mother does now. It's called fee-for-service. Some insurance companies still allow
you to see your doctor and get reimbursed after the fact. That's what her patients do. It shifts some of the burden onto her patients but she won't put up with insurance companies micromanaging her practice anymore.

Sadly her patient pool has dwindled as a result, and as HMOs have dropped her from their lists patients who have seen her for decades have to come in with the list of doctors and ask her who they should see now. It's really heartbreaking.

I say that knowing how many feel about Michael Moore and his tendency towards spectacle.

i immigrated to the U.S. from a European country some nine years ago. your comment here (Americans of any stripe having a problem with excessive spectacle??!!) just serves to underscore an ongoing observation of mine: that hypocrisy, not "football", is the true national sport of the USA.

...oh, and i should have kept on topic. i, too, saw Sicko last night. pay the movie ticket, all y'all, you need to see this film.

Mark, is your mother a "GP" or a Family Physician? The members of the American Academy of Family Physicians are actively searching for the way out from under all these bureaucratic burdens.

Actually, the commenter who noted that it's better way to discuss universal coverage rather than universal care is correct. Unfortunately, each move to put medical coverage under government control has resulted in emphasis on "control" rather than "care." And it goes far beyond the limits of formularies or age-limits on new technologies that we've seen in the past (such as age cut-offs for dialysis).

For instance, nothing in the physician's office is private, thanks to the "Health Insurance Portability and Privacy Act." Everything and every record in your doctor's office is subject to viewing and most is subject to copying by anyone who comes into the office claiming to be working under the authority of the US Secretary of Health. The Clinton administration had a history of sending armed investigators into hospitals and doctor's offices and the heads of the FBI and the Department of Health and Human Services held rallies in football stadiums to encourage Medicare patients to turn in their doctors for "fraud and abuse."

Doctors who do fee for service are accused more than others of looking to profit off of other's misfortune, or running "boutique" practices for the rich and elite. Any effort to "discount" anyone's care puts us at risk of being accused of insurance fraud - or worse - being threatened with RICO violations.

The problem actually goes all the way back to the '70's and the invention of the HMO. The HMO was an attempt to control Medicare and Medicaid costs to the government. Next, came the attempt to control costs by controlling the number of doctors, then the "Stark" laws to control the control by doctors.

As late as the early '80's, we paid cash at the doctor's office and had major medical insurance for the hospital. By the time I finished med school, everyone had co-pays and deductibles and tons of paperwork.

Much of the deterioration of the Canadian system over the last decade is due to privatization and American-style tax cuts for the wealthy that have left social programs underfunded. I hope the movie convinces the Conservative Canadian government to stop trying to copy the U.S. system (but I doubt that it will). It may at least convince the Canadian public that the PR coming from the American insurance companies that's now appearing on our TV and radio commercials is BS. Those companies are making a big push north of the 49th parallel, and are contributing to the campaigns of Canadian politicians. They are making inroads.

Our healthcare system still works relatively well though, and British Columbians have the second highest life-expectancy in the world. How about moving to Vancouver??

Unfortunately, each move to put medical coverage under government control has resulted in emphasis on "control" rather than "care."

and how would that be different from having an HMO, again...?

any health care system will be subject to abuses, naturally. as well, any health care system will have to ration care to patients, since we'll never have the infinite resources to provide everyone with just everything. but from my own position (clinging to the bottom-most edge of the lower class by my bare white knuckles)

augh. cancel that last post; mouse pointer slipped.

i'm lower middle class, and my complaint is that under the current U.S. health care system i am not only subject to abuses but cannot feel sure of receiving any actual health care whatsoever. a rationing system that provided me with some care could scarcely be worse than one that does not reliably give me anything at all... yet still takes my money.

Unfortunately, each move to put medical coverage under government control has resulted in emphasis on "control" rather than "care." And it goes far beyond the limits of formularies or age-limits on new technologies that we've seen in the past (such as age cut-offs for dialysis).

This is correct, and I think this is why Hillary's healthcare proposal failed - the doctors would not back it. Doctors should have control of medical care, they are the ones seeing the patients and they are the ones who know best what their patients need. To some degree government control would be beneficial and shouldn't be used as an absolute bogey-man to frighten people away from universal health care. If, for instance, the government refused to pay for some drugs, like Nexium, rather than omeprazole, I wouldn't call that interference so much as common sense. Many drugs that are expensive and paid for by insurance companies - due to lobbying by drug companies - are redundant and unnecessarily expensive. Some control of pharmaceuticals would be welcome to stop pointless waste.

Also, even if government control were invasive it could not possibly be worse than the current control and invasiveness of the profit-motive which denies necessary care while putting people in debt and bankruptcy. Some control could be reasonably ceded for the benefit of preventing the unmitigated harm of the uninsured, underinsured and ruthless practices in denying care that the insurance companies practice.

Let's be specific, here: there are multiple kinds of profit, and not all of them are interchangeable.

Our medical system must not be permitted to function on the principle of maximization of monetary profit - that's a ridiculously bad idea. The system should produce a very different kind of profit - patient outcomes - and anything that leads to that end, including competition, should be used.

A few points:

- Anecdotes and personal experiences are not a rational basis for evaluating or comparing health care systems. I'd expect science bloggers especially to understand that.

- The "profit motive" is a major influence on the health care systems of all major nations. Even where health care funding is primarily public and non-profit (as in Canada and France), health care delivery is generally private and for-profit. The only major nation I am aware of whose health care delivery is primarily non-profit and state-owned is Britain.

- Countries with health care systems primarily funded publicy seem to be moving in the direction of greater private funding. This includes Britain, Canada and France, the three nations whose health care systems are most often cited favorably by proponents of reform in the U.S.

Countries with health care systems primarily funded publicy seem to be moving in the direction of greater private funding.

Quite possibly, but is anyone (apart from those who stand to make a profit) claiming this is a good thing? Or does it simply mean these countries are in a race to the bottom to see who can "catch up" to the US?

Quite possibly, but is anyone (apart from those who stand to make a profit) claiming this is a good thing?

Yes, I am. The role of private funding is growing because public funding has been unable to satisfy the demand for services. As health care services become increasingly expensive and sophisticated, and governments find it increasingly difficult to make them broadly available to the population through public funding (that is, taxes), I expect the role of private funding to grow further. I also expect most health care delivery to remain in the private sector.

I don't understand the resistance to universal health care, because it seems to me that there will always be a private market for those who have more money and want special service. I have a boutique doctor, and love it. Never have to wait for anything...get scripts over the phone...can email the doctor...he'll see my friends as a favor...

So, half the privacy problems in the medical field are actually caused by the lack of single payer...Another thing to think about, esp when genetic information starts to be used to deny you for claims.

"Yes, I am"

Well that settles it then.

The problem with government control is that government is the ultimate example of bureaucracy. The growth of the bureaucracy (in size, security and power) seems to be the main agenda of government bureaucracy, outlasting any political changes. (All over the world, not just the US - I still laugh at the Civil Service ploys in the old reruns of the British show, "Yes, Minister") Unfortunately, government bureaucracy has guns and prisons to back it up.

Remember the fuss a few years ago when we found out that Medicare's experts gave wrong advice 4/5 of the time and that following the advice risked fines and even prison, half of the time?
( http://www.gao.gov/new.items/d011006t.pdf see page 8 ) That was about the same time that some Medicare patients were threatened for privately contracting with physicians. It turned out that only the docs were at risk, of course.

Last year, Medicare payments were purposefully delayed for weeks to meet Federal budget restraints. This last month, those who complied (or tried to) with the new National Provider Identifier mandate found their personal information open under the Freedom of Information Act and quite a few had significant delays in payment as the system choked on that new number.

While there may be atheists in foxholes, there can be no laissez faire attitude to healthcare after you have been to India. Here you can see an uncaring and unaccountable government; a very vast private sector where quality varies from best-in-class (Escorts, Apollo) to very-dodgy (hole-in-wall); and a public health machinery that has all but collapsed. The only bright spot is the success of the few 100 non-profit private health systems, such as the Sankara Netralaya in Chennai, Ramakrishna Mission Hospital in Calcutta, Arvind Eye Hospital in Madurai, and the Baba Amte run Anand Van for rehabilitation of people affected by leprosy.

Institutions can't be built, they can only be destroyed. Giving a free reign to a value-destroying intermediary like the health-insurance sector, serves no purpose. A friend of mine in US who has a successful private practice group has stopped working with private insurers, leaving patients to deal directly with them. She tells me that Medicare is far superior to any health insurer she has worked with.

My friends in Canada chortle when they hear the tall tales about the horrors of government healthcare in Canada from the likes of ignorants in the Cato Institute, Walter Williams, Thomas Sowell etc., One friend has been on a xplanted kidney for over 15 years; another recently underwent emergency brain surgery that was done in double quick time.

Chris H,

Part of the problem is that "universal health care" is a term of art that can refer to many different kinds of policy. Cuba and France are both commonly said to have "universal health care," but the set of services provided by France's "universal" health care system is far more comprehensive and sophisticated than the set provided by Cuba's "universal" health care system.

Another issue is waiting lists and rationing of services. In its ruling striking down the ban on private health insurance in Quebec, the Supreme Court of Canada wrote that "access to a waiting list is not access to health care." Delayed service can be effectively equivalent to no service at all.

Yet another issue is co-pays and other out-of-pocket costs to the consumer at the point of delivery. These are obviously a disincentive to the consumer seeking services. The higher the cost, the greater the disincentive. For some group of people covered by a system that nominally provides "universal health care," these out-of-pocket costs may represent an absolute barrier to the receipt of services, just as they do for many uninsured Americans.

The point is that "universal health care" isn't a clearly defined set of health care services that a country either provides or does not provide, but a vague and ambiguous phrase that can refer to a wide range of different services whose actual availability to people may be severely restricted in a variety of ways even if they are nominally available to everyone on demand.

What can I say? I am diabetic. I have had my share of crazy experiences with our health system.

I have posted my own personal take on this (it's aRe: to Moore's call for personal testimonials about issues with the healthcare system):
http://manuelhp42.blogspot.com/2007/06/anticipating-michael-moores-sicko.html

And I invite you to read what others diabetes have to say about the movie, in TuDiabetes.com, a community for people affected by diabetes that I run:
http://www.tudiabetes.com/forum/topic/show?id=583967%3ATopic%3A3488
(you are invited to join if you are touched by diabetes in any way).

It's very interesting how the message, coming from Moore can be disturbing even to some people who acknowledge many of the points he makes to be true...

I feel compelled to make a statement that may be perceived as naive but worthy of long thought:

A fundamental value is lacking -- that of the highest well-being of all persons and their environment, both short- and long-term.

If this value were a primary principle guiding the decisions of individuals and institutions, things might be better. That said, I realize that good intentions make for nothing without real commitment and action.

Jason, you appear to conclude that because universal health care can be abused sometimes (throwing out some major strawmen along the way), therefore everything is fine here? You talk about anecdotes and personal experience but completely avoid any of the data and studies that MarkH provided too. I don't feel like looking right now, but anybody want to go find the cards this guy is using?

Chris H: "I don't understand the resistance to universal health care"

I can think of a couple reasons:

1) It's [insert ominous sound effect] Socialism(TM). Obviously, to the extent that universal health care is socialist at all, it's socialistic in the way many European governments are, which works pretty decently, rather than the way the USSR was. Still, that fear of "socialism," which usually takes the form of scares about Big Government(TM) and the denialist "Competition is Magic" card, dies hard.

2) It's against the interests of certain groups with enough money to buy legislators. Insurance companies would be made superfluous by a single-payer system, IIRC. The government would have even more bargaining leverage to drive drug costs down, which wouldn't sit well with pharma businesses. There is a lot of business invested in the current broken system.

The problem with government control is that government is the ultimate example of bureaucracy.

And the insurance companies are chopped liver?

Another issue is waiting lists and rationing of services.

any healthcare system will ration services, by necessity. providing completely comprehensive services to everyone would take effectively infinite resources, which we do not have; rationing, then, is unavoidable.

the major complaint could be stated as, the current U.S. system uses unacceptable rationing criteria. it provides totally comprehensive services to those few wealthy enough to pay cash out of pocket; provides effectively no services to those who can't pay at all; and to the middle class, provides an "insurance" system, which on some occasions appears to be set up to rob them of their moderate means while providing token, or at best moderate, services.

rationing is unavoidable, but making the rationing system one giant argumentum ad crumenam does not seem obviously the best solution.

Nomen,

Yes, there is always rationing. The point is that "universal health care" doesn't mean that everyone will get the health care services they need when they need them. They may not get the service at all, even if it is nominally "covered" by the system. The long waits for services that plague the British and Canadian health care systems illustrate this. And the waits are not just for minor consultations and treatments, but also for major, potentially life-saving services.

For example, according to this report in Britain's Observer newspaper, delays for colon cancer treatment under Britain's "universal health care" system are so long that 20% of cases considered curable at the time of diagnosis are incurable by the time of treatment. And the average wait for heart-bypass surgery is a year. The story also reports the case of a diplomat who had to wait seven months for a referral from his Primary Care Physician for a diagnosis of prostate cancer, and then faced an additional eight-week wait for a body scan to see if the disease had spread to his bones before he was allowed to see a consultant.

And according to this editorial, from the Canadian Medical Association Journal, during one 12-month period in Ontario, Canada, 71 patients died waiting for coronary bypass surgery while 121 patients were removed from the list because they had become too sick to undergo surgery with a reasonable chance of survival.

Health care system horror stories are not limited to the United States, you know.

By the way, I said the profit-motive must be removed from the distribution of medical care - that is - coverage, payment, insurance etc.

The bogey-men of rationing and bureaucrats are tiresome. We have a far worse system of rationing now. We have bureaucrats, who rather than being unable to provide service to all actively try to deny care to save money.

