• Best in the world! (at crappiness)

    The United States is in the midst of the most sweeping health insurance expansions and market reforms since the enactment of Medicare and Medicaid in 1965. Our 2013 survey of the general population in eleven countries—Australia, Canada, France, Germany, the Netherlands, New Zealand, Norway, Sweden, Switzerland, the United Kingdom, and the United States—found that US adults were significantly more likely than their counterparts in other countries to forgo care because of cost, to have difficulty paying for care even when insured, and to encounter time-consuming insurance complexity. Signaling the lack of timely access to primary care, adults in the United States and Canada reported long waits to be seen in primary care and high use of hospital emergency departments, compared to other countries. Perhaps not surprisingly, US adults were the most likely to endorse major reforms: Three out of four called for fundamental change or rebuilding. As US health insurance expansions unfold, the survey offers benchmarks to assess US progress from an international perspective, plus insights from other countries’ coverage-related policies.

    -Health Affairs, “Access, Affordability, And Insurance Complexity Are Often Worse In The United States Compared To Ten Other Countries


    • “Best in the world! (at crappiness)”

      When one sees this type of headline over and over again one has to recognize there is no balance in what follows.

      • Thankfully, reality does not heed balance.

      • Not sure this post lacked balance, so I disagree with your comment. I believe the title correctly refers to a very self-promoting culture in the US, with outcomes in many areas which do not match the aggrandizement. We’re not the worst country, but we’re culturally wired to overpromote a bit, which I believe blinds us to the realities we face. In healthcare, those are grave.

        • “Not sure this post lacked balance”

          Of course it did Chris.

          Though some argue differently the US has some of the best healthcare in the world. I wouldn’t have added the words “at crappiness” because that isn’t true even if one wanted to argue that some other countries were better. As I said that type of statement immediately shows a bias because there are many that would obviously fit that definition “crappiness” and the US isn’t one of them.

    • Comparing US healthcare to the rest of the world is important for medical competence as well as cost. I know you dislike personal anecdotes. but my personal experience with US spine care leads me to believe that our unique combination of healthcare greed, medical lawsuits, and Dr. protectionism results in the worst spine care in the civilized world.

    • US adults were significantly more likely than their counterparts in other countries to forgo care because of cost

      This is not bad in all cases. Assuming as I do that you cannot subsidize the median person, if a procedure is not worth he cost to the median person perhaps it should not be done.

      • It’s got to be bad in pretty much all cases. Patients are not experts in medicine, and simply don’t know when forgoing care is a good idea. They’re not capable of making that decision. Asking people who don’t have any training to make decisions they aren’t capable of isn’t smart.

        It’s one of those “what could possibly go wrong?” sort of things.

        Real people have kids that need music lessons, a favorite winter coat that really needs replacing, and asking people with limited resources to choose is going to result in bad choices.

        • While you are correct, doctors do have information on their side, doctors will ALWAYS recommend all treatment and testing, whether it makes ‘sense’ or not, and regardless of cost or even benefit. Often, the best thing to do is wait and see, but the hospital will order a couple of MRIs and a lumbar puncture with a few days in the hospital, just in case.

          So you have the consumer who is not the payer, who doesn’t know what they should really buy, but who has a fear incentive (not necessarily wrong) to buy something; the seller who is not the payee who has that information but an incredibly strong incentive system to make the patient buy everything (lawsuits, humiliation, and a genuine wish to help); and a payer, the insurance company, who is not part of the above set of information and decision making.

          No wonder, this goes poorly. It’s really not a market at all.

          • Chris, ALWAYS is a dangerous word to use as “always” and “never” are frequently not true descriptors. Maybe you don’t ALWAYS know why something is done. Lumbar punctures are generally done to rule out diseases that can quickly kill. I bet some extra lumbar punctures are done because of malpractice concerns, but other than that I doubt that physicians do lumbar punctures just for the sake of doing them.

            But, all this is very easy for you to solve. 1) Don’t go to a doctor or a hospital or 2) If you do go sign a paper refusing the test or procedure. Above your signature will be an explanation why the physician thinks it is necessary. Then you can decide. No one will do these things without your permission.

            “It’s really not a market at all.”

