• Senator Johnson’s odd dislike of the PPACA

    (If you’re coming here from Paul Krugman’s post on cancer survival, you may also enjoy my take on the subject:  Survival rates are not the same as mortality rates)

    It’s the one year anniversary of the PPACA, and there have been a number of op-eds praising and cursing it. The WSJ took the opportunity to print a piece by Senator Ron Johnson, on the health care his daughter Carey received at birth, and how he is so thankful that the US system was not under the PPACA at the time.

    Let me start by saying I’m thrilled Carey received top-notch care and that she’s doing well. I wouldn’t have it any other way. I wish the same for all children who need it. But let’s be clear. She received that care in part because she had insurance, and getting more people insurance is the whole point of the PPACA.

    The arguments Senator Johnson makes are numerous. So I want to take them one at a time.

    Here we go:

    The procedure that saved her, and has given her a chance at a full life, was available because America has a free-market system that has advanced medicine at a phenomenal pace.

    So much wrong here. First of all, maybe you can make an argument that the free market system of drugs or devices helped here. But the “free market” insurance system? Name me a single procedure developed by an insurance system. We’ve had a single payer system covering everyone over 65 for decades and there have been plenty of improvements in care for the elderly.

    I don’t even want to think what might have happened if she had been born at a time and place where government defined the limits for most insurance policies and set precedents on what would be covered. Would the life-saving procedures that saved her have been deemed cost-effective by policy makers deciding where to spend increasingly scarce tax dollars?

    Those definitions the government is setting are all being attacked by many governors for being too high. The definitions are setting minimums, not what should not be covered. Nothing at all prevents private insurance companies from creating policies that cover anything, as long as they cover the minimum. Senator Johnson has this completely backwards.

    Compared to the U.S., breast cancer mortality is 9% higher in Canada (according to the government statistics of each country), 52% higher in Germany and 88% higher in the United Kingdom (according to studies published in Lancet Oncology). Prostate cancer mortality is 604% higher in Britain.

    I’d like to see his data.  Here’s what I have.  First breast cancer:

    Here’s prostate cancer:

    Yes, we do better than a lot of countries in preventing mortality from those cancers. But we’re not the best, and the differences don’t appear to be nearly as large as Senator Johnson says. Moreover, he’s cherry-picking. We’re great at treating those cancers. But here’s overall mortality from cancer:

    That’s a much tighter clustering of results. And again – I don’t dispute that we may do some things better here. But to give the credit to our insurance system and claim that the PPACA will change that? Where’s the proof?

    Those in need of timely care from specialists are better off in the U.S. Drawing on several peer-reviewed studies, Dr. Scott Atlas of the Stanford University Medical Center notes that patients who need knee and hip replacement, cataract surgery, and radiation treatment wait months longer in the United Kingdom and Canada than in the United States.

    Senator Johnson makes a classic mistake here.  Who needs the most hip replacements and cataract surgeries in the US? The elderly. How do the elderly get their care financed? Medicare. What is Medicare? A single-payer system. Surely Senator Johnson is not advocating that we should give everyone Medicare because it outperforms Canada and the UK, is he?

    Our health-care system has problems that must be addressed. But ObamaCare will make those problems much worse. Instead of increasing consumer choice, it narrows it.

    For those who have private insurance through their employers, nothing has changed. For those with Medicare and Medicaid, nothing has changed. For many of the uninsured, they will get Medicaid or have choices in the exchange. We can quibble about some anecdotes, but those are the broad brush strokes.

    Instead of encouraging innovation, it stifles creativity. Instead of expanding access to care, it will ration it. And instead of allowing competition to help bring down costs, it increases spending and puts our health-care system on a path to ruin.

    Most of the companies and people doing the innovation supported the law. They haven’t made any complaints about creativity. No one is rationing as Senator Johnson suggests, regardless of the rhetoric. And while I agree that it increased spending and doesn’t contain costs enough, the PPACA does more to contain costs than any other laws passed in quite some time.

    Moreover, Senator Johnson seems to be under the illusion that no government money or insurance is in the system now. Did the hospital where Carey got her miraculous surgery accept Medicaid? Did it accept Medicare? Did it have any federal funding? Was it an academic medical center? Were residents involved in her care? Did it accept NIH grants? Was the procedure or care delivered developed by people who accepted those grants?

    I ask, because all of those are ways in which the federal government contributes to health care right now. And without those things, Carey – and millions of others – may have had much different outcomes. The PPACA gives more people Medicaid and gives some others federal subsidies to buy private insurance. That’s pretty much the gist of it.

    We can argue about the details or the cost, but after a year since the law’s passing, it would be nice for the rhetoric to stop. It would also be nice if we could start to have a substantive debate on how to make things better instead of seeing the status quo through rose-colored glasses.

    • Nicely done and well thought-through take down.

      I just wish you weren’t so polite.

      They don’t deserve it.


    • Let’s be clear here: He’s lying for idealogical reasons.

    • As a Wisconsinite who’s followed him, I suggest Johnson is merely mouthing the cherry picked cancer statistics, the confusion of minimum for maximum requirements, etc. that he imbibes from the wingnut propaganda he is immersed in, generated by RW thinktanks and lobbyists. He is a self-isolated ideologue.
      As Seinfeld’s Constanza said “It’s not a lie if you believe it.”