Rationing, bureaucrats, these things are inevitable when it comes to any distribution of money. The question is what is the value of throwing away 30% of the money to stockholders and profit when we know that medical systems can operate with lower overhead? And how can anyone justify our current system when we spend more per capita yet the quality of our care is 37th in the world? We are spending more than any other country for less than any other country. What kind of capitalist thinks that's a good deal?

By the way, I said the profit-motive must be removed from the distribution of medical care - that is - coverage, payment, insurance etc.

Well, good luck with that. I think your imperative is politically and economically naive in the extreme. As far as I'm aware, not a single industrialized democracy has a health care system in which the "distribution" of medical care is not significantly determined by the profit motive. Even Britain has a substantial supplementary private health insurance system that provides superior or faster health care for those who can afford it. And the role of the private, for-profit sector seems to be growing, as governments find it increasingly difficult to satisfy the demand for health care services through public funding.

The bogey-men of rationing and bureaucrats are tiresome. We have a far worse system of rationing now.

I'd like to see your evidence that "we have a far worse system of rationing now."

Rationing, bureaucrats, these things are inevitable when it comes to any distribution of money. The question is what is the value of throwing away 30% of the money to stockholders and profit when we know that medical systems can operate with lower overhead?

We're not throwing it away. Again, your argument is just so economically naive. On your account, we should fund products and services in general through the government, not just health care services. Think of savings we'd get from eliminating profit and stockholder dividends and marketing costs! Only it doesn't work that way. The market is much better at matching up supply and demand than the government. That's why our economy is based on private enterprise and not state-owned enterprise.

And how can anyone justify our current system when we spend more per capita yet the quality of our care is 37th in the world? We are spending more than any other country for less than any other country.

There's no serious evidence that the quality of our care is 37th in the world, or that we don't get more than other countries.

No serious evidence? So the WHO report that shows that we provide poor medical care in terms of access, coverage, life expectancy etc., is just a big lie?

Someone is starting to sound a bit cranky...

Off topic, but Tag

Mark,

Assuming you're referring to the WHO World Health Report 2000, it's a joke. Its methodology and conclusions have been strongly attacked in the academic public health community as fundamentally flawed. For instance, its ranking of countries by health care system effectiveness relies on a single aggregate health indicator--disability-adjusted life expectancy--that is known to be only very weakly related to the services provided by a nation's health care system (life expectancy is determined primarily by social, environmental, and genetic factors, not health care services).

See, for example, this paper by Vicente Navarro, of the Johns Hopkins School of Public Health.

OK, this is a bit snarky but since 2 of the suspects in the terror attacks in the UK are physicians, how long do you think it will take for there to be a socialized medicine/terror link?

Hmmm. From your reference:

Another area that Coyne and Hilsenrath do not touch on is the bias of the WHO report in choosing the experts or informants who ranked the countries according to the responsiveness of their health care systems. In general, the WHO report shows a well-documented bias toward what may be called the conventional wisdom in US and, increasingly, European health care establishments, which promotes managed competition and privatization in the management and delivery of health services as a way of improving the efficiency and responsiveness of medical care.

Not surprisingly, therefore, the report lists the US health care system as the most responsive in the world, even though the US population is the least satisfied (among the populations of Organization for Economic Cooperation and Development countries) with the organization and funding of its health care. According to a nationwide poll on Americans' perception of their health care system prepared for the American Hospital Association,the majority of the people in the U.S. see in the health care services they receive neither a planned system nor a consumer-oriented organization, except one devoted to optimizing profit by blocking access, reducing quality, and limiting spending. They blame most of it on the pursuit of profits by health insurance companies. Americans believe that their health insurance companies have too much influence and hold too much control over their care.8Similarly, Colombiaa country that has introduced managed competition at the cost of dismantling its national health systemis ranked in the WHO report as having the most responsive health system in Latin America.

From what he writes it sounds as if the criticism is that the WHO report is unfairly biased towards making industrialized countries look better - and attributing all their mortality benefits over the third world to better medical care. Nowhere in that paper does it suggest that the US rankings relative to the other industrialized nations is unfair. So, try reading the link next time.

On your account, we should fund products and services in general through the government, not just health care services. Think of savings we'd get from eliminating profit and stockholder dividends and marketing costs! Only it doesn't work that way. The market is much better at matching up supply and demand than the government. That's why our economy is based on private enterprise and not state-owned enterprise.

I'm not talking about making us a communist country and this is a despicable little straw man. There are some things that are too important to be left to private enterprise. Critical infrastructure. The military (sadly we're seeing our government hire mercenaries - and the absence of oversight is disgusting). Critical services like power, water and communications need to be at the very least tightly regulated. Fire, police and emergency response - all socialized. We're saying that healthcare belongs in this list, not that we need to become communists, that's classic industry denialism there - the communist socialist card.

There's no serious evidence that the quality of our care is 37th in the world, or that we don't get more than other countries.

No? 44-46 million uninsured? The higher morbidity and mortality of US citizens - controlled for race and class even - compared to Canada and Britain on just about every measure from life expectancy to things like high blood pressure, heart disease, MIs, etc?

You're using arguments right out of the deck, and the data not just on access but on outcomes shows the inferiority of US health.

I have to be cynical about the taking patients to Cuba and the Cuban physicians being all over themselves to treat them.

I'm not saying that Cuban doctors, or Cubans in general aren't generous. I think it's a disgrace that the 9/11 rescue workers aren't being treated as (basically) war heroes and given every assistance by their Government. But I do recall that Cuba and the USA have "issues", and the Cuban Govt. would be happy to do anything that would make the US of A look very, very bad - or themselves very good by comparison.

That being said, I am only just a little bit cynical. And I am very glad I am Australian. BTW, I would happily admit that, strictly from the technological and scientific viewpoint, US medicine probably is the best in the world. The problem lies in getting access to it. I'd rather have not quite such a whiz-bang system, and free access when I needed it.

I'm no expert, and can't produce evidence but, Jason, it's my understanding that:

Even Britain has a substantial supplementary private health insurance system that provides superior or faster health care for those who can afford it.

is only half correct.

Faster: yes; superior: only in the sense that you might get more or better ancillary hotel type services. The actual medical care is not, to my knowledge, better. Even 'faster' is less of an issue than it was: I think it's telling that your example of waiting lists is from 2001.

The private sector is very dependent on the public one, too, as the latter does all the training, much of it on the job.

MarkH: "There are some things that are too important to be left to private enterprise."

Nitpick: I don't think it's a matter of more important or less important so much as the right tool for the job. The market is good tool for some forms of distribution, while the government is better at others. Based on comparison of healthcare in the U.S. with that of other countries, it so happens that the market isn't such a wonderful tool for healthcare.

I'm ok with a government run single payer system but I'm not convinced that it's the only solution. The current system is broken, not denying that. I'm just not sure that the system couldn't be made vastly better by regulation .ie (no pools/cherry picking, mandatory participation, ...)

I have a few questions about what you wrote in your original post.

"As I am going into medicine and one day will treat patients, I'd like to say I'd rather be paid a half or even a quarter of what would be expected if I could practice medicine unimpeded by the incessant fight for reimbursement, and the constant second-guessing of medical care by insurance companies that only want to deny, deny, deny."

Could you please explain why you think that government will not act this way? I thought that Medicare negotiations for reimbursement were worse than any insurance company. There always seem to be articles talking about how few medical providers will accept the heavy handed neogitations for reimubrsement from Mediare and Medicaid.

I am somewhat familiar with with pharmacist aspect of medical practice. The average cost to a pharmacy in term so labor, supplies, benefits and expenses is $10 to fill one prescription. Recently, there were bills in Congress trying to set a cap of $7.00 for Medicare reimbursement for the pharmacy's expense in filling a prescription. No insurance company would have that kind of clought to devastate a branch of medicine like the federal government would have.

I have to be cynical about the taking patients to Cuba and the Cuban physicians being all over themselves to treat them.

I'm not saying that Cuban doctors, or Cubans in general aren't generous. I think it's a disgrace that the 9/11 rescue workers aren't being treated as (basically) war heroes and given every assistance by their Government. But I do recall that Cuba and the USA have "issues", and the Cuban Govt. would be happy to do anything that would make the US of A look very, very bad - or themselves very good by comparison.

This scene was almost certainly scripted. Americans do not get to walk around Cuba with video cameras freely. They almost certainly had minders, and it's likely that things were made quite easy for them because the Cuban government would like to embarrass us.

We should remember, that Castro went to Spain for his GI surgery. While Cuban doctors are apparently very good, and very well trained, they lack a great deal of the technology we do. This is unlikely to be from having national health care though - more likely the 50-year embargo that keeps them driving cars from the 1950s. They do a lot with what they have.

Could you please explain why you think that government will not act this way?

Of course government has the ability to abuse people just like insurance companies. The difference is we elect the leaders of our government, have oversight and things are done publicly and openly. Insurance companies tell doctors all the time what they'll pay for and what they won't pay for, what the doctor should do to treat a specific problem, and by the way, they'll only be reimbursing 70% of the cost of the procedure (which medicare and medicaid do as well). Who do we lobby to change their practices? To explain how they come up with cost structures? To change their policy?

Could you please explain why you think that government will not act this way? I thought that Medicare negotiations for reimbursement were worse than any insurance company. There always seem to be articles talking about how few medical providers will accept the heavy handed neogitations for reimubrsement from Mediare and Medicaid.

Well, that's because the doctors are having to tackle the bureaucracy one by one, just like they have to do with the HMO's, who have been driving doctor's incomes down as well. In Soviet Canukistan we aren't allergic to collective agreements, the doctors get to negotiate en bloc, just like a (*gasp*) union.

Having to negotiate even single payment strikes me as like an employee having to negotiate every single paycheck, an idea that loses several IQ points to dirt. However, it wouldn't suprise me if this was a deliberate tactic to make Medicare look bad.

Mark H,

Nowhere in that paper does it suggest that the US rankings relative to the other industrialized nations is unfair.

It most certainly does. Navarro's very first point is that the report's measure of health care system "effectiveness" is fundamentally flawed:

Regarding effectiveness of health care, for example, the WHO report assumes erroneously that health care is the primary force responsible for the decline of mortality and morbidity in both developed and developing countries.

As I said, the primary determinants of mortality and morbidity are behavioral factors (diet, exercise, smoking, alcohol, stress, etc.) and environmental influences (things like air pollution, climate or the safety of food and water supplies). Most of the services provided by a nation's health care system have very little effect on overall rates of health and premature death.

I'm not talking about making us a communist country and this is a despicable little straw man. There are some things that are too important to be left to private enterprise. Critical infrastructure. The military (sadly we're seeing our government hire mercenaries - and the absence of oversight is disgusting). Critical services like power, water and communications need to be at the very least tightly regulated. Fire, police and emergency response - all socialized. We're saying that healthcare belongs in this list, not that we need to become communists, that's classic industry denialism there - the communist socialist card.

Sorry, but you haven't provided any serious argument to justify your position that health care funding should be removed from the private sector, but not health care delivery, or the funding and delivery of almost all other products and services we consume, including basic necessities such as food, housing, clothing and employment. Those would seem to be even more "critical" to human welfare than health care, and yet you don't seem to be proposing a government takeover of them. The military, police and fire services are "socialized" (at least with respect to funding) because they are public goods, unlike food, housing, employment or health care.

No? 44-46 million uninsured? The higher morbidity and mortality of US citizens - controlled for race and class even - compared to Canada and Britain on just about every measure from life expectancy to things like high blood pressure, heart disease, MIs, etc?

That's right. The higher morbidity and mortality of Americans has little or nothing to do with shortfalls in our health care system. Health care services have very little influence on those statistics.

Faster: yes; superior: only in the sense that you might get more or better ancillary hotel type services. The actual medical care is not, to my knowledge, better. Even 'faster' is less of an issue than it was: I think it's telling that your example of waiting lists is from 2001.

"Faster" effectively is "superior." A health care system that provides services promptly is superior to one that provides them only after substantial delays. The human cost in pain and suffering of having to wait for even "non-essential" services like hip replacements or hernia repairs is considerable. And in some cases it can make the difference between life and death, as the examples I cited above demonstrate. Those costs must be included in any serious comparison of different health care systems. But proponents of health care reform in the U.S. often ignore or dismiss the huge costs imposed by rationing and waiting lists in Britain and Canada, and focus only on the costs imposed by the lack of "universal coverage" in America. Any honest evaluation of the merits of different health care systems must involve a comprehensive analysis of costs and benefits. Long waits for services are certainly a cost.

Well, that's because the doctors are having to tackle the bureaucracy one by one, just like they have to do with the HMO's, who have been driving doctor's incomes down as well. In Soviet Canukistan we aren't allergic to collective agreements, the doctors get to negotiate en bloc, just like a (*gasp*) union.

Huh? American doctors generally make two to three times as much money as their Canadian counterparts. So, apparently, your Canuck collective bargaining isn't terribly effective from the doctors' point of view.

This is one reason, by the way, why you're not likely to get most American physicians to support a Canadian-style health care system in the U.S. They stand to lose half or more of their incomes under such a system.

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This is one reason, by the way, why you're not likely to get most American physicians to support a Canadian-style health care system in the U.S. They stand to lose half or more of their incomes under such a system.

Are you honestly claiming that half your doctors make $800,000 or more per year as NET income?

The AMA doesn't think so.

Graculus,

See the table of average annual income of physicians by country on page 14 of this document:
http://www.pnrec.org/2001papers/DaigneaultLajoie.pdf
It indicates that on average American physicians make twice as much as Canadian physicians. Admittedly, the data is from 1996, but there's no reason to think the ratio has changed dramatically since then.

The disparity is probably lower for primary care physicians than for specialists, but the basic point is that American doctors would stand to lose a huge amount of income under a single-payer, government-funded health care system. So they're not likely to support such a policy.

It most certainly does. Navarro's very first point is that the report's measure of health care system "effectiveness" is fundamentally flawed:

Regarding effectiveness of health care, for example, the WHO report assumes erroneously that health care is the primary force responsible for the decline of mortality and morbidity in both developed and developing countries.

Incorrect and inaccurate reading of this paper. The author is saying that the assumptions are incorrect, not the data. Further he is critical of these assumptions because of the comparison of non-industrialized countries to industrial countries does not make sense. Nowhere does he say that comparison between the industrialized nations is invalid using these metrics. Here is the rest of the paragraph:

That assumption is evident in statements such as [If] Sweden enjoys better health than Ugandalife expectancy is almost exactly twice as longit is in large part because it spends exactly 35 times as much in its health systems. Not surprisingly, the report concludes that what is needed to eradicate disease in less-developed countries is a greater investment in health care: with investment in health care of $12 per person, one third of the disease burden in the world in 1990 would have been averted. Such statements reveal a medicalization of the concept of health that is worrisome and surprising, coming as it does from the major international health agency of the United Nations.

This paper does not mean what you think it means

Admittedly, the data is from 1996, but there's no reason to think the ratio has changed dramatically since then.

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That's right. The higher morbidity and mortality of Americans has little or nothing to do with shortfalls in our health care system. Health care services have very little influence on those statistics.

Umm, then what is it? It was a comparison of people of similar class, weight, and health habits. Free for all to read here in JAMA. Explain that away. Is it the weather?

What about infant mortality? Those infants been lighting up in the womb?

This is BS and classic American exceptionalism. And why are we only talking about Britain? How about Sweden? Or France? We're the only ones operating on a private insurance model without some form of universal national healthcare. The best system to emulate would probably be the french or the swedes - not even necessarily the Brits or Canucks - although I know few who would trade even their systems for ours.

Mark H,

Incorrect and inaccurate reading of this paper. The author is saying that the assumptions are incorrect, not the data.

The rankings are based on the assumptions. The assumptions are incorrect, so the rankings are meaningless.

Further he is critical of these assumptions because of the comparison of non-industrialized countries to industrial countries does not make sense. Nowhere does he say that comparison between the industrialized nations is invalid using these metrics.

Yes, he does. As he says, the assumption that disability-adjusted life expectancy is a meaningful indicator of the "effectiveness" of a health care system is erroneous.

Umm, then what is it?

I've explained this repeatedly. The primary determinants of morbidity and mortality in a population are behavioral and lifestyle factors such as patterns of diet, exercise, tobacco consumption, alcohol consumption, stress levels, etc. and environmental factors such as air quality and food and water safety. The services provided by a nation's "health care system" have very little influence compared to these other factors. That is why you cannot meaningfully rank the effectiveness of different nations' health care systems on the basis of morbidity and mortality statistics. In fact, studies suggest that shortfalls in medical care contribute only about 10% of the causes of premature death. The other 90% comes from other sources. The relationship between "health" and "health care" is WEAK, and the relationship between "health" and "health care insurance" or "health care coverage" is even weaker.

It was a comparison of people of similar class, weight, and health habits. Free for all to read here in JAMA. Explain that away. Is it the weather?

I guess you missed this sentence: "...health insurance cannot be the central reason for the better health outcomes in England because the top SES tier of the US population have close to universal access but their health outcomes are often worse than those of their English counterparts."

And you still haven't provided any serious argument in support of your position that it is imperative (or even merely important) to eliminate the profit motive from the funding of health care, but not from the delivery of health care, or from the funding or delivery of other important goods and services such as food and housing and employment.

Mark H,

The best system to emulate would probably be the french or the swedes

In 2003, a commission established by the French govenment to evaluate its health care system concluded that the system is overburdened, wasteful and in urgent need of overhaul. Its annual budget deficit as of 2004 was projected to be 11 billion Euros. Projected to increase to 66 billion Euros by 2020. In U.S. terms (adjusting for population size and currency), the corresponding annual deficit figures would be about $70 billion and $415 billion.

The closest thing we have to the French health care system in the U.S. is Medicare. Medicare is already a fiscal train wreck in progress. The latest Medicare trustees report projects that Medicare will be bankrupt in little more than a decade. Extending a Medicare-like system to the entire U.S. population is probably impossible as a matter of politics, and would be grossly irresponsible as a matter of fiscal policy even if it were politically feasible.

Jason, when you said 'faster, superior', I read it that you were not double counting there. So if speed is the only source of superiority (except for the hotel services) we are on the same page (well, except for that whole outlook on life thing).

If proponents of reform in the US ignore an element of the cost-benefit analysis, sure, that's wrong. Since nobody here has put forward any actual figures to check, we don't know if your pre-emptive strike hit a relevant target.

The rankings are based on the assumptions. The assumptions are incorrect, so the rankings are meaningless.

Oh for the love of god. He's not dismissing the healthcare rankings as a useful metric - he's saying that the WHO is wrong to suggest such metrics mean that the third world need better healthcare to dramatically improve their life expectancy. It says nothing about whether or not the entire methodology is flawed or if it can be used to compare industrialized countries. Nothing at all. And so what? One guy says the WHO relies on a false assumption in a piece that's essentially an editorial. If I relied solely on editorials to believe in science I could get a fellowship in the discovery institute. It's not disproof of the WHO report at all, just a single dissenting voice saying that it's not making valid assertions about comparisons between the first and third world. He has a point, it's interesting, get over it. It's proof of nothing.

I guess you missed this sentence: "...health insurance cannot be the central reason for the better health outcomes in England because the top SES tier of the US population have close to universal access but their health outcomes are often worse than those of their English counterparts."

Actually that was exactly my point. Health insurance in the group they were discussing was almost a non-issue. White middle class middle-aged men aren't exactly the poster-children for lack of insurance. What I was suggesting was it was an example that the British receive better overall health care. If you take a Brit and an American, similar age group, similar class, similar health habits, the Brit has better life expectancy and lower morbidity. Further this is a group that tends to be highly insured. It's a worse condemnation of being insured in America than anything else. It suggests in a class of people who should be enjoying the great benefits of healthcare in this country, we're lagging behind the British - and pretty badly, even when you control for all those diet and health habits you keep harping about. There is a similar study done between Canucks and the U.S. showing the same thing - we perform poorly in things that are obviously related to good prevention, monitoring, and routine health intervention by PCPs. Cheap stuff. Physicals, bloodwork, and control of morbidity.

And you still haven't provided any serious argument in support of your position that it is imperative (or even merely important) to eliminate the profit motive from the funding of health care, but not from the delivery of health care, or from the funding or delivery of other important goods and services such as food and housing and employment.

Ah, I have to deal with the communist card again? This is such bullshit, I don't need to deal with such classic denialist garbage as this. You think it's clever but it's just nonsense. It's perfectly acceptable to regulate and socialize things for the common good that the market fails to provide. The market sucks at health care. We have huge numbers of uninsured. We have people going bankrupt to pay for medical bills - even when they are insured. These are the signs of a failed system.

Just because I advocate for socialization in one area doesn't mean we have to become communists, that's an obnoxious red herring and if you keep trolling that one up I'm disemvowelling.

Jason, when you said 'faster, superior', I read it that you were not double counting there. So if speed is the only source of superiority (except for the hotel services) we are on the same page (well, except for that whole outlook on life thing).

I don't think speed is the only source of superiority, but my point was that there is considerable overlap. Even if there were no superiority of other kinds (e.g., better doctors and nurses, longer consultations, better equipment, etc.) faster service is itself a benefit.

If proponents of reform in the US ignore an element of the cost-benefit analysis, sure, that's wrong. Since nobody here has put forward any actual figures to check, we don't know if your pre-emptive strike hit a relevant target.

It hits the target of those such as Mark H who claim we would be better off with an alternative system, without having produced anything remotely like a comprehensive cost-benefit analysis to support that claim.

It hits the target of those such as Mark H who claim we would be better off with an alternative system, without having produced anything remotely like a comprehensive cost-benefit analysis to support that claim.

Charming, what a wonderful contribution you make to this discussion Jason. Such insight.

I've explained, clearly, that the US system is demonstrably providing worse healthcare coverage than 37 other countries. Aside from your little editorial which does not in any way challenge or disprove the such a ranking of industrialized countries, you have shown no evidence that contradicts the WHO or JAMA on this one.

At the same time we spend more per capita than any other country. You are the one with the indefensible position - the one of American exceptionalism. You repeatedly assert there is no problem - or at the very least that we have superior medical care to these other countries. The available data suggests otherwise. As does common sense, the experience of every commenter that has shown up, the experiences of those in this movie, and anyone who isn't a member of CEI or Cato.

So, we have the available metrics and experiences of the citizens of this country showing unsatisfactory performance in comparison to the British, Canucks, and other socialized medical systems. At the same time, we spend far more per capita than any of these other countries on medical care.

Now do I really need to do a thorough cost-benefit analysis? Or are you just being a typical denialist crank playing the "needs more study" card? Hmmm. I'll have to think on that one.

Mark H,

I'm tired of arguing with you over what you think Navarro is saying. If you're still not convinced that public health experts agree that health care services are of little importance to the morbidity and mortality of a population relative to other influences, read this classic essay on health policy by Phillip Longman:
http://www.washingtonmonthly.com/features/2003/0304.longman.html

Quote:

In a recent issue of Health Affairs, three researchers from the Robert Wood Johnson Foundation examined scores of studies dating back to the 1970s on what factors cause people to die prematurely. They reported that genetic predispositions account for 30 percent of premature deaths; social circumstances, 15 percent; environmental exposures, 5 percent; behavioral patterns, 40 percent; and shortfalls in medical care, 10 percent.

That's right, "medical care shortfalls" contribute JUST TEN PERCENT of the causes of premature death. The other 90% comes from other factors. As Longman goes on to say:

even a Cadillac health- insurance plan plays little, if any, measurable role in improving health and life expectancy. A RAND Corporation study compared two groups of families over 15 years, one with full medical coverage, the other with a large deductible. The families with full coverage consumed 40 percent more health-care dollars than the other groups, but researchers couldn't detect any measurable differences in health.

So improving "medical care" offers very little scope for improving health and reducing mortality. This is especially true because most Americans already have access to high quality health care and because the sickest segment of the population (the elderly) are already covered by Medicare. Any further gains from expanding health insurance or health "coverage" would be marginal. There is much greater potential to improve health and reduce premature death from other kinds of policy.

Mark H,

It's perfectly acceptable to regulate and socialize things for the common good that the market fails to provide. The market sucks at health care. We have huge numbers of uninsured. We have people going bankrupt to pay for medical bills - even when they are insured. These are the signs of a failed system.

Sorry, but this is still not an argument. Asserting "The market sucks" is not an argument, it's a handwave. Where is your evidence that "the market sucks" (whatever that's supposed to mean in empirical terms) at funding health care, but not at delivering health care? Where is your evidence that "the market sucks" at funding health care but not at funding food, housing, clothing, employment or any other types of goods and services that are in the private sector? How is the number of uninsured an argument for public funding of the entire health care system (or even just most of it), rather than an argument for expanding private funding or for expanding public funding to cover just those people? Ditto for the fact that people sometimes face bankruptcy from medical bills. So what? People face bankruptcy from lot of other types of debt also. Credit card debt. Rent or mortgage debt. Car loan debt. Debt caused by the death or abandonment by a spouse, or the loss of employment due to disability. Are you also proposing to nationalize the homeowner's insurance industry, the auto insurance industry, the life insurance industry, the mortgage industry, etc.?

I would have thought a scientist would understand the need to present a clear, logical, quantitative argument for the position you're espousing, but instead all you do is keep going on about "denialism" and "exceptionalism" and citing facts ad hoc that have no clear logical relationship to the position you're trying to defend.

Moore makes no mention of the increasing religiosity of our healthcare system?

Wow, that Rand study was done when, in 1970 right? Think that still is applicable to the current situation? I've heard a lot about that study, it would be interesting to see it performed in the current medical climate, it has been almost 40 years after all.

Ditto for the fact that people sometimes face bankruptcy from medical bills. So what? People face bankruptcy from lot of other types of debt also. Credit card debt. Rent or mortgage debt. Car loan debt. Debt caused by the death or abandonment by a spouse, or the loss of employment due to disability. Are you also proposing to nationalize the homeowner's insurance industry, the auto insurance industry, the life insurance industry, the mortgage industry, etc.?

Well, when someone repeatedly throws the communism card at me it's hard not to go on about denialism. In other countries people are not bankrupted by the necessity of medical care. This is not just an issue of economics but a moral failing of our current policies. It's also pretty pathetic when other countries are able to provide for the old and the poor and uninsured and we can't because we're addicted to this idea that the markets can solve problems better than government. The markets have had their chance, it's time to consider emulating the models developed by other countries that are performing better for the people. As far as the other systems I wouldn't nationalize them, but they sure as hell could use tighter regulation to prevent predatory lending practices that have led to bankruptcy rates as high as 1% in some states. And enough people are being screwed by subprime lending you might just see some changes in that law in the future.

I would have thought a scientist would understand the need to present a clear, logical, quantitative argument for the position you're espousing, but instead all you do is keep going on about "denialism" and "exceptionalism" and citing facts ad hoc that have no clear logical relationship to the position you're trying to defend.

What is clearer than the argument that the JAMA and WHO studies show we receive poorer health care in the US than in socialized countries and yet we are still paying far more per capita? I am actually trying to stay more scientific and argue outside of mere personal experience, which has shown me that insurance companies are next to the devil when it comes to nitpicking, forcing doctors to fight for every payment, erecting pointless barriers to payment and care, and arbitrarily denying payment just to see if doctors will fight it. Since that is anecdotal - as is much of the evidence in the movie but by no means all - I'm citing studies that show the overall health of Americans is poorer than controlled populations in other countries. This is directly related to the problem and not some logical leap.