    • And if the hospital was operating before 1975 there is a very good chance it received Hill-Burton funding to expand its facilities.

      Clueless anti-health insurance reform folks often like to say that people can show up at an emergency room and not be turned away. They are clueless because they are referencing a requirement of the Hill-Burton act, a government program to ensure that the country had enough hospital beds.

    • Thank you so much for your thoughts. I find Senator Johnson’s op-ed piece so despicable precisely because his daughter had a life-threatening condition. I believe his misinformation is ideologically-based. He knows that if the ACA is repealed, he would deny other (non-multi-millionaire) parents the opportunity to save their child’s life.

      I take this personally because I live in the socialist state of Massachusetts (ha ha), and my son was born with a life threatening birth defect, for which he still receives copious, expensive medical care. We have private insurance, which is supplemented by MassHealth and a system that is quite similar to the ACA. He receives excellent care. I have never had to fight for any procedure. I don’t have to worry about caps on his care. Most importantly, my middle class family has not had to worry about covering the expensive co-pays and deductibles of my private insurance – which would number in the tens of thousands of dollars.

    • “Prostate cancer mortality is 604% higher in Britain.”

      What Johnson is saying here is that on a per capita British males are 7 times as likely to die of prostate cancer as US males. Johnson seems to be pulling statistics out of a hat.

      There are many males in the US that have to wear diapers and have lost the ability to have fun with their wives because of over treatment for prostate cancer. Needlessly treating prostate cancer can be very profitable for the medical establishment but costly for everyone else.

    • You should send this to the WSJ as a letter to the editor. It would be interesting to see whether or not they’d publish it.

      • As of this posting, Sen. Johnson’s WSJ op/ed has generated 723 comments. I strongly suspect he’s gotten the feedback he expected. My bet: WHEN the Journal published feedback to his piece, there’ll be at least four letters to the editor featuring a cross-section of opinion. Much as the NYT would do, were a Sen. offering a defense of the law to get an op/ed published.

    • I think its important to keep in mind that the only reason his daughter had insurance is because of government regulations forcing workplace insures to offer pooled insurance. I doubt they would be able to find a infant with a serious heart condition insurable on the open insurance market.

    • I was with you until the end. In my mind the greatest thing about Obamacare, is that the status quo changed forever. Luckily they are no longer looking at the status quo through rose colored glasses, they are looking at the former status quo through rose colored glasses.

    • You mislead with the charts. When you show the third one, deaths from cancer per 100,000, you remark “That’s a much tighter clustering of results.” In fact, it’s on a much different vertical scale, and if you correct the scales, you will find it’s the same spread, not a “much tighter clustering of results.

    • A great article. It’s really good to see this sort of analysis.
      Please write off to Senator Johnson and tell him that Medicare is government provided.
      And ask him where he got his breast cancer statistics from.
      And tell him that NHS heart surgeons lead Europe, with a 25 per cent lower mortality rate, and faster recovery rates for patients. The NHS operates on elderly patients, but with low death rates (The Guardian Thursday 25 November 2010.)
      And that’s a government system.
      I would love to read what sort of answetrs he can offer, if any.

      • @David Simmons – If you’re just joining us, please stay (subscribe!). We do this kind of thing daily. Not always take downs, but evidence based and policy relevant. It’s what we do.

      • @Samuel

        Oh, thank you for your kindness in offering the American medicines to us Europeans. After all only 6 out of the world’s top 12 pharmaceutical companies are based in Europe and the meager population of EU alone of just 500 million could never support any innovation.

    • To answer some of your (obviously rhetorical) questions:

      Johnson’s daughter was treated at the University of Minnesota Medical Center by a doctor who was working on an NIH grant at the time.


      The breadth of Johnson’s obliviousness on this issue is staggering.

    • I had the misfortune of tuning in to Johnson’s televised victory speech after he defeated Feingold in November. In it he said his first priority as a senator would be to save the government “trillions” of dollars by repealing PPACA. So he’s already proven that he will basically say anything to discredit the law, no matter how outrageous. Or he’s a complete fool. Or both.

    • Let me see if I can explain innovation and technology transfer to our “progressive” friends.

      Senator Johnson was referring to INNOVATION that allowed his baby to survive. The baby would, have course, otherwise died. Is this good or bad? From an economic perspective, it depends. On one hand, a surviving child will eventually pay taxes, generate wealth, and so on. However, it costs money for the child to survive, and there is a risk that the child will die despite the innovation before she can pay taxes.

      Which gives “progressives” (like my former congressman, Alan Grayson) two statistics to cherry pick to claim that European medicine is better than US medicine. First, because we count live births differently, our infant mortality rate is “higher” than elsewhere. Second, a market driven medical system rewards innovation with profit. This creates the innovation, of course, but it also creates costs. So “progressives” claim that European medicine is cheaper than the US. From which you hear the repeated deception that “all other countries get better medicine cheaper than in the US.” The very deception that is repeated here.

      Now, just as the dynamic, non-“progressive” US economy can pay for the defense of sclerotic social democrasies in Europe, the US also pays for its medical innovation. European medicine does not use “leeches”. But they DO use drug developed in the US and paid for by US taxpayers (in its basic research funding) and patients. Thus, 20 million Canadians can buy prescription drugs cheaper than Americans ONLY because 300 million Americans are subsidizing the cost of research, risk, and development in the pharmaceutical industry.