Again and again you assert that healthcare has a small part in controlling morbidity and mortality. But that's for overall figures. These studies are showing the differences between controlled populations of similar age, income and controlling for smoking, drinking, and obesity, and still there is a difference. It's hard to believe that comes from something outside of healthcare.

Finally, I simply don't want to practice medicine in the current system. As long as I work in hospitals and stay in academics I can avoid the worst of this - but the experiences of the doctors I know, not to mention related to, have helped me realize that the current system is highly defective and prevents the fair distribution of necessary care even to the insured. The fact that people have insurance yet are routinely denied care as Sicko demonstrates, is a huge fundamental flaw in the system.

How about a compromise. We should instead propose a government system paid for by taxes and based on socialized medical systems of other countries. If you don't want it, you can get a tax credit for the difference and buy your own private insurance. If private insurance, with 30 percent overhead, can compete with the government system then let it. But to suggest the current system is meeting our needs is nuts.

Mark H,

Wow, that Rand study was done when, in 1970 right? Think that still is applicable to the current situation? I've heard a lot about that study, it would be interesting to see it performed in the current medical climate, it has been almost 40 years after all.

I don't know when the study was done. Do you? Why would you expect health to vary significantly by level of insurance coverage now if there wasn't any effect when the study was done? The Health Affairs metastudy that found that medical care shortfalls account for only ten percent of premature deaths is not from 1970. It's from 2003. Longman also describes a great deal of other evidence indicating that the services provided by health care systems have little effect on health and longevity compared to other factors. The text I quoted just describes a couple of particularly clear examples.

In other countries people are not bankrupted by the necessity of medical care.

This just isn't true, although your phrase "by the necessity of medical care" is a bit unclear. The primary factor in illness-related bankruptcies is not medical bills, but the loss of income resulting from time off work (or losing one's job altogether) that typically accompanies an extended period of serious illness. In order to protect people from this risk, a "universal health care" system would need to cover far more expenses than just the direct costs of medical treatment. No health care system in the world does that. Illness-related bankruptcy occurs in Britain and Canada and France, too. At best, a feasible "universal health care" system might reduce the size of the problem, but it wouldn't solve it.

And of course people become bankrupt for many other reasons than illness. Uninsured costs to homeowners from fire, flood, theft or storm damage can easily be in the tens or hundreds of thousands of dollars. From car theft or accidents, in the tens of thousands of dollars. From disability (loss of ability to work), in the tens or hundreds of thousands of dollars. From death of a spouse, or abandonment by a spouse, in the tens or hundreds of thousands of dollars. And so on. And yet you don't seem to be advocating huge new government insurance programs to protect people from all these other financial risks. You still haven't provided any clear argument explaining why health insurance, and only health insurance, must be removed from the private sector and funded publicly instead.

Mark H,

Again and again you assert that healthcare has a small part in controlling morbidity and mortality. But that's for overall figures. These studies are showing the differences between controlled populations of similar age, income and controlling for smoking, drinking, and obesity, and still there is a difference. It's hard to believe that comes from something outside of healthcare.

But you haven't cited any such studies. The two studies you have cited are the WHO report and the JAMA study. The WHO rankings are based on average life expectancy, which for reasons explained at length by Longman is meaningless as an indicator of the "effectiveness" or "performance" of a health care system. And the JAMA study explicitly states that the differences in health it found between Americans and Britons cannot be attributed to differences in their health care systems. If this is still not clear to you, here's a New York Times piece on the study, including an interview with one of its authors, Dr Michael Marmot. Marmot suggests the differences in health are primarily due to differences in lifestyle-related stress. Quote:

Nor could varying levels of health be attributed to differences between the health care systems of the United States and Britain, [Marmot] said. "I'm arguing that it's due to the differences in the circumstances in which people live," he said Tuesday in a telephone interview. "Work, job insecurity, the nature of communities, residential communities, et cetera. I think that's the place we should try to look."

How about a compromise. We should instead propose a government system paid for by taxes and based on socialized medical systems of other countries. If you don't want it, you can get a tax credit for the difference and buy your own private insurance. If private insurance, with 30 percent overhead, can compete with the government system then let it.

This sounds like one of the provisions of John Edwards' health care reform proposal. It's not a "government system" resembling the "socialized medical systems" of other countries. Participation in those systems is mandatory and universal. Instead, it seems to be just another option for buying health insurance. You could buy it from a private insurer, or you could buy it from the government. Presumably, the government insurance would be priced affordably for people who could not otherwise obtain affordable coverage from a private insurer due to pre-existing conditions, etc. I might support such a reform, depending on the details. What I am pretty much unalterably opposed to is a mandatory "single-payer" system like the ones in Britain and Canada.

In case it isn't obvious to all those posting here, Jason is part of an "astroturf" campaign to simulate a "grassroots" groundswell against universal healthcare. He is a paid to put out the company line. So, when you see "Jason", just substitute "Aetna".

Jerry C:
In case it isn't obvious to all those posting here, Jason is part of an "astroturf" campaign to simulate a "grassroots" groundswell against universal healthcare. He is a paid to put out the company line. So, when you see "Jason", just substitute "Aetna".

What's the payscale on a gig like that? Bah, it's probably a SE Asian sweatshop operation.

They reported that genetic predispositions account for 30 percent of premature deaths; social circumstances, 15 percent; environmental exposures, 5 percent; behavioral patterns, 40 percent; and shortfalls in medical care, 10 percent.

Jason, I feel your pain. Here are all these narrow-minded people banging on about peripheral stuff like healthcare, and you just can't get them to see that the real reasons it sucks to be American are the rampant pollution, the ossified class structure, the self-destructive mores, and basically just being genetically defective. *Sigh* So frustrating.

Anonymous said: "There always seem to be articles talking about how few medical providers will accept the heavy handed negotiations for reimbursement from Medicare and Medicaid."

Not familiar with the Medicaid stats, but regarding Medicare, such articles are a perfect illustration that the plural of 'anecdote' is not 'data.' Upwards of 96% of doctors nationwide accept Medicare. (Research "Medicare participating providers" if you'd like to see for yourself.) If you're seeing articles about those who don't accept Medicare, likely it's because something so unusual is considered newsworthy.

Mark H,

By the way, mortality statistics provide another illustration of the small impact health insurance has on health. The Institute of Medicine estimates that 18,000 Americans die each year due to a lack of health insurance. To put that number into perspective, it is less than 4% of the number who die from tobacco, less than 5% of the number who die from poor diet and physical inactivity, less than 20% of the number who die from alcohol, and less than the number who die from each of numerous other causes, including motor vehicle accidents, adverse prescription drug interactions, firearms accidents, and sexual behaviors. This is not to say that extending health insurance is not a legitimate goal. But it is just one goal, and there are many other kinds of public policy that are likely to produce a much greater improvement in the health and longevity of Americans than "universal health care."

Jason,

You seem to have lost me. Are you arguing that there shouldn't be socialized medicine? Or are you arguing that there shouldn't be medicine period? Because if all this high-fallutin' medicine is providing no increase in quality of life or lifespan, perhaps we should just get rid of it altogether?

I have a hard time believing that you actually think that...

By the way, mortality statistics provide another illustration of the small impact health insurance has on health.

Jason, your arguments have reached an impressive height of absurdity. 18,000 isn't a lot of excess deaths because it's only a percentage of the biggest killers? Please. That is really a despicable view, and a bizarre new iteration of the "no problem" argument. It ignores that fact that many of the uninsured are young and healthy and don't need insurance except in case of catastrophe. The properly controlled experiment would be to compare people who get sick with and without insurance, and you'll see just how valuable it is.

Further, you also refuse to address the implication of the JAMA study which shows the difference in healthiness between similar individuals in the NHS system of Britain and the private enterprise system in the US. When controlling for risk factors, sex, age and race Americans haver higher morbidity and mortality. Instead, you repeat over and over again this mantra that health insurance doesn't affect health - maybe it's because Moore's point in this movie is valid - health insurance in this country sucks and is doing an inadequate job in health maintenance.

God damn libertarians. 18,000 deaths isn't enough to justify government interference, classic. What a ghoul.

Mark H,

I just quoted the author of the JAMA study explicitly denying your "interpretation" of his findings, and yet you still insist the study says something meaningful about differences between the health care systems of Britain and America.

And I never said that 18,000 isn't "a lot of excess deaths." In absolute terms, you could certainly consider 18,000 "a lot." But it's only a very small fraction of the premature deaths attributable to other preventable causes (tobacco use, poor diet, alcohol consumption, etc.) So surely those other causes represent a much bigger social problem in America today than the lack of "universal health care." Our public policy priorities should reflect that reality.

I go back to Mark's challenge while I add a few strings. I think that private insurance should be allowed to compete with a 'medicare for all' system. The only requirement I would put on the private insurers is 'no cherry picking/no pools'. As far as the requirement I would put on Joe Q. Public, health insurance is like auto insurance (at least in Minnesota). You have no choice, you can't skip out, you MUST have it. We can certainly debate subsidies for the poor as a separate issue. If you allow the further refinement of the health insurance actuarials, we will succeed in determining before you are born what your health insurance premiums should be. Are we looking at spreading the risk? If not, get rid of insurance as it serves no purpose.

I found a summary of Minnesota's auto insurance law here:
http://www.superiorcarinsurance.com/CarInsurance/minnesota.html
It appears to be stricter than the law in most other states, but even MN requires only $20,000 in personal non-medical coverage and only $10,000 in liability non-medical coverage. Not terribly helpful if you total someone's $80,000 BMW. The mandatory medical coverage is similarly inadequate.

And this illustrates the point I made earlier about financial risk. We don't legally compel people to buy insurance to protect themselves against non-health risks that could easily burden them with debts in the tens or hundreds of thousands of dollars, nor do we provide huge, publicly-funded government programs to cover these debts. So why is there a moral imperative to do this with respect to health care? Especially when most illness-related debt seems to come from costs other than direct health care expenses.

Jason, the point I was trying to make is that if we allow people to 'opt out' of having insurance, we will end up with a large section of the population (probably the healthy and young) outside of the insurance pool. I will never shed a tear for the hardships that befall an insurance company but I will give them this; if young and healthy people opt out, -and- people are allowed back in when they become sick, it will be impossible to have a profitable business providing health insurance. I'm a small business owner. I don't think that profit is a dirty word. However, the only way I see insurance as being viable, is to require that all participate.

Jason I am not using the JAMA paper as an example of how universal coverage would improve health outcomes. In the populations studied, health coverage was essentially universal in both.

Here is what I said:

Further, you also refuse to address the implication of the JAMA study which shows the difference in healthiness between similar individuals in the NHS system of Britain and the private enterprise system in the US. When controlling for risk factors, sex, age and race Americans haver higher morbidity and mortality. Instead, you repeat over and over again this mantra that health insurance doesn't affect health - maybe it's because Moore's point in this movie is valid - health insurance in this country sucks and is doing an inadequate job in health maintenance.

The JAMA study isn't about having health insurance versus not having it, and I didn't claim it was. It is about the relative performance of our two healthcare systems. When you control for risk factors, sex, age and race Americans have higher morbidity and mortality. Since the populations compared both had coverage - in the US insurance and in Britain the NHS - I believe this study suggests that our healthcare system, even among the insured, is inferior to Britain's. This is consistent with the WHO report.

You are also repeatedly misinterpreting the authors words. The author is saying that the difference isn't due to whether or not the individuals in the study had coverage - both groups do. But it does say something about the quality of the coverage in the United States.

Finally, the fundamental problem you seem to have is the idea that government should not try to improve the health of the population. You don't think that should be a role of the federal government, and that it wouldn't work primarily for ideological reasons. I think the data suggests that other countries by nationalizing coverage have provided better care more cheaply than we have, while covering all of their citizens. Further, the experiences of individuals with health coverage in this country is dismal, they clearly want something else. Libertarians may believe this is not a role for government - others of us do. If you don't want government to play a role in healthcare, just say that. But I don't for a second believe that the data shows the US system is better, or that it provides better outcomes, or that it is cheaper. All the data suggests otherwise.

Fortunately, this debate seems to have broken out of the Jason v Mark H death spiral - so here's how it looks from the UK, with its 'socialized' system (which is actually correct, since it was the 1945 Labour Government which made the NHS happen in 1948).

Jason - I think you have a view of government which is very much part of the 19th century 'small government' way of thinking. You seem happy with defence paid for out your taxes, and one or two other things, but yet healthcare is seen as some sort of personal wish, rather than a universal need. But if it helps, the NHS is basically a universal insurance system, which is deducted at source, and which has no interest (in most cases) of pulling cover or declaring you a bad risk. Now that means that there is 'rationing', but you can only build the sort of redundancy which would allow everyone to have instant access to whatever care they want with vast amounts of money, which of which would be wasted. The French system is the nearest i can think of, and Sarkozy will certainly be trying to cut the costs of their system, fine though it is.
Instead of meddling government deciding who gets what (as in the NHS), you have the case where you have the government partially deciding who gets what (government spending in the US as a percentage of GDP is not much diffrent to the UK), but also insurance companies (who take 30% for admin, and still dont want to spend a penny more than they have to), plus big pharma, who have ensured that the government does not negotiate special rates for drugs (even though they are a major customer), but instead take the companies price as given, allow direct marketing to patients (which the EU does not) and make it illegal to buy drugs abroad (a Mother Jones article about smuggling in drugs from Canada some years ago was heartbreaking). The market has not kept costs down, but instead has led to inflation in the medical sector far higher than would be acceptable in the economy as a whole, and far higher than inflation in other medical systems (which does tend to be high). It has basically turned Ford & GM into junk bonds (because of their massive costs), and takes far more money from you as insurance (and tax) than we pay in tax alone. I can get insurance in the UK, but its not essential - I have a choice. can you say you also have a choice, because one day you will probably be ill, and suddenly the very expensive health care system you support will start to look much less attractive than you currently think. We need a system which cares for us all adequately because we all tend to get ill. A regular poster on this subject (where is Mr Kruger?) said he pays $450 a month for insurance. Would you be willing to pay that as extra tax - say a 'sick' tax? Probably not, yet thats what it is. If I am going to pay for something which I need, then why pay more, simply because in theory I have a 'choice'? You do have choice by simply taking your chances, but its not a good one.
I have to go now, my 7 month old is crying, the one born in an NHS hospital, looked over by an NHS health visitor, and with an NHS GP. I could have paid for insurance, but it would have been my choice, not simply unavoidable.

God damn libertarians.

Which is why this plays so much better as a combined emotional issue vs. solely logical issue. The astroturfing makes the logical argument just too exhausting; it's liberating to just say, "Yeah, sure -- you vote your way, and I'll vote mine. I may be even be wrong, but for the time being I'll feel better."

Kucinich anyone? I mean, setting aside the conspiracy stuff. :-)

Ted -

I think that's one of the aims of denialism - making the argument itself just too difficult and unpleasant.

MikeB -

I'm from the UK; I'm just thinking through some calculations.. Although it's hard to do a full calculation, I think our household pays around £1500 in assorted taxes per month; with the NHS being around 20% of budget, that puts my 'insurance' at £300 per month (~$600). And that would be well above average.

And that $600 means no co-pays, no insurance claims, no worrying if losing my job means losing medical care, no hassle/cost for my employer arranging it in the first place.. I wonder how much goes on top of that $450p.m. in taxes.. and how much fun it would be to claim.

Andrew - I'm not sure what the average insurance payment per month is in the States (perhaps we are about to find out if some people say how much they are paying, and what they get for it), so his figure could have been way off, but the idea that paying more money to an insurance company and getting a worse deal (rather than less to the state) defies logic - does it matter who the money goes to, since your paying it anyway? The arguement is based on an anti-government ideology, rather than the reality of peoples lives.

Sorry for the rambling and slightly strange tone of my previous post - I wrote it having had too little sleep (7th month olds night feeds) and far far too much coffee.

perhaps we are about to find out if some people say how much they are paying, and what they get for it...

I'm on one of those government subsidized HMO programs. I pay ~$480 per year (for myself and family) plus $12 co-payments per visit. I'm not on the vision or dental with the gov subsidized plan. I pay about $400 per year for those (for entire family as well) through insurance with the dayjob people. For pharmacy, I have a $3 copayment on just about everything I need. The $3 co-payment doesn't cover selective drugging that I may opt for.

The HMO availability and access is a bit limited, but generally it's a bit of an incentive to stay healthy. Members of family have had several major surgeries (bill said things like $30,000) but I paid about $70 of that. The rest was covered or waived. My urchins like to do physically excessive things so annually family-wide it also includes about 10 MRIs spread around plus various therapies.

I got no real complaints about the government program so far and I'm with Kevin Drum when he says:

HEALTHCARE CHALLENGE....Libertarian Arnold Kling talks about our recent healthcare battles. His conclusion:

I once wrote that "The original sin of America's health care system is employer-provided health insurance." The best outcome might be for America to abolish employer-provided health insurance, try single-payer, have it fail, and then experiment with the sorts of policies that I talk about in my book.

I'm up for that. Like Kling, I have the courage of my convictions. Medicare (i.e., single-payer healthcare for the elderly) has been around for 40 years and the elderly don't seem to think it's a failure. In fact, they like it quite a bit better than the rest of us like what we have now. Bring it on, baby.

Ditto: Bring it on Baby!

Mark H,

The JAMA study isn't about having health insurance versus not having it, and I didn't claim it was. It is about the relative performance of our two healthcare systems.

I don't know why you keep saying this when the study's author himself has denied it. "Nor could varying levels of health be attributed to differences between the health care systems of the United States and Britain, [Marmot] said." The study is about differences in HEALTH, not HEALTH CARE.

When you control for risk factors, sex, age and race Americans have higher morbidity and mortality.

So you keep saying. The point you keep missing is that sex, age and race (and drinking and smoking) are not the only risk factors for poor health and premature death. The study's author suggests that the differences in health he found are primarily attributable to differences in LIFESTYLE-RELATED STRESS between the two countries having to do with the nature of community, patterns of work, job insecurity, etc. Please read the New York Times piece on the study that I linked to if you haven't already done so.

Finally, the fundamental problem you seem to have is the idea that government should not try to improve the health of the population.

I never said that and I don't believe it. The issue here, in part, is the nature and magnitude of the proper role of government in improving the health of the population.

Mike B,

Yes, your post is rambling and unfocused.

Here's the point: A nominal strength of Britain's NHS is that it "covers everyone." But the coverage is relatively poor. The NHS is plagued by shortages, rationing and waits for services, in part because its budget is constrained by the government instead of being allowed to grow through market forces to satisfy the demand for services. So the strength of universal coverage must be weighed against the relatively poor quality of health care that the NHS delivers. On balance, it doesn't seem to be a good deal. That's probably why few proponents of reform in the U.S. cite the NHS as the health care system model we should emulate.

I don't have time to go into all your individual claims, but I do want to say something about the pharmaceutical industry. Europeans and Canadians are getting a free ride on the U.S. drug companies. The higher prices Americans pay for drugs subsidize the lower, government-controlled prices that Canadians and Europeans pay. Government regulation stifles innovation and investment in the European drug sector, which is why U.S. companies are a far larger source of new and innovative drugs. This is the conclusion of the European Commission itself. See:
http://ec.europa.eu/enterprise/phabiocom/docs/comprep_nov2000.pdf

Europeans and Canadians are getting a free ride on the U.S. drug companies.

Well for God's sake lets not kill the golden goose. Only a fool would do that. The goal is to live as long as possible, regardless of what it takes.

The higher prices Americans pay for drugs subsidize the lower, government-controlled prices that Canadians and Europeans pay.

That must explain why our health costs grow at such a disproprtionate rate. It's our duty to sibsidize the Europeans. Thanks dude.

http://www.workingforchange.com/comic.cfm?itemid=22429

Jason, the point I was trying to make is that if we allow people to 'opt out' of having insurance, we will end up with a large section of the population (probably the healthy and young) outside of the insurance pool.

That obviously depends on how many people choose to opt out.

I will never shed a tear for the hardships that befall an insurance company but I will give them this; if young and healthy people opt out, -and- people are allowed back in when they become sick, it will be impossible to have a profitable business providing health insurance. I'm a small business owner. I don't think that profit is a dirty word. However, the only way I see insurance as being viable, is to require that all participate.

Health insurance is obviously "viable" without such a requirement. Universal, affordable coverage could be provided through some combination of regulation of private insurers (community rating, restrictions on exclusion for pre-existing conditions, etc.) and publicly-funded or subsidized coverage for those unable to obtain affordable coverage from a private insurer. That's how "HillaryCare" would have achieved universal coverage, for example.

But to repeat my basic point again, "universal coverage" just isn't very important to the health and welfare of the population in relation to other influences. TWENTY-FOUR times as many Americans die from the effects of tobacco as from inadequate health insurance. TWENTY times as many die from poor diet and lack of exercise. FOUR times as many die from alcohol consumption. Even adverse prescription drug reactions kill more people than inadequate health insurance.

But to repeat my basic point again, "universal coverage" just isn't very important to the health and welfare of the population in relation to other influences. TWENTY-FOUR times as many Americans die from the effects of tobacco as from inadequate health insurance. TWENTY times as many die from poor diet and lack of exercise. FOUR times as many die from alcohol consumption. Even adverse prescription drug reactions kill more people than inadequate health insurance.

Your basic point is idiotic and ghoulish. I'm tired of saying this over and over again, but you're comparing apples and oranges. Yes people do things that adversely affect their health, so what? That is not an argument for correcting a problem such as absence of health care. It's a total red herring, a separate problem.

Further, the reason the stats may seem low is because many of the uninsured are healthy. You want to see the difference health insurance makes in care? Compare two sick people, one with and one without health insurance, and then you'll see what difference it makes.

Finally, this movie is about how private health insurance sucks, the profit motive creates more impetus to deny coverage to provide it, and how our health care sucks compared to the rest of the world. I have yet to hear how our system is actually better. Instead we just have two red herrings over and over, the idea that 18,000 deaths is nothing because smoking kills more, and the idea that health insurance doesn't make that big a difference in health - both incorrect and based on some goddamn Cato source material I'm sure. And how do you justify our health care costs? More than anyone else in the world? And yet we are providing worse health care than any other industrialized nation - except to the rich of course. Funny how you never find any libertarians in the ghetto.

That linked tom tomorrow cartoon is perfect Khan. Thanks for that. It's like Jason's arguments in a nutshell.

Mark H,

I'm tired of saying this over and over again, but you're comparing apples and oranges. Yes people do things that adversely affect their health, so what? That is not an argument for correcting a problem such as absence of health care.

Tobacco use, alcohol use and poor diet are much, much bigger causes of poor health and premature death among Americans than inadequate health insurance. If your goal is to improve the health of Americans and reduce the rate of premature death among Americans, it makes far more sense to focus on these other causes of poor health and premature death than to focus on health insurance. Even a small reduction in the rate of smoking would save more lives than providing health insurance to everyone in the country. That's the point.

Compare two sick people, one with and one without health insurance, and then you'll see what difference it makes.

You're missing the point. Our efforts would be better directed at keeping those people healthy than on trying to fix them after they get sick. An ounce of prevention is worth a pound of cure. As the evidence I have cited shows, insurance coverage is a small factor influencing the health and longevity of the population.

and the idea that health insurance doesn't make that big a difference in health - both incorrect

No, it's NOT incorrect. The voluminous evidence cited in Longman's essay, including the RAND study that tracked families for 15 years, overwhelmingly indicates that health insurance doesn't make that big a difference in health. You can keep denying this as many times as you like but unless you can produce evidence to support your assertion it is worthless. EVIDENCE is what matters, not unsubstantiated assertion. Again, I would expect a scientist to understand that.

Our efforts would be better directed at keeping those people healthy than on trying to fix them after they get sick.

And health insurance has no role in keeping people healthy? You may disagree with this interpretation of the JAMA paper but the way I read it it showed people under the NHS were getting better healthcare through monitoring and maintenance of morbidity - high blood pressure, hypercholesterolemia etc. The system in Britain, since everything is based on electronic records, actually rewards doctors for providing better health outcomes for their patients. And since patients aren't penalized with co-pays, and aren't ruined if they find out they're sick, they're more likely to actively participate and managing morbidities.

But to suggest that not having insurance has nothing to do with maintaining health is simply nuts! For people to stay healthy and avoid coming into the hospital sick as hell, very inexpensive interventions are required. Yearly physicals, simple bloodwork, urinalysis and a thorough patient H&P every year is absolutely required. Routine mammography, pap smears for women, and at 40 and 50 prostate exams for men and colonoscopy are beneficial. Without insurance do you think this happens? You're giving a new classic industry denialism argument. You're playing the "education" card, as if health is entirely dependent on people behaving perfectly, which we know they will never do, and is even more difficult when they don't have access to medical care that will make it easier for them to be healthy.

Finally, that RAND study was done almost 40 years ago in a very different health environment. Medicine was not the same back then. There are those who would like to see the study repeated in the current climate, but the study is simply not relevant any more. People's health is maintained in a completely different way, diagnostic tests can be used to prevent diseases that were untreatable back then, new drugs, new interventions, and better knowledge of how to maintain health exists. It simply is no longer relevant.

You're missing the point. Our efforts would be better directed at keeping those people healthy than on trying to fix them after they get sick. An ounce of prevention is worth a pound of cure. As the evidence I have cited shows, insurance coverage is a small factor influencing the health and longevity of the population.

I will assume then that you have decided to save money and forego healthcare. That is the rational choice.

It's interesting, that in other countries that have public healthcare, they also spend more time and money on public health (i.e. your ounce of prevention). For example, in Canada they are starting an initiative to vaccinate the entire population - free of cost - against the flu every year. This will save the government money (and save thousands of lives). All because they are interested in keeping people healthy and keeping costs down. Whereas a health insurance company merely has an interest in keeping you out of the doctors office until you switch to another carrier.

Mark H,

And health insurance has no role in keeping people healthy?

No, not "no" role, but only a small one. That is what the EVIDENCE overwhelmingly indicates.

You may disagree with this interpretation of the JAMA paper but the way I read it it showed people under the NHS were getting better healthcare through monitoring and maintenance of morbidity - high blood pressure, hypercholesterolemia etc.

The study didn't find any such thing. In fact, it found that Americans in the top socioeconomic stratum, with the best health insurance, had the same or worse levels of health as Britons in the bottom SES. That is one reason why the authors concluded that health insurance has little if any effect on health. That finding is consistent with a mountain of other evidence indicating the same thing, from the RAND Health Insurance Experiment to the scores of studies on the causes of premature death.

But to suggest that not having insurance has nothing to do with maintaining health is simply nuts!

Well, it's a good thing I didn't suggest that health insurance has "nothing" to do with it, then, isn't it. Your posts are full of this kind of strawman argument. You keep saying things like "To suggest X is ridiculous" or "The idea that Y is true is wrong," where X and Y are claims I HAVE NOT MADE. It would be more constructive if you would respond to what I actually write instead of statements that no one has made.

Mark H,

Finally, that RAND study was done almost 40 years ago in a very different health environment.

The RAND Health Insurance Experiment began in 1971 and tracked the health of over seven thousand Americans for over a decade. It is by far the largest study of the relationship between health insurance and health ever conducted. The overwhelming finding of the study was that health insurance has little to do with health. This conclusion is supported by a mountain of other evidence all pointing to the relatively small role of health insurance on health. Here is a British Medical Journal article summarizing the RAND findings:

The important issue is what difference this change in use of health services makes to health. The general conclusion is none. This is a little surprising given that the reduction in use includes services which can be shown to be highly effective. Part of the explanation may be the reduction in iatrogenic disease, such as side effects from (inappropriate) prescription of antibiotics. There is also a proportion of effective treatments which are used in ultimately self limiting conditions. Whatever the explanation it is clear that the effects of reduced use of health services on health are at most small.