      Now, “progressives” want to make the US into Europe. Like (former) Congressman Grayson, this page distorts statistics to ignore the fact that we pay for the innovation that the Greeks benefit from. The problem: After Obamacare destroys US medicine (note, it places taxes on medical innovation), no country is left with the profit-driven medicine needed to deliver innovation. For the rest of history, “death panels” will rely on “comparative effectiveness” studies of older and older medicine to divvy out leech-like medicine decide who lives and who dies.

      Now, perhaps the US taxpayer should not be so generous. Perhaps we should not provide free to the world our medical innovations, our defense, or our aircraft carriers that help tsunami victims or create “no fly zones”.

      • There are 33 million Canadians, not 20 million. If your other “facts” are as accurate as your population numbers, your argument is worthless

      • Like many “conservatives” you lack a basic understanding of facts and repeat lies and “talking points” as if they were valid points.

        Actually, if you check, you will discover that only two of the seven largest drug companies are US Companies. Many drugs are invented outside of the US, and US drug companies are realizing that foreign innovation may drive the next wave of profitable drugs:

        The average US drug company spends 35% on marketing, but only 15% on research. The high prices in the US pay for glossy magazine ads, TV commercials, and junkets for doctors, not for research.

        Canadians gets drugs cheaper for one reason: their government negotiates a price for the drugs. In the US, the government is prohibited by law from negotiating a price for the drugs it buys as part of its health insurance programs for seniors and the poor. Same drugs, made at the same factory, but Canadians get a discount, while Americans pay the sucker, I mean sticker, price.

      • You’re right Samuel. A single payer for a given sector will stifle growth and innovation.

        That’s why the defense/aerospace sector in the US is lagging so far behind the rest of the world

    • Would the Wall Street Journal print this rebuttal for the sake of balanced reporting? It should, but probably wouldn’t, since the rebuttal might disturb the journal’s reactionary spin..

    • Samuel,

      I know a bit about the history of NICUs (Neonatal intensive care units), having a baby receive excellent care in one. The incubator is the most pronounced feature of a NICU. The brand used in my baby’s NICU was Drager, a German company that makes the “Isolette,” and in fact the nurses call the incubator the Isolette just like a bandage is called a Band-Aid, because the brand is so dominant. Drager developed the isolette in Germany under its social medicine system. Of course, they derive a lot of income from the U.S., but with the expansion of Medicaid under the U.S. health care reform, I assume that this revenue would rise, not fall, and thus the incentive for innovation would increase rather than decrease.

      More generally, it seems to me that health care has been massively subsidized in the U.S. by government, and generally subsidies result in more of a product, not less. I also understand that people and firms will continue to be allowed to purchase health insurance in excess of the minimum required by the new health care law.

    • @Samuel

      If we, and every other country in the world, had a single payor system that would not stifle innovation. The reason we create these advancements is because they sell not because we have private insurance.

      Your entire post is invalid because you don’t understand this.

      The reason these other single payor systems are cheaper is because there are 20 people suckling off the tit of our health insurance system for every 1 person in europe.

      Hell, I am one of them. I work for a company that wouldn’t exist if we didn’t have such a ridiculously complex insurance system. Our key product that generates 90% of our revenue is successful because it does an excellent job of abstracting out the insurance portion of the healthcare billing process. Our practices are able to basically treat billing like a single payor system because our practice management solution is that good. But the average practice that uses our system pays 100K a year. That’s 100K that is transfered to patients and wouldn’t exist in a single payor system.

      This is the crap that needs to be eliminated. The innovation will persist because there is still plenty of money to be made in innovation. All us progressives want to do is fix the insurance aspect.

      No one should make a profit off the suffering of others.

    • @John – you beat me to my comment! The interpretation of that 3rd figure is really dodgy.

    • Thanks to Samuel for giving me a glimpse into the conservative mind. Most conservative minds I know tend to remain so closed, it’s hard to follow the thinking. I do have one tiny little question, though. If the pharmaceutical industry has been so heavily subsidized by the U.S. government for “the cost of development, risk and research” (and it certainly has been subsidized), why does the industry turn around and charge all of us taxpayers outrageous prices for the very pharmaceuticals we’ve already paid for with our tax dollar subsidies?

      It sounds strangely parallel to the story of how we taxpayers give (actually our conservative politicians SPEND) billions of dollars in subsidies to petroleum companies who still turn around and charge us enormous prices at the gas pump. Wow, do we love paying not once, but twice and sometimes many times more for what we enjoy in America! Business is king because who else is going to line the party coffers for the next election. The Supreme Court has granted corporations permission to spend as much as they like to buy as many politicians as they like.

    • @Tyson and @John

      Stop. There’s nothing misleading about the charts at all. It’s not “dodgy”. Of course the y-axes are different. The number of people who die of ALL cancer is much greater than the number who die of breast cancer or colon cancer.

      If you don’t believe me, go look at the OECD data. But here are the numbers anyway. Let’s take 2004 as an example. In that year, mortality in the UK (which had the highest mortality) was about 24% higher than the US mortality. For prostate cancer in 2004, mortality in the UK (which had the highest mortality) was about 40% higher than the US mortality.

      But for all cancer in 2004, mortality in the UK (which had the highest mortality) was about 9% higher than the US mortality.

      That’s tighter clustering, No matter how the chart is made.

    • Samuel,

      Their are large pharmaceutical companies in Europe, so the gain goes both ways

      And on your last paragraph, the US Navy uses the Harrier which weren’t developed in the US!

    • @Aaron Carroll

      Disagree. First, “clustering” is an mal-applied term in this context, but that’ besides the point.

      What the author is drawing the attention of the reader to, based on the data provided in the article, is the graphic; and the spread in the data in the numbers is about the same, while the graphical representation is “tighter.” That’s all.

    • @John

      Um, I am the author. And I’m telling you what I meant by tighter clustering was that there was less spread (difference) in the mortality due to cancer than you might think. There’s more of a difference in breast and prostate cancers, but that’s cherry picking. We do worse in other cancers, so the overall differences are less.

      The spread is NOT the same. There’s a might higher percentage difference in breast and prostate cancer than there is overall.

      Should I made the y-axis cover less ground to make a smaller percentage look bigger?

    • @Austin: ” We do this kind of thing daily. Not always take downs, but evidence based and policy relevant. It’s what we do.”

      I’d sure love to see some evidence based and policy relevant takedowns of dishonest health care related op-eds from Democrats. Both parties are equally shameless on this.

      • @AB – I have done it! Biden once opined that the Cadillac tax is just a tax on insurance companies, not individuals. Well, technically OK, but in full honesty, no! I called him on that. We have slammed the Obama administration for rolling back the MA cuts. I routinely talk about the insufficient cost cutting of the ACA. I call it like I see it. I noticed you didn’t list any links to recent op-eds you think are “dishonest”. I’m sure some come to mind. Let’s have it. What? (I don’t doubt you can list them. I want to know what they are. Don’t assume I read everything. I do not. I miss stuff.)

    • Jeff

      Good points but the innovation that Samuel seems to think will be hindered under universal healthcare is more of a problem with the free market and its need to maximize profit resulting in the cheapest solution. e.g. US hospitals still use tubing that permit dangerous connections, a design that been designed out in Europe.

      source: Nursing: November 2010 – Volume 40 – Issue 11 – p 59–60
      “Staff at a facility were considering switching to an enteral-only feeding tube set. They evaluated one such product on the market and found that, although the label stated that it was a non-I.V. compatible connection set, I.V. tubing was easily connected to the system.”

    • Arguing about the charts used here is to lose sight of the fact that Johnson just cherry picked a few stats where the us does better. It is a dishonest form of argument to begin with. That Japan, with a universal system beats the us on all of his cherry picked metrics only highlights the emptiness of the right’s potion here.

    • @John The usual measure of clustering would be deviation expressed as a percentage of the mean value. You are talking of absolute deviations, which is the wrong way to do it. Both graphs have the zero point shown, so the eye can see intuitively the deviation compared to the average values. If neither graph had any numbers on the vertical axis, we could still say the second graphs shows “clustering” round the mean for each year.

    • Ab: both parties are not equally dishonest on this. There is no Democratic lie equivalent to “death panels.”. Johnson didn’t use the phrase, but made sure to include the idea nonetheless.

    • Using mortality rates seems inappropriate. In evaluating a health care system, shouldn’t we be concerned with the expected number of years of life remaining given that a person is diagnosed with the cancer in question? Different countries could have different cancer mortality rates for reasons completely unrelated to health care.

    • “Those in need of timely care from specialists are better off in the U.S. ”

      This is Senator Johnson’s cruelest argument. What timely access to ANY healthcare to the 50+ million Americans without health insurance have?

      What access to EXPERTS do the tens of millions of Americans with minimum health benefits have?

      I’d like to know how long the “wait time” is for all these people. In DC they ran a free colonoscopy clinic and 1/3 of the (uninsured) people who came in had pre-cancerous lesions. So if you are uninsured in America your timely access to an expert is whenever someone runs a free clinic.

      • Mortality: stop the silliness! Life expectancy after 65 isn’t so hot in the US, and that has nothing to do with how infant mortality is figured. See http://theincidentaleconomist.com/wordpress/how-flawed-is-life-expectancy/ .

        There are many other quality measures that show the US system to be not as good as some think. See http://theincidentaleconomist.com/how-do-we-rate-the-quality-of-the-us-health-care-system-introduction/

        Want a detailed look at what we pay for that quality, see: http://theincidentaleconomist.com/wordpress/what-makes-the-us-health-care-system-so-expensive-introduction/

        Still think we’re number 1?

        • One additional point on the issue of quality.

          Although raw death rates overall and from specific diseases are valuable because they are easy to access and are indisputable, they are colored by the underlying prevalence of various conditions in the population, a figure that is heavily colored by factors not managed through health care (poverty, eating habits, smoking, drug and alcohol use, etc.)

          A more interesting question is how well the health care system does in managing various illnesses once the patient presents to the system. In other words, if you walk in with some problem, what are the chances that you will walk out and how long can you expect to do well after that?

          That is less easy to get hard data on, but what hard data there is makes the US look even worse than the estimate that Aaron gave in his series. In measurements of outcomes of patients presenting with various diseases, the US generally ranks dead last in almost every category except cancer — a measure that is also biased by the high levels of early detection in the US.

          Granted, there are issues that color this measure as well, especially the relative severity of disease at the time of presentation, something that is effected by underlying population factors and by the fact that the US health care system generally uses financial incentives to encourage many people to wait longer before getting care compared with other systems. However, this is one more piece of evidence that the US does not have the best health care system in the world nor the most effective care.