For example, in Canada they are starting an initiative to vaccinate the entire population - free of cost - against the flu every year. This will save the government money (and save thousands of lives). All because they are interested in keeping people healthy and keeping costs down.

Increased rates of vaccination is a good example of the kind of public health measure that could produce large benefits at low cost.

From the evidence I have seen, the main barrier to universal vaccination in the United States against common infectious disease is not difficulty in obtaining vaccination services, but the widespread public belief that vaccination is ineffective or that it is actually a cause of disease and disorders (such as autism). Because of these fears, many parents simply fail to seek vaccination for their children. So the solution to this problem is not "universal health care," but better public information and awareness of the benefits of vaccination.

Oh, so it's only 25 years out of date with data collected mostly in the 70s. Now I'm convinced. A lot happens in medicine after a couple of decades. Further the RAND study was a comparison between people who were insured and people who were allowed unfettered access - not insured and uninsured, which would be a comparison showing the advantage of having health coverage. If anything, it's proof that there should be rationing of health care, too much healthcare clearly wasn't helpful and might be worse. An odd study to reference to in this instance.

As far as your reading of the JAMA paper, we're in an argument over the interpretation of the data. Your way is to say health insurance has no effect on health. My way of reading it is that American health insurance doesn't have a positive effect on health compared to the NHS. Now tell me, since they are controlling for disease risk factors, what is causing the excess morbidity and mortality? You say stress. Really? We're dying of stress? Brits aren't stressed out too? That's the only god damned difference between our countries - some vague notion of our lives being harder and not the nationalized health care system? You can read it as a proof that insurance doesn't work, but if anything, it's a condemnation of American-style insurance versus the NHS.

Finally, this is all a big stupid distraction I finally realized. The point of Moore's movie wasn't who gets the best treatments or that we should have unfettered access to care. The point of Moore's movie was that when people get sick in the US, even with insurance, they frequently undergo financial ruin. We can argue about the importance of health coverage to healthcare until the cows come home. But that doesn't change the fact that insurance is failing to cover people from financial ruin when they get sick.

Mark H,

Oh, so it's only 25 years out of date with data collected mostly in the 70s. Now I'm convinced. A lot happens in medicine after a couple of decades.

You haven't presented any evidence indicating that medicine has changed since the study was completed in such a way as to invalidate its findings. Speculation is not evidence.

Further the RAND study was a comparison between people who were insured and people who were allowed unfettered access - not insured and uninsured, which would be a comparison showing the advantage of having health coverage.

This is irrelevant. The study addresses the relationship between health and out-of-pocket health care costs to the consumer at the point of delivery. The only difference between "no insurance" and "inadequate insurance" in this respect is the magnitude of the uncovered cost. It's a quantitative difference, not a qualitative one. And the finding was that there is little or no difference. As Longman says, even consuming 40% more health care services by dollar value produced no measurable improvement in health.

As far as your reading of the JAMA paper, we're in an argument over the interpretation of the data. Your way is to say health insurance has no effect on health. My way of reading it is that American health insurance doesn't have a positive effect on health compared to the NHS.

First, you're not arguing with my "interpretation" of the study; you're arguing with THE CONCLUSIONS OF THE STUDY'S AUTHORS. Those conclusions are (1) Britons tend to be more healthy than Americans, and (2) Those differences in health cannot be attributed to differences between the two nations' health care systems.

Now tell me, since they are controlling for disease risk factors, what is causing the excess morbidity and mortality? You say stress. Really? We're dying of stress? Brits aren't stressed out too?

First, stress is not an either/or; it's a matter of degree and type. So "stressed out" vs. "not stressed out" is a false dichotomy. Second, the author did not firmly conclude that differences in stress are the cause of the differences in health; he just proposed stress as a plausible explanation of the differences in health. And third, there are abundant reasons to think Americans tend to be more "stressed out" than Britons. The U.S. has higher rates of crime, higher rates of illicit drug use, and higher rates of social pathology in general. Americans also tend to work longer hours and take fewer vacations than Brits. Rates of divorce and other forms of social isolation are also higher in the U.S. All of these things may contribute to significant differences in stress.

Mark H,

Finally, this is all a big stupid distraction I finally realized. The point of Moore's movie wasn't who gets the best treatments or that we should have unfettered access to care. The point of Moore's movie was that when people get sick in the US, even with insurance, they frequently undergo financial ruin.

But I've already addressed this claim too. The EVIDENCE indicates that medical bill debt is a relatively small cause of "financial ruin." The number one contributor to bankruptcies in the United States is general credit card debt. So if reducing the rate of "financial ruin" is your primary goal, "universal health care" is unlikely to do much to advance it. Other kinds of policy--such as reducing the availability of easy credit--are likely to be much more cost-effective.

And to the extent that medical bill debt is a problem, it again just highlights the importance of focusing on public health measures to prevent illness rather than the "free" provision of health care services to treat it.

Is there data out there that estimates the amount of $$$ that goes to Emergency Room care that is the result of the uninsured using the ER for issues that should have been dealt with in other means?

You haven't presented any evidence indicating that medicine has changed since the study was completed in such a way as to invalidate its findings. Speculation is not evidence.

Oh no? Try and think, really hard, about what's happened with drugs in the last 20 years. HMG-CoA inhibitors, ACE inhibitors, Azoles for type II diabetes. Also better and more useful screening tools and tests that are now recommended at specific ages - fecal occult blood, Hemoglobin A1C, improved mammography, colonoscopy, PSA, etc. Doctors are doing far more to detect and control disease today than they were 20 years ago and it is far more costly. In the 80s a geezer might be on 2 or 3 drugs, a calcium channel blocker, maybe a beta blocker like propranolol for the heart, diuretics etc. that are still good today. These days, beyond testing for illnesses earlier with routine screenings a typical 60 or 70 year old will be on half a dozen, maybe more drugs. Not uncommon for even relatively healthy people to be taking a plavix, an HMG-CoA, an ACE inhibitor, and an aspirin. Once there is one event the number of drugs jumps - diabetes being the most likely offender - now you've got two, maybe three more more. Have a major event you'll see people on 8 to 10 pills a day. Medicine is different, yes, even in 20 years. There is more that we can do even for healthy people to prevent disease, and more that we can do when they have it. The RAND study refers to throwing antibiotics at people - another practice fallen into disrepute. You can't say you know anything about medicine if you don't realize what a big difference there is between today and 20 years ago.

The only difference between "no insurance" and "inadequate insurance" in this respect is the magnitude of the uncovered cost. It's a quantitative difference, not a qualitative one. And the finding was that there is little or no difference.

Again, universal coverage is about gathering up the uninsured and protecting people from financial ruin. I don't think the RAND study is applicable to uninsured vs insured, whatever you say. That is just economics hand-waving.

You're stress explanation is joke, I'm not even going to bother with it. It's a poor hypothesis, better access to healthcare, more rigorous screening etc., are more likely to be the causes of better health among Brits vs Americans with private insurance are loathe to pay money for co-pays and lack incentive to get routine screenings as they are penalized for sickness.

But I've already addressed this claim too. The EVIDENCE indicates that medical bill debt is a relatively small cause of "financial ruin."

Ooooh, you capitalized EVIDENCE, how convincing. Well the EVIDENCE is from the Himmelstein study is that 50% of people who go bankrupt cite medical bills as part of the reason they're in debt, with the average bankrupt having 12,000 in medical expenses. Worse yet, 68 percent of people who go bankrupt have insurance - it's not just the uninsured getting ruined, medical expenses hit the insured hard too in our system. This is why our system sucks.

And to the extent that medical bill debt is a problem, it again just highlights the importance of focusing on public health measures to prevent illness rather than the "free" provision of health care services to treat it.

How do you think you prevent illness! You make people go to the damn doctor before they get sick. Smokers will get their chantix, the obese can get help losing weight, people with preventable cancers will get caught in screening. You want to save money on health care, every study shows you need people to get their yearly screenings and routine checkups. The most cost-effective way to improve health is to get people into the GP's office. Not chase them away with out-of-pocket expenses, co-pays, and ruination with illness.

Himmelstein, D, E. Warren, D. Thorne, and S. Woolhander, "Illness and Injury as Contributors to Bankruptcy, " Health Affairs Web Exclusive W5-63, 02 February , 2005.

RMP, yes, it has been shown that a large portion of ER visits could have been taken care of more easily and more cheaply at a GPs office months before.

The cheapest and most cost effective health intervention is getting people to go to the GP. Routine, cheap screenings prevent big fat medical bills - and would make a huge difference for the uninsured who get their tab picked up by the state.

This is one of the things that needs to be explained better (at least to me).

If the people who are uninsured avoid GP visits and rely on the ER AND IF the ER is a very expensive alternative to GP visits, isn't there an argument that can be made that overall medical costs would decrease with less reliance on ER and that universal health care coverage would SHIFT some of the financial flow from ER to GP but NOT increase the total cost?

Wouldn't the only fly in the ointment be that now that people have coverage they elect to have unnecessary care?

BTW: is there really data that supports the argument that people elect to have excessive care if they don't face some 'ownership' (co-pay)?

Mark H,

Again, universal coverage is about gathering up the uninsured and protecting people from financial ruin.

Well, make up your mind. I thought it was supposed to be "about" reducing premature death and improving health. The WHO and JAMA studies you cited don't say anything about "financial ruin." They're about measures of health, not measures of "financial ruin."

I don't think the RAND study is applicable to uninsured vs insured, whatever you say.

Unless you can explain why the study isn't applicable to uninsured vs insured, this comment is worthless. Why do out-of-pocket costs matter with respect to differences between the degree of insurance coverage, but not to the difference between no coverage and some kind of coverage?

You're stress explanation is joke,

For the umpteenth time, it's not "my" explanation, it's the explanation proposed by Dr Michael Marmot, the author of the JAMA study you cited. And if you think it's a "joke," you need to explain why you think that, rather than just declare it to be so. As I said, there is plenty of evidence that stress levels may differ substantially between Brits and Americans. Why is it a "joke" to conclude that this a likely explanation of some or most of the health differences between them?

.... better access to healthcare, more rigorous screening etc., are more likely to be the causes of better health among Brits vs Americans with private insurance are loathe to pay money for co-pays and lack incentive to get routine screenings as they are penalized for sickness.

Huh? How are "better access to healthcare, more rigorous screening, etc." more likely causes when even the top socioeconomic segment of Americans, with the best health care coverage, are as sick or more sick than the bottom segment of Brits? Your hypothesis conflicts with the findings of the study. And it also conflicts with the RAND study, which also found that better health care coverage produced little or no measurable improvement in health.

Jason - at least try to get your facts right when you cite 'EVIDENCE'. A quick search shows that medical bill debt plays a large part in bankruptcies in the US. In 2005 a study estimated that about half of all bankruptcies were caused by medical debt http://www.consumeraffairs.com/news04/2005/bankruptcy_study.html , and in many cases it was relatively small amounts which sent the over the edge http://www.post-gazette.com/pg/04219/357527.stm. And far from the classic picture of feckless credit card junkies escaping their debts having maxed out the cards on a spending spree, credit cards are often used by the poor as a way of tiding them over when unexpected expenses occur, such as medical bills. Just read 'Nickel and Dimed'.
Poverty is the biggest cause of ill-health, and being in poverty increases your likelihood of dying from smoking, poor diet, etc. I would love everyone to look after them selves better, stop smoking etc, so that no one would have to see a doctor. But since people do insist on getting sick, and since many of them have little money, and are unable to afford insurance - what are we to do? You suggest that the very poorest get a free basic service, but everyone else pay. How about you make it simple - everyone is covered. If they want more, then there is still private provision. Its simple, affordable, and understandable.
Of course they might have to put up with waiting sometimes (as we do here in the UK with our poor standard of healthcare as you put it), but it's generally better than bankruptcy.
Mark H - relax - a burst blood vessel is not worth it!

Mark H,

Well the EVIDENCE is from the Himmelstein study is that 50% of people who go bankrupt cite medical bills as part of the reason they're in debt, with the average bankrupt having 12,000 in medical expenses. Worse yet, 68 percent of people who go bankrupt have insurance - it's not just the uninsured getting ruined, medical expenses hit the insured hard too in our system.

Yes, Himmelstein found that medicals bills are ONE FACTOR in about half of U.S. bankruptcy cases. He did not find that medical bills are the only factor, or even the primary factor. Other studies of the causes of bankruptcy have found that the primary factor is general credit card debt.

And you seem to have completely missed the implication of the insurance finding. If a large majority of medically-related bankruptcies ALREADY involve people who HAVE health insurance, then extending health insurance to people who don't currently have it is not likely to significantly reduce the rate of medically-related bankruptcy. This is especially true since most of the costs of serious illness are indirect costs arising from lost income, not the direct costs of medical treatment that would be covered by health insurance.

And by the way, even Himmelstein's 50% figure has been strongly contested. Dranove and Millenson reexamined the same data and concluded that medical debt is a factor in only about 17% of U.S. bankruptcies. They also cite other bankruptcy studies supporting a figure much lower than 50%.

So "universal health care" isn't likely to substantially reduce the number of people facing "financial ruin" due to illness.

Jason, how do you support your claim of

"So "universal health care" isn't likely to substantially reduce the number of people facing "financial ruin" due to illness." We aren't talking about everyone having bad insurance, we are talking about everyone have insurance the 'insures' against personal bankruptcy.

MikeB,

Jason - at least try to get your facts right when you cite 'EVIDENCE'. A quick search shows that medical bill debt plays a large part in bankruptcies in the US. In 2005 a study estimated that about half of all bankruptcies were caused by medical debt

No, the study did not estimate that. Read my last post. The study estimated that medical debt was merely ONE FACTOR in about half of all bankruptcies. Not even necessarily the biggest factor.