          As Aaron points out, we do have the most and best expensive machines and the most expensive care, however.

    • I came here following a link from a Paul Krugman blog piece today.

      My take, as a retired physician (practitioner, FDA medical officer and clinical researcher in the pharmaceutical industry) is that the graphics suggest our results in the cases the Senator put forth are similar to Europe and Canada and inferior to Japan.

      My opinion is that the pharmaceutical companies have been able to make good profits not because of great innovations in treatments of serious diseases but because of excellent marketing skills. Ideal medications from the industry’s point of view are not curative but rather ongoing use throughout the lifespan – often for risk factors rather than diseases (elevated blood pressure, hyperlipidemia), since these maximize income. Recently, the industry has emphasized treatments for non-diseases (menopause, erectile dysfunction).

      For no rational reason, the US has maintained a generous attitude towards the pharmaceutical industry, at significant cost to the US population. Unlike other developed nations, there has been few negotiations on a national basis of the acceptable price of a drug in the US.

      Comparison of the pricing negotiated by the Veterans Administration (VA)versus the median price paid by Medicare patients in a 2004 study of the costs of the 20 most prescribed drugs demonstrated almost a 50% lower cost for the VA.

      I don’t think that the citizens of the US with 5% of the world’s population should be responsible for “subsidizing” the for profit pharmaceutical industry. Note that the industry spends more on marketing than on research, and that most research has not been trail-blazing new therapeutics but modifications of approved drugs to improve its competitiveness and extend “exclusivity”.

      It is unreasonable to maintain a non-system of disease care in our country, because it costs too much and leaves out too many people. The reform bill doesn’t go nearly far enough, but it represents a small step forward in my opinion.

      As a retired doctor, I practice nowadays at “free clinics”. I don’t get payment (and luckily don’t need any income at this time); some of these clinics are completely without charge, while others have had to implement fees. The continuing need for “free” clinics in our wealthy nation is a shame and a blot on our moral stature. Senator Johnson apparently didn’t include that in his description of the wonders of “free market” disease care.

      • I was waiting for someone to point out the obvious logical flaw in Samuel’s argument about innovation. Even if it is true a potential for greater profits in this country furnishes pharmaceutical companies with greater incentives for innovation, why would you assume this additional innovation would be aimed at producing the drugs which most benefit society?

        On the contrary, you would assume that innovation would be aimed at producing drugs which result in the greatest profits. Thus, diseases and other afflictions which occur more often among the poor and uninsured would get LESS attention than conditions which disportionately affect the more afluent and insured.

        Research into drugs which are associated with popular elective surgeries, or with non-life-threatening conditions like ED (not to mention “quality of life” drugs), are going to get a larger share of the revenue pie. Drug companies aren’t stupid, nor should we fairly consider them altruistic. They will go where the money is, which is often the last place you would want to go if you want to improve the overall performance of a society’s health care.

    • I also think that the graph are misleading, but not in the same way.
      As Nathan commented just a few post above, these graphs show the overall cancer mortality, which depends on a lot more of factors than just the quality of care provided.
      The real question is not: ” For 100 000 women, how many will die of breast cancer?”, but rather: “For 100 000 women with a breast cancer, how many will die because of that ?”

    • For everyone complaining about mortality rates, and suggesting survival rates are a better measure, I ask you to go read this:


    • I hope you submitted this to the WSJ letters page. Why hide it here?

    • Actually, the charts are “skeezy” not “dodgy”. They were clearly done in Excel (the horror!) and that color scheme(!). Gah! Don’t even get me started on the font choice. Nothing says Marxist, pink-o, socialist, facist, commie like Arial (I said don’t get me started!!). Jesus created serifs for a reason.

      And the data clearly shows “bunching” not “clustering”. Liberals. Bah.


    • Hey Samuel,
      I agree with tanstaafl,
      I suppose you didn’t know that Germany generates more new pharmaceuticals [INNOVATTION] per capita than the US?
      (that stat. from an article in The Economist.)

    • @Aaron
      Thank for the link.

      This is an off-topic question, but I looked for some data on breast cancer here:

      And I have some trouble to understand why there seems to be no direct relation between incidence and mortality (figure 1.3)

    • Another huge hole in his “argument”: he presumes that “free-market competition” will necessarily bring down health care costs. But as Harvard innovation guru Clayton Christensen has shown, in health care competition is actually driving costs UP.

      Here’s what Christensen wrote in a March 2010 Business Week column:

      “Economists are wrong in asserting that competition controls costs. Most often innovation and competition drive prices up, not down, because bringing better, higher-priced products to market is more profitable. Hospital-vs.-hospital competition causes providers to expand their scope and offer more premium-priced services. Equipment suppliers boost the capability and cost of their machines and devices. Drugmakers develop products that bring the highest prices. It’s because we have such competition, not because we lack it, that health costs are rising by 10% a year.”

    • @Monsieur Paul

      There is some relation, but you’re right it’s less than you might think. A lot of the discrepancy has to do with what constitutes a diagnosis. If you do a lot more screening and a lot more surveillance, you will pick up some breast cancer that might never have progressed or killed. So you have a higher incidence, but no increase in mortality. You improve survival rates, but not mortality rates. Again, I encourage people to read:


    • On foreign vs. American medical innovation:

      It would be useful for people talking about medical systems and medical innovation to actually know about what is going on. I am a retired physician and know a bit about this.

      The following medical devices and procedures were developed in Europe or Japan under their horrible socialized systems then adopted in the US:

      The modern mammogram machine
      The CT scanner
      The modern helical CT scanner
      The MR scanner
      The modern technique for angiography
      Angioplasty and stent placement
      Most minimally invasive radiologically guided treatments
      Modern endoscopy
      Laparoscopic surgery
      Modern spine surgery techniques
      Key classes of drugs too numerous to mention
      etc. etc. etc.

      On a per capita basis, most Western European countries and Japan are far ahead of the US in development of health care innovation. In fact, apropos Senator Johnson, the major center of innovative study of congenital heart conditions and their management and treatment is the noted socialist haven NORWAY. When a friend of mine became a specialist in the sturdy of congenital heart disease, the Mayo Clinic (that’s THE MAYO CLINIC) sent him to Norway for a year, since as his employer they wanted him to receive the best possible training.

      Even then, most innovation in the US is government sponsored, paid for by government financing and done in government owned institutions. The US private drug industry actually spends more money on TV ads than on research.

      The US excels most clearly in the extraction of money from health care by drug companies, equipment makers, hospitals, and providers because they function in a massively fragmented market with no effective counterweight to their power, such as exists in all other developed countries. As a result, we pay over twice as much, both in absolute dollars per capita and in percentage of GDP, and get worse overall results. Right wingers always cite cancer data in this argument because it is the only bright spot (and there are some arguments that it is not all that bright.) However, take a look at data on trauma, heart disease, asthma, lung disease, kidney disease, GI disease, and so on, where the US consistently is last or next to last against all other developed countries. In fact, in one of the most telling bits of data, it turns out that people in the lowest income quintile in Britain get better overall health results than people in the highest income quintile in the US.

      Most of what conservatives cite about US health care quality is a result of swallowing the propaganda of the health/industrial complex without examining it, or the naive belief that expansive and high tech is always better.

      Please excuse the rant, but this very wrong idea always makes me crazy.

    • I agree the lack of epistemological discussion on this topic by those who should spear head it is appalling (both republicans and democrats but particularly republicans.) Looking at the data Mr Carroll presents and it’s entirely believable I think the differences are so small as to be statistically insignificant. If they are significant I bet only just so. For all countries the trend is heartening and the Japanese results suggest there is more than just treatment involved. I have not read the papers though. The numbers Senator Ron Johnson presents are absurd. Where did he get them? I cannot find them in Lancet (and even if they are there I bet Ron Paul misinterpreted them.) As for stifling creativity and, as one who works in medical research I suggest there are two principal places that research and creativity are found. The drug companies and the universities. The latter who depend on the NIH for funding are likely to see their funds diminish if the republicans have their way and cut the NIH budget (democrats are not blame free here.) The NIH, besides providing a very big bang for the buck have a remarkable history of success in providing treatment for a variety of diseases (heart disease and aids come to mind). I imagine cutting their funds could do significant harm to medicine. It is far from clear that abandoning Mr Obamas proposals will have the opposite effect.

    • @Aaron: Survival rates can definitely be problematic and/or misleading depending on the amount of screening and the timing of the screening, but mortality rates are definitely not much better if we’re trying assess quality of care. We have to be able to control for varying levels of incidence, otherwise mortality rates tell us very little about the quality of care received.

    • More on innovation and location: a Seattle startup I’m aware of developed affordable technology to increase the safety and efficacy of bagged blood products. The big U.S. manufacturers essentially shrugged. So they went to Europe and Canada and found willing research partners (government-sponsored, naturally) to help verify their claims and develop the technology for commercialization. As a result, patients in other countries will see the benefits before Americans do.

      • India is one of the few countries inthe world where women and mevhane nearly the same life expectancyat birth. The fact that thetypical female advantage in lifeexpectancy is not seen in Indiasuggests there are systematicproblems with women’s health.Indian women have high mortalityrates, particularly during childhoodand in their reproductive years.

    • Johnson also uses the all-too-common rhetorical tactic of conflating insurance with ownership of/restrictions on health-care assets.

      In France, the UK, etc., doctors can operate outside of the government health care system. If you are a great heart surgeon in France, you do not have to take the government’s prices and can accept cash-paying customers only, or those with private insurance that reimburse better. Want the best quality, or immediate service? By-pass insurance by paying cash.

      Same with the US: no one is saying that any private health-care provider in the US has to take Medicare or any other kind of insurance, government-provided or not (of course, conservatives try to make others think that’s what people are saying). If you as a doctor don’t like Medicare’s reimbursements or don’t want Obamacare, opt out. Take cash customers only.

      How ironic that libertarians complaining about Medicare reimbursement, etc never advocate this. They are just special pleaders for the USG and taxpayers to pay them a higher price..

    • As a dual citizen who recently moved back to Canada after 18 years in the US, the absolute first thing I obtained on Day One of my eligibility was my government health care card. I still roll my eyes at the reports that many Americans still don’t like the Act, which I presume is largely based on ignorance and fear. Frankly, I don’t like it so much, since it didn’t include a single payer system alternative, but it is much better than the status quo. Meanwhile, to take Charlton Heston out of context, you’ll need to pry my Ontario health care card out of my cold, dead Canadian hand… which will statistically live a couple years longer than my American one.