And in case you didn't notice, the study also found that most of those cases involved people who had health insurance. So having health insurance does not seem to provide much protection against bankruptcy if you become seriously ill.

Jason,

You missed my point entirely. There is no economic incentive for insurance companies to pay for vaccinations. There are *huge* economic incentives for a government in a country with government-provided health care to provide public health services.

Were you obscuring the point I was trying to make deliberately?

We aren't talking about everyone having bad insurance, we are talking about everyone have insurance the 'insures' against personal bankruptcy.

I don't know how to explain it any more clearly than I already have. Medical bill debt is only one kind of debt. And most of the debt incurred by people who declare bankruptcy is not medical bill debt. Even most illness-related debt is not medical bill debt. It is other kinds of debt arising from loss of income and indirect medical costs. Health insurance won't pay your mortgage when you're too sick to work. Or your utility bills. Or your food bills. Or your child care bills. Or your credit card bills. Those are the kind of expenses that usually push people into bankruptcy, and "universal health care" won't do anything about them.

The burst blood vessel is hard to avoid when you've got the typical libertarian with one study from 20 years ago saying it essentially disproves health care works. It's somewhat maddening. Again and again you explain that the RAND study does not apply to insured vs uninsured, and is from another era, but the crank will not relent. They'll hold on to the one study that conflicts with every other god damn study out there that shows the best thing for healthcare is getting people in to see GPs, for the patients benefit and for reducing cost.

As far as Marmot, well he and I disagree. That's a stupid explanation, and about as bad an example of handwaving as I've ever seen. Stress? Give me a break. The last uncontrollable variable to explain away the real findings of the study, that those of us with the best private insurance have worse health than those in the NHS system. I could give a crap what the study author thinks it says, he's nuts if he thinks it's stress that's killing us. Is stress causing us to have a high infant mortality rate too? All those stressed out infants in the womb? Our child mortality rates are also higher, is that because 1st grade is getting them down? I'm also not the only one that disagrees. Some suggest it's a breakdown of primary care - I think that's a much better explanation than stress which is frankly idiotic. Some of the letters in response or interesting. These chumps, for instance are way off. These guys think it's sleep another poor explanation if you ask me. These guys blame long commutes interesting, but unlikely a complete solution to the problem since Americans also show the same pattern of ill health when compared to canadians which found " ...US respondents (compared with Canadians) were less likely to have a regular doctor, more likely to have unmet health needs, and more likely to forgo needed medicines. Disparities on the basis of race, income, and immigrant status were present in both countries but were more extreme in the United States."

I'm going with the inadequate primary-care hypothesis and I'm not alone, it's a far better explanation for the results, it explains why it persists when we're compared to Canada.

a large majority of medically-related bankruptcies ALREADY involve people who HAVE health insurance, then extending health insurance to people who don't currently have it is not likely to significantly reduce the rate of medically-related bankruptcy.

Exactly! Insurance is not doing its job! This is the point of the goddamn movie.

There is no economic incentive for insurance companies to pay for vaccinations.

Huh? There is obviously a huge economic incentive for insurance companies to pay for vaccinations. Vaccinations tend to be much cheaper than treating the diseases they prevent. That's one reason why child immunizations are covered by virtually all standard family health insurance policies.

So having health insurance does not seem to provide much protection against bankruptcy if you become seriously ill.

Oooh, he made our point twice now in two different posts.

Mark H,

Exactly! Insurance is not doing its job! This is the point of the goddamn movie.

The movie is not about "insurance," it's about HEALTH insurance or health care. Is it now your position that it is the "job" of the nation's HEALTH CARE SYSTEM to protect people from every kind of risk that could cause "financial ruin?"---everything from their house burning down to their husband abandoning them?

I assure you, no health care system in the world does that. Not Britain's. Not Canada's. Not France's. Not Sweden's. No one's.

Health insurance won't pay your mortgage when you're too sick to work. Or your utility bills. Or your food bills. Or your child care bills. Or your credit card bills. Those are the kind of expenses that usually push people into bankruptcy, and "universal health care" won't do anything about them.

My annual expenses are around $30,000. To live my life I need $30,000 a year (or rather, I would go into debt $30,000/year if my income disappeared due to an illness.

The surgery that removed a tumor from my father (1 surgery, 5 days of recovery) cost $80,000. One surgery. Then he had chemo.

So if I were to require 100K of medical expenses, and I wasn't able to work for a year, you're arguing that universal health insurance wouldn't protect me from bankruptcy?

Huh? There is obviously a huge economic incentive for insurance companies to pay for vaccinations.

Wrong. There is a small incentive for them to pay for extremely effective vaccines that will provide rapid benefits.

How about the flu vaccine? Does your insurance pay for it? Mine doesn't. How about other public health measures. Does your health insurance pay for HIV testing? Mine doesn't. And I work at a major American medical school.

I asked our wonderful veterinarian if there was any way I could be treated like a dog, medically speaking.

She recommended her doctors -- saying they do _nothing_ with insurance, it'd be up to me (as it is to her) to file the papers and deal with our own health insurance provider for reimbursement.

Anyone else doing this? It sounds on the one hand like pure hell. On the other it sounds like the best chance of good medical care I can find, short of emigrating.

My old high school friend works as an ER doctor. He said he'd have quit long ago, except that the only way to _get_ good health care these days is to be in the profession and know the other doctors or know how to learn about them.

anon,

My annual expenses are around $30,000. To live my life I need $30,000 a year (or rather, I would go into debt $30,000/year if my income disappeared due to an illness. The surgery that removed a tumor from my father (1 surgery, 5 days of recovery) cost $80,000. One surgery. Then he had chemo. So if I were to require 100K of medical expenses, and I wasn't able to work for a year, you're arguing that universal health insurance wouldn't protect me from bankruptcy?

No, I'm arguing that the costs that would be covered by "universal health insurance"--most or all of the direct costs of medical treatment--are only a small part of the total costs attributable to the illness in typical illness-related bankruptcy cases. Your contrived scenario is not remotely representative of those cases. In the Himmelstein study, for example, medical bills averaged $11,000 during the two years prior to bankruptcy (i.e., about $5,500 per year, or about 5% of the $100K number you use in your made-up scenario). Dranove and Millenson cite a Department of Justice report that examined over 5,000 bankruptcy cases and found that 90% of them had medical debts less than $5,000, and that of those with medical debt of any kind, medical debt accounted for only 13% of total unsecured debt. As I said, the evidence (as opposed to fabricated anecdotes) indicates that medical debt is generally only a small factor in U.S. bankruptcy cases.

To further illustrate the point, D&M cite a 2004 study on the costs of breast cancer. The average monthly direct medical costs for women undergoing breast cancer treatment represented only 41% of the total costs of the disease. The other 59% of the costs came from lost income, non-medical expenses such as child care, and uncovered, out-of-pocket medical expenses such as over-the-counter drugs and medical supplies.

So, again, the EVIDENCE indicates that "universal health insurance" would make little difference to the rate of illness-related bankrupcty.

You can find the D&M paper here:
http://www.kellogg.northwestern.edu/research/chime/papers/myth_vs_fact…

anon,

Wrong. There is a small incentive for them to pay for extremely effective vaccines that will provide rapid benefits.

There is a large incentive to pay for child immunizations for serious infectious diseases because the cost is low and the benefit high. That's why private insurers are willing to pay for them. If they weren't, most immunizations would have to be paid for by the government or out-of-pocket by the parents.

I don't know what proportion of private insurers cover the flu vaccine for adults, but I don't know why you think the question is terribly important, anyway. Flu is not a serious illness for most adults, and flu vaccinations are commonly available at low cost or for free during flu season. Last winter, my local grocery store was offering them for $15. My employer offered them to all employees for free.

Mark H,

Again and again you explain that the RAND study does not apply to insured vs uninsured, and is from another era, but the crank will not relent. They'll hold on to the one study that conflicts with every other god damn study out there that shows the best thing for healthcare is getting people in to see GPs, for the patients benefit and for reducing cost.

You have not cited even a single study, NOT EVEN ONE, that contradicts the statements I have made about the relationship between health care insurance or health care "coverage" and health. So where are all these "other god damn studies" that supposedly contradict what I have said?

And since you're still claiming that the RAND study is irrelevant or out of date, here is YET ANOTHER piece of evidence indicating that the relationship between health insurance and health is weak, a metastudy from 2004 by Helen Levy of the University of Michigan's Economic Research Initiative on the Uninsured, and David Meltzer of the University of Chicago. They conclude:

It is clear that expanding health insurance is not the only way to improve health� Policies could also be aimed at factors that may fundamentally contribute to poor health, such as poverty and low levels of education. There is no evidence at this time that money aimed at improving health would be better spent on expanding insurance coverage than on any of these other possibilities.

You have not cited even a single study, NOT EVEN ONE, that contradicts the statements I have made about the relationship between health care insurance or health care "coverage" and health. So where are all these "other god damn studies" that supposedly contradict what I have said?

Ahh, the old "do my work for me" gambit because the libertarian knows all about healthcare. Oh well, I guess I'm screwed. How about a Cochrane review? Systematic reviews really are the best.

Implementation of preventive measures was directly related to health. Mortality and morbidity rates were reduced with the following intervention measures: prescribing aspirin to persons with high cardiovascular risk; controlling blood pressure; providing anti-smoking advice; treating cardiac insufficiency with angiotensin converting enzyme (ACE) inhibitors; prescribing statins for primary and secondary hyperlipidaemias; prescribing oral anti-coagulants for atrial fibrillation and immunizing against influenza, pneumonia and tetanus.23 Table 4 summarizes the relationships between the attributes of primary care and the costs. Having the same family doctor over a long period of time was associated with lower costs.10,21 Continuity was associated with decreased total annual health care expenditure.10 Continuity of care was related to indirect indicators of efficiency such as fewer hospital days, fewer intensive care days, shorter hospital stays and lower percentages of emergency hospitalizations.6,10 Continuity of care was associated with reduction in resource utilization and of costs.

That's one, and a systematic review at that. Want 100 more?

You bore me.

Enough with always having to provide evidence for every little detail of your arguements. Michael Moore is fat and stupid and a jackass, and thats all that needs to be said.

I remember somewhere someone said that in America we think of health care as a privilege while in other countries they think of it as a right. I think that's the fundamental difference.

Just a few personal notes:
1. My wife and I are both public school teachers and we pay about $1000 a month for coverage including our daughter. This is the cheapest HMO in our plan.

2. We don't go to the doctor as much as we would like because we can't afford the $25 co-pay each time. Our daughter's health is our priority so we save up for her co-pays.

3. My personal dental and vision are about $40 /month.

I've never lived anywhere but the US so I can't say if national health care is better, but my wife and I definitely don't get the care that I think our premiums would suggest.

She recommended her doctors -- saying they do _nothing_ with insurance, it'd be up to me (as it is to her) to file the papers and deal with our own health insurance provider for reimbursement.

Anyone else doing this? It sounds on the one hand like pure hell. On the other it sounds like the best chance of good medical care I can find, short of emigrating.

See the post up above where I say that I got a bill from the hospital for ~$30,000 but I paid out about $70.00 and they waived like $18K while my HMO picked up the other $12K. That deal was due to an HMO coverage agreement. If I had to go to the hospital and get the work done, THEN try to file for the $30K with the HMO, it sure wouldn't have been a pretty picture.

I keep hearing this blather about negotiating with your doctor. Good grief, who actually has the upper hand in that negotiation? Do you think the doctor is EVER going to try stop curing you? Will you get a chance and have the knowledge to choose the options correctly in saying, "Uh, no, I don't want that treament"?

Again, I have a US government subsidized program. Not a luxury plan at all; it makes the process unpleasant enough that one doesn't actually engage it willingly and frivolously, but on the other hand, it seems to work well enough that I still have most of the major limbs. Of course my expectations aren't very high, and I'm not TRYING to live to be a 100 so that may play into it too.

Mark H,

That's one, and a systematic review at that. Want 100 more?

No, it's not one. The paper you cite is about the relationship between certain kinds of health care intervention and health, not between health care INSURANCE or health care COVERAGE and health.

And just to reiterate, I am not saying that there is no relationship at all between health care insurance or health care coverage and health. The point is that the relationship is WEAK and that policies other than the expansion of health insurance or health coverage would produce greater improvements in health at lower cost.

The point is that the relationship is WEAK and that policies other than the expansion of health insurance or health coverage would produce greater improvements in health at lower cost.

This paper shows that one of the most cost-effective health interventions is making people see a GP and have continuity of care. How does one do that without insurance? Lack of insurance means you see people in the ER, not the PCP office, you see them when they're deathly ill, rather than when they have preventable illness.

The fundamental problem with your assertions and why they piss me off so much is that you're basically saying that routine health visits don't benefit health substantially. Either with uninsured not visiting doctors at all, because they can't afford the visit or the diagnosis, or people under-utilizing because of co-pays and deductibles, etc. People are paying thousands of dollars a year, and because actually receiving health care is an additional expense, they don't see their primary care doc - which we know is the #1 way to reduce medical costs.

Then there is the fundamental unfairness of this, people are spending thousands of dollars and getting essentially nothing. They are also not engaging in the most basic and cost-effective health care intervention available - seeing their PCP. And people who are uninsured certainly aren't doing this.

Finally, what are these policies that will provide greater health? What are these fantastic libertarian alternatives that will do so much more than making sure everyone sees their PCP each year? More "just say no" programs telling people not to smoke? Stupid TV ads to raise "awareness" of obesity? Yeah, those things have such a great track record of improvement. Maybe it's time for you to do some work and show us how you'd improve health so much more effectively than actually providing health care to people who need it.