    • @Michael and Aaron,

      Hi Aaron, didn’t realize you were the author.

      I am honestly not trying to pick a fight, and I’m not a troll. But I disagree on the argument per the graphics.

      Aaron says:

      “Should I made the y-axis cover less ground to make a smaller percentage look bigger?”

      Michael says:

      “You are talking of absolute deviations, which is the wrong way to do it. Both graphs have the zero point shown, so the eye can see intuitively the deviation compared to the average values. ”

      My response is “no,” and “no, I’m not,” respectively.

      The data plotted are rates, not absolute values. That is, they are first-derivatives, the number of cancer deaths per 100,000, not the ‘absolute’ number of cancer deaths. More correctly, they are the first derivative of the ‘absolute’ numbers.

      I used elementary graphical analysis to determine from the charts, that for the year 2004 (pick a year), the difference in the mortality rate, US v. UK, is 7.4 deaths per 100,000 for prostate, 6 for breast, and 15.7 for all cancers. So, not only is the so-called clustering not tighter, the ‘spread’ of death rate due to all cancers for US v. UK is greater!

      Without taking a position in this issue, I’m just saying – the presentation is misleading, e.g., there’s no reason to show the zero point on the y axis when it expresses a rate; and, the conclusion drawn from a visual analysis is wrong, and is contrary to your case.

    • It doesn’t help Johnson’s “innovation” argument that the procedure that saved his daughters life was developed in the single-payer socialist hellholes of Canada and Brazil:


    • @John–

      I think that you have a different idea of what clustering means than some other people. It is not terribly surprising that the absolute number of deaths/100,000 is greater for all cancers than any particular cancer because so many more people die of all cancers than any one type of cancer. Let me use an extreme hypothetical example (not the real rates, admittedly). Assume that for one cancer (e.g., protate or breast cancer) the rate in the U.S. is 5 deaths/100,000 and in the U.K, it is 10 deaths/100,000. Now assume that for all cancers (including all kinds of cancers) the death rate in the U.S. is 500 deaths/100,000 and in the U.K. it is 520 deaths/100,000. In your view, the depiction of the death rate for all cancers is “less clustered” than the single cancer rate because 20 (520 – 500) is bigger than 5 (10 – 5).

      I strongly disagree with this concept of what “clustering” means. In my view, the depiction of the single cancer rate will show–visually–that the U.K. rate is double the U.S. rate, so the distance from the X axis to the U.S. data point will be as large as the distance from the U.S. date point to the U.K. data point. On the other hand, the depiction of the overall cancer rate will show–visually–that the difference in rates is not very large (only 4% greater in U.K. rather than 100% greater for the single cancer rate), and thus the distance between the X axis and the U.S. data point will be much larger than the distance between the U.S. data point and the U.K. data point. Thus, even though 20 is a bigger number than 5, the overall cancer rates (520 v. 500) will be more “clustered” than the single cancer rates (10 v. 5).

      I hope this hypothetical example clears up the confusion over why others believe that the graphs above are not misleading, and that even though the absolute number for the overall cancer rate may be higher, the results still may be more “clustered” than for a single cancer rate. The issue is one of percentage differences–not absolute number differences.

    • Great analysis. How about some additional metrics, infant mortality rates, expected life span, to think of a couple..

    • Unless I have missed something, there appears to be something wrong with this site. It tells me that there are 52 comments to this post but will only let me see what seem to be the last two, from zzz and steve Chicago.

    • @Rob Lewis–

      I am seeing the same thing. All the earlier comments (which I read ealier today when they were on my screen) have now disappeared and only comments starting with my response to John are showing up. It seems to be a website error. Hopefully it will be corrected soon.

    • According to Wikipedia, Senator Ron Johnson chose a public option for his own education. He chose to attend a government-financed, government-managed, government-controlled public university, even at the risk of being educated by liberal academics. It does not seem to bother him that he obtained and has greatly benefitted from his higher education received at taxpayers’ expense.

    • First of all, I have fixed things so all comments should be viewable.

      @Steve, I encourage you to read my series on quality in the US health care system!


    • PROMISED Single-payer or Obamanible single term(ination)!

    • RE: Getting more people insurance is the whole point of the PPACA?
      If so, why did it take nearly 2,500 pages to spell it out? A minority of those pages dealt with getting more people insurance. In that minority of pages is sloppy, disjointed lawmaking. The rest is lard and legislation wholly disconnected from “the whole point.”

      What provisions there are seem designed to push individuals and employers toward making government-provided health insurance the preferred (and eventually, only) decision. These points, and the fact that the bill was pushed as the nation slept during the last days before Christmas, are the main reasons the law has garnered such vocal opposition.

      PPACA is laden with junk. When passed, it was a triumph of shell-game accounting. It appears to be Constitutionally flawed, perhaps fatally.

      There are strong reasons for working toward government-sponsored health insurance system. There are equally strong reasons to be concerned about it. There are even stronger reasons to toss PPACA in the trashcan, start over with a clean slate and write a bill that resolves the issues, honestly and transparently. Which was the main message from the outcome of the 2010 General Election.

      Unfortunately, if the two sides cannot even admit that the other side has points worth considering, discussing and debating – which way too many commenters here and elsewhere have demonstrated – no solution is pending.

      That is no good for anybody. And that … is the whole point.

    • I think it might be helpful to reflect on the following “facts,” which are put forth without a claim to absolute certainty, but with some claim to a reasonable probability.

      1. Senator Johnson did not write his Op-Ed piece. He may not have even seen it until it was published in the WSJ.

      2. A staffer “wrote” it.

      3. And that means that the staffer, given the assignment, went to one of the PR hacks for hire inside the Beltway to write it. Probably there were phone calls to Cato or Heritage, or one of the usual suspects asking for help.

      4. Those “think tanks,” which are for the most part shills for corporate interests, then wrote it up, or probably themselves farmed it out to some recent Harvard or Yale graduate trying to make it in Washington and who votes Democratic himself anyway. But heck, gotta pay the rent. And do it on deadline. So get to the ole Google and cherry pick away the way you did your Senior Thesis.

      5. Or, and this is equally probable, this was actually initiated by a lobbyist of one sort or another whose job it is to bash “Obamacare,” and who hit upon Senator Johnson’s story by chance at a cocktail party — when he was actually trying to hit on something else — and saw a neat way to use Johnson as a willing tool for the cause — that would be the cause of keeping himself in tasseled loafers.

      6. Meanwhile Senator Johnson, Citizen Johnson at the time, took a nice corporate tax deduction — as well as his own individual tax deduction for whatever he paid toward the premiums — for the gold-plated insurance that he had as a function of controlling his corporation.

      7. Now that he is in Washington, he wants to set about cutting down on the possibility that others “less enterprising” than himself will enjoy the same sort of coverage for their daughters — not to mention, with his buddy Paul Ryan, for their fathers and mothers who are totally dependent on Medicare.

      A Republican like Johnson is somebody who tells himself stories about how he did it all on his own with no meaningful contribution from social capital and who thinks the Social Contract is something you take out on those who would “steal our hard earned money through taxation — except when our own tribe benefits — keeping in mind our Second Amendment rights.”

    • The 2010 elections were NOT so much about PPACA (or Cap & Trade) as the large unemployment rate which, while not at the 14% or higher it could have been without the stimulus, was NOT coming down. The worry about what would happen upon a job loss with rampant house foreclosures around the nation was palpable.

      The lack of progress on the job front was the major problem and it kept Democrats (particularly the young) from voting as they had in the 2008 elections. And that youth group is the the cohort that is paying the big price in lost income that will follow them for the rest of their lives.

    • @Bob Beasley–

      The PPACA is not a perfect piece of legislation–no legislation is. But if you are going to assert that it is “laden with junk” it would seem to me that you should give a few examples. The legislation also was not “pushed as the nation slept” as you assert. It was debated and negotiated and drafted over about a 1-1/2 year period. The portions done in private were primarily done among small groups of Dems and Repubs (remember the “gang of 6”), which ultimately went nowhere because the Repubs were never going to agree to anything. The rest was just the legislative process. You just don’t like the result–stop blaming process when you should focus on substance.

      The reason that the legislation is so long (and the number of pages is a bit misleading) is because it does not work to simply say “Thou shalt provide health insurance to all people.” Once insurance companies are required to accept all people, no matter how sick, the mandate becomes an important method to make this affordable to the insurance companies (“free riders” should not be able to get insurance at the “last minute”). The mandate dictates the need for subsidies to low income people. These costs then required coming up with ways to raise revenue so the act would be deficit neutral (at worst–in fact is is “scored” to reduce the deficit). The exchanges also became necessary to faciliate the increased number of people going into the individual market. Health care is a complex area, so complex legislation is not surprising.

      There also was an attempt to try to adopt programs to begin to bring down the cost of health care. The biggest driver of future deficits is health care expense. All of these pilot programs will not necessarily work, but we have to start finding out now what will work.

    • Here’s another presumably-deliberately-misleading statement by GOP Senator Johnson:

      For the first time in U.S. history, a personal inaction (not purchasing something, in this case, a health- insurance plan) will be deemed unlawful. The person not committing this act (or is it committing an inaction?) will be subject to a fine. Or is it now, as the government contends, a tax? I’m confused.

      This fallacy is the foundation of Tea Party-GOP law suits to upend Obamacare, that the Federal government can’t force people to buy products or services from private parties. Problem is, the first Congressional Congresses, comprising largely the Founding Fathers that wrote our Constitution did just that.

      In 1798, faced with problems staffing civilian shipping, our Founding Fathers and the rest of our Congress passed a health insurance bill requiring that civilian mariners buy health insurance.

      Nor, was this the first time that Congress required citizens (or at least, free, white males) buy a commercial product; the Militia Act of 1792 required that all of us have muskets, and expressed ordered those that did not buy one:

      But, heck, what did our Founding Fathers know about the U.S. Constitution compared to the Tea Party-GOP and Fox News?

    • Did Sen. Johnson’s daughter receive drugs as part of her treatment? If so, the odds are substantial that those drugs were developed with public funding–and that the pharmaceutical company has the patent.

      The Bayh-Dole Act effectively allows universities, non-profits organizations, and for-profit pharmaceutical companies to patent drugs they develop with federal funding. The patient thus pays twice: once when he pays the taxes that fund the research; and again when he pays a monopoly price for the drug.

      Did Big Gov’t pharmaceutical research save his girl’s life/

    • It strikes me that Aaron Carroll thinks very clearly.