And you have to describe to me why we're getting such a great deal on health insurance when we have people going bankrupt to pay their bills, we have poorer health, higher morbidity and mortality to Canada and Britain by comparison, are rated 37th in the world for health care and yet spend more per capita than any other nation. How is this cost-effective?

Mark H,

The study you cite doesn't say anything about the cost-effectiveness of the interventions it discusses in comparison to other kinds of policies for improving health, and it doesn't say anything about the relationship between health care insurance or health care coverage and health. I have cited a mountain of evidence showing that the relationship between health insurance and health is weak, and yet you still discuss them as if they are tantamount to being the same thing. You don't seem to be able to let go of this false equivalence in your mind between health insurance, health care, and health, no matter how much evidence I cite showing that the correlation between them is weak.

Here is a summary of your biggest misunderstandings on this matter, as best I can tell:

1. You falsely assume that health care services have a greater impact on health then social, behavioral and environmental influences. They do not. The effect of the latter is around 10 times greater than the effect of health care services.

2. You falsely assume that "having health insurance" or "having health care coverage" is the same thing as "getting health care services." There are many reasons why people with health insurance do not receive health care services that would improve their health, from a general reluctance to go to the doctor to financial obstacles like deductibles and co-pays.

3. You falsely assume that "not having health insurance" is the same thing as "not getting health care services." There is large network of public and private programs and institutions that provide free or low-cost health care services to the uninsured. For example, the federal government's Bureau of Primary Health Care funds a network of hundreds of Community Health Centers that provide free or low cost health care services to people without health insurance.

Mark H,

Finally, what are these policies that will provide greater health? What are these fantastic libertarian alternatives that will do so much more than making sure everyone sees their PCP each year? More "just say no" programs telling people not to smoke? Stupid TV ads to raise "awareness" of obesity? Yeah, those things have such a great track record of improvement.

Anti-smoking policies have clearly had a huge impact. According to the Institute of Medicine, the rate of smoking among Americans has declined by 58% since 1964. Since smoking is still by far the leading cause of premature death (around 24 times as large a cause as inadequate health insurance), this decline represents an enormous improvement in public health. There is no reason to think that additional anti-smoking policies could not produce further large reductions in the rate of smoking. And contrary to your sarcastic dismissal of these policies, they are in fact much more than "just say no," although public information campaigns are certainly an important component. Other anti-smoking policies include cigarette taxes, restrictions on smoking in public places, cigarette advertising restrictions, cigarette sales restrictions, and civil litigation against tobacco companies. Even a small additional reduction in the rate of smoking would likely save as many lives as "universal health care."

Mark - one of the strange things about libertarians is that they seldom have to live with the ultimate consequences of their philosphy. For instance, those who advocate no restrictions on drug use seldom have to live next door to a crack house, and those who reckon that the market can supply all simply ring up the local (taxpayer funded) fire brigade should their house be on fire. Mother Jones had an article a while ago of what would happen if someone actually tried to live by the idea of no government, and relied only on themsleves - it was of course insane.

Jason - you constantly refer to various studies, but why not look at some of the figures you yourself mention, and some of the evidence that has appeared on this thread?

To start with, you dismissed the experience of the poster whose father had required surgery and then chemo as an 'your contrived scenario' - the poster was describing a real case, one which cost some $80,000 to begin with, and of course the costs of chemo would have increased that still further (i don't know what a 6/8 week course costs, but even taking the oral dose must be costly, and inpatient stays due to tests, adverse reactions etc will be anything but cheap.

$80,000 plus is a very large sum for anyone to find, and without insurance might mean selling a house, etc. And of course if there was insurance (and there may well be a cap on the total amount paid out), premiums in future would most likely increase, and possibly any reoccurance might simply not be covered as a prior risk. Would bankrupcy be more likely as a result? Most of us would say yes.

Then there's your citing of the Dranove and Millenson study. You point out their findings that 'The average monthly direct medical costs for women undergoing breast cancer treatment represented only 41% of the total costs of the disease. The other 59% of the costs came from lost income, non-medical expenses such as child care, and uncovered, out-of-pocket medical expenses such as over-the-counter drugs and medical supplies' You regard that as a plus. Of course a universal health system would have left her potentially 41% better off (if a self payer). It would be interesting to see what that cost is, but I suspect it is not small. And in the UK, many of those other costs, such as medical suppliies and over the counter drugs would possibly be free as well.

Or take the example of the two school teachers (a group which is the epitome of the middle class professional) who say they find it difficult to afford to go to their GP when they need to because of the cost, and instead make sure their daughter goes instead, even if they might also need help. When people in their position cannot go to their GP when they need to, what chance do others, who have less stable and less paid jobs?

There are a vast number of factors at work in relation to peoples health (and I applaude the drop in smoking rates, as someone who spent five years talking to families of the dead when I worked in a cancer hospital), but once people are sick, all too often dispite all their best efforts, someone has to treat them. And discouraging access to healthcare, even at the primary level, makes things worse. A small lump which might be nothering could turn out to be cancer. A quick trip to the GP would probably clear this up one way ofr another. But if people don't go, because they feel they cannot afford it, then by the time they are dignosed, it may be too late, or far more difficult and expensive to treat. Fast treatment, as you said at the start, is very important, so why make it so difficult to get primary care? Over 90% of people treated by the NHS never need to go anywhere near a hospital, and good primary access helps keep it that way.
Strangely enough, you refer to the problems relating to care access even with insurance when you say 'There are many reasons why people with health insurance do not receive health care services that would improve their health, from a general reluctance to go to the doctor to financial obstacles like deductibles and co-pays.', so why dont you think this is something that needs fixing?

These articles both say the same thing http://www.alternet.org/healthwellness/56134/, http://www.prospect.org/cs/articles?articleId=12683,
the US spends a great deal of money already on a system which could be much more efficient. You could up with a better system for less money. That sounds like a solution the market could live with. If you cant,perhaps you should read these two links http://sentineleffect.wordpress.com/2007/07/02/daydream-believers-liber… & http://www.joepaduda.com/archives/000933.html#more which point out the more obvious practical problems with your arguements.

BTW - if US drug companies are giving the Canadian and UK health systems such a free ride, why is it that at least one of them is sueing http://www.nice.org.uk/ in order to have its drug approved for use in the UK? As Mark points out http://scienceblogs.com/denialism/2007/07/hire_google_for_your_denialis… , 'One should also remember what is new is not always better, this is medically stupid thinking. And doctors that practice medicine by throwing the newest stuff off their shelves at their patients aren't doing them a favor.'. The US drug companies don't like NICE because NICE actually tests whether the drugs used are cost effective. They can stop the NHS buying the drug if they think it isn't - which loses them a market. If you want to sell an expensive drug, do you really want to have your claims tested? Possibly not.

OK, a bit of a tangent but can someone explain to me why the normal market pressures of a large consumer putting pressure on its vendor (lets say Walmart applying it's leverage against it's suppliers) is considered acceptable but when that customer is a large group of medical consumers and the vendor is a drug company, we are supposed to feel sorry for the drug company?

And btw, yes that was an extremely long run on sentence.

Anonymous,

No, the "$100K" thing really was a contrived scenario. Read his description again. And the point is that the scenario is not remotely representative of actual, real-world bankruptcy cases, as the studies I cited show. Public policy has to be based on the needs of the population as a whole, not the needs of worst-case-scenario individual cases. We cannot effectively protect people from all risk of major financial loss, whether it's due to illness or any other kind of misfortune.

You're also wrong about the breast cancer issue. In the United States, the woman's direct medical costs for treatment would be covered by either a private insurer or the government. But, again, the point is that direct medical costs are only a fraction of total costs. Britain's NHS does not reimburse people for lost income and other non-medical costs caused by their illness, nor does it cover out-of-pocket costs for non-prescription drugs and medical supplies.

Anonymous,

Strangely enough, you refer to the problems relating to care access even with insurance when you say 'There are many reasons why people with health insurance do not receive health care services that would improve their health, from a general reluctance to go to the doctor to financial obstacles like deductibles and co-pays.', so why dont you think this is something that needs fixing?

You seem to have missed the point. It would be wonderful if we could provide everyone with gold-plated, cadillac health insurance with no deductibles, no co-pays, no economic barriers of any kind to the acquisition of any form of health care that might benefit them. But we can't. Resources are limited. So the fundamental question is how best to spend the limited resources that are available. Every dollar spent on reducing co-pays for people who already have insurance is a dollar that is not available to spend on extending insurance to those who don't have it at all. Every dollar spent on extending insurance is a dollar that is not available to spend on anti-smoking programs. Reducing co-pays would probably be a very cost-INEFFECTIVE use of our limited dollars. We would probably get much more bang-for-the-buck by spending them on public health programs, or even on extending insurance.

BTW - if US drug companies are giving the Canadian and UK health systems such a free ride, why is it that at least one of them is sueing http://www.nice.org.uk/ in order to have its drug approved for use in the UK?

I don't know. What is the nature of the claim the drug company is making against NICE? If the drug company believes that NICE is not acting in accordance with its own approval practises and standards, then I'm not sure why you think the drug company is wrong to make that challenge. In any case, I don't understand how think such a legal challenge implies that the UK is not getting a free ride on the U.S. drug market. Americans pay much higher prices for drugs than Europeans. That's a subsidy for Europeans.

Sorry for being Anonymous in my previous post - I simply forgot to put my name in when I posted.

Jason - you should read the gentlemans post more carefully. he wrote 'The surgery that removed a tumor from my father (1 surgery, 5 days of recovery) cost $80,000. One surgery. Then he had chemo.' That sounds like something that actually happened. His question about $100K costs is hardly fanciful in the circumstances, since thats pretty much the amount his father paid out for his treatment.

As for the costs of being treated for breast cancer - for the 40 million American's who don't have health insurance, the steps they have to go through http://www.natlbcc.org/nbccf/access/affordable.html do not look exactly easy. And of course, Sicko's central point is that even with health insurance, you cannot always get the treatment you need. You say that 'the point is that direct medical costs are only a fraction of total costs' - true, but 41% (the figure you cite) is hardly a small fraction of costs. And I should add that in most European countries (including the UK), benifits are available to those who cannot work through illness, and in many cases, non-prescription drugs and medical supplies may well be free.

Do copaymets limit access to treatment? Apart from the post above which clearly states that two schoolteachers do not go to their GP when they need to because of co-payments, these links http://www.painpolicy.wisc.edu/publicat/94jpsma.htm http://www.cahealthadvocates.org/newsletter/2006/08/cancer.html http://www.hon.ch/News/HSN/603546.html http://books.nap.edu/html/care_without/reportbrief.pdf would suggest that the anser is yes. And the idea that somehow people with insurance should carry on with copayments in order to extend ' insurance to those who don't have it at all' does seem a little more like 'universal healthcare' and a bit less like the free market which you seem to support.

Public health education is very important, but I would interested to see how using X dollars on stopping people smoking also means you dont have to spend X dollars on primary care, hospitals, etc. We all will continue to need access to primary and hospital care, even if we all stop smoking, drinking, eating junk food, etc. This, as Mark pointed out, is a variation of the 'education' myth.

Why are the drug companies sueing the NHS (via NICE)? According to your version, Canadian and European patients are getting a subsidy from US drug makers, because of the lower prices that their healthcare systems ruthlessly squeeze out of the US companies (in exactly the way rmp pointed out that buyers in a free market do).

Logically, faced with being forced to sell the drug for a price too low for them to cover their costs and plow money back in to R & D, they should simply refuse to sell the drug to the national health provider. If the drug is so good, then either the national provider will come back with a much better price, or the company can sell the drug privately.
Yet these companies are desperate for the NHS to buy their product! So much so that they are willing to take NICE http://www.guardian.co.uk/medicine/story/0,,672491,00.html to court, as well as undertaking very large lobbying campaigns http://www.guardian.co.uk/medicine/story/0,,1703650,00.html http://society.guardian.co.uk/health/story/0,,1741858,00.html?gusrc=rss in order to force the governments hand.
But why would they want to do this. It isn't about approval for any of these drugs, since they are already approved for use. They want the NHS to use them, because thats the main market. You can only conclude that they are not about to make a loss on the deal.

It may well be that the US subsidises the costs for these drugs, but the companies seem to be doing very well in American markets http://www.calnurses.org/media-center/in-the-news/2007/april/page.jsp?i…, http://www.ombwatch.org/article/blogs/entry/2464/39. Indeed Pfizer seems to have doubled its profits last year. And of course about 50% of those costs to develop a new drug are actually not R & D costs but marketing costs (for which I'm sure there are generous tax breaks). US companies also enjoy a non-negotiation deal with the US government over drug costs for Medicare, etc (although the VA apparently can make deals - I wonder who pays less?), and importing drugs from other countries(as in a 'grey' market) are outlawed http://www.motherjones.com/news/feature/2004/03/02_403.html.

They have excellent relations with the FDA, and are allowed to advertise directly to patients (something which they are lobbying for in Europe). In other word, the drug compnaies have created anything but a free market in the US http://www.nybooks.com/articles/17244, and make large profits as a result. Can they afford to charge less to Canada and the UK - yes, because you pay more. Are we being subsidied, or are we paying a realistic price? I suspect you are subidising the drug companies, rather than us.

here's an idea, instead of people having to make co-payments in order to see their local doctor, and thus not always getting care when they need it, why not use the money ', drug companies, hospitals, insurance companies and doctor organisations spent 400 million dollars in 2005 and 2006 lobbying Congress and federal candidates to enact policies the companies favour, according to Opensecrets, an organisation which tracks the records'.

'It would be wonderful if we could provide everyone with gold-plated, cadillac health insurance with no deductibles, no co-pays, no economic barriers of any kind to the acquisition of any form of health care that might benefit them. But we can't. Resources are limited. So the fundamental question is how best to spend the limited resources that are available.' Exactly!
You can afford to do away with copayments,deductibles and economic barriers already, and save money. But simply saying that your current system works, when it plainly does not, is not an answer.