            You are correct. There has been no free market in healthcare at least since WW2 so you are right to say what you did and not blame the market place for so much chaos. What we have is a hybrid and what we see is that year by year the market forces decrease and year by year the costs rise. I have to agree with what I think your sentiments are, this is crazy.

            The problem we face today is that we created a healthcare program that is terrible. Sometimes it seems to have taken the worst of ‘Medicare for all’ and the worst of the ‘market place’ and put them together. We are starting to see the ACA unravel as we watch.

    • I don’t know. Did you see the story about the 500 lb French kid? His parents brought him to the capital of obesity care for treatment. We certainly have that field all sewn up.

    • Another example of posts offering false dichotomies. The solution to Amerika’s healthcare incompetence and inferiority is NOT to punish the Amerikan people by introducing socialist policies of other countries, but to take advantage of the wonderful and cheap healthcare offered in Cuba, Mexico, Costa Rica, Brazil, Colombia, Prague, Budapest, India and Thailand.

      They offer what we need at a fraction of the cost in the USSA.

    • US adults are most likely to endorse major reforms right up until the moment when it looks like their own situation will be changed.

    • Maybe the title was a bit “in y our face”, but the facts are there. Physicians practicing in many parts of the US, know this all too well. When you make someone with limited income choose between a screening colonoscopy or a mammogram, and putting food on the table…food always wins. I work in a non-profit hospital now, so no one is refused care. But I worked in a small private practice before, and we had no choice but to send the un-isured or under-insured to the closest non-profit (which was 200 miles away). What are the chances of someone that poor (and by the way still not qualify for medicaid) to be able to travel 200 miles every 2-3 weeks for chemotherapy??? By the way this has nothing to do with ACA…This was back in 2006-2007, when everything was nice and rosy.

      • Danny what you say might be true, but those people generally qualify for Medicaid and food stamps, But, there are always those that fall through the cracks so it is something we have to be on the lookout for.

        What we should not do is base a health plan on the needs of the poor and needy. They will require subsidies no matter what type of health system we have. That has been a problem with policy making. We join two different groups together when they require two different solutions though in the end we could and should integrate the poor into the health system meant for everyone else. Programs set up like Medicaid are bad because they prevent that type of integration from happening.

        • Emily,

          Medicaid does cover some of those patients, in some states. Unfortunately the poorest states also have some of the strictest criteria for medicaid income eligibility. (ex: Mississippi, Arkansas,…etc). So many of the poor just do not qualify.

          I’m not sure i understand what you are proposing. How do we have two separate systems for the “two different groups” …. and then integrate the poor into the “health system meant for everyone else”. ?

          The author’s claim is not something he invented. The USA, in terms of health outcomes, performs pretty poorly by most measures. Most industrialized countries do better than the US in most cancer outcomes. in heart disease, in infant mortality, in maternal mortality, in life expectancy, not to mention access to care and cost . We apparently do great in treating Colon cancer, but not so much in anything else. We might have great Hospitals and lead the world in specialty centers, but that does not change the big picture.

          • You might believe the US health *outcomes* perform poorly, but that is not true. What you probably are looking at is WHO which doesn’t compare outcomes. It compares many things and combines them together into a number. Many of these things have nothing to do with the different health care systems and very little if anything to do with outcomes.

            Infant mortality: Is WHO still measuring that? Many recognize how bad the WHO rating is and I thought they were going to stop with that nonsense. They may have done so already. I don’t know.

            Look at infant mortality based upon what a health care system can actually have impact upon. Low birthweight deaths. The US is the best in that area. A bunch of nations lead the top listing at normal birth weights where the system doesn’t matter that much. A baby can be born in a bathtub at home and many people have done so intentionally.Thus it is hard to conclude that the US is bad at least in the area of mortality that occurs shortly after birth.

            I’ll finish with cancer outcomes. There are very few studies of cross national cancer outcomes. The best and most well known is Cancer survival in five continents: a worldwide population-based study (CONCORD). If I remember correctly there were 8 components to that study. If one added the placement of each of the 29 countries (excluding Cuba), adds up the numbers and divides by 8 to get a global placement of the best overall outcome the US comes in number one at ~1.4. Australia follows at number ~3.4. This study compared the “totally insured” (or however you wish to classify those others) countries to the US insured and *uninsured*.

            • “You might believe the US health *outcomes* perform poorly, but that is not true.”

              There are numerous posts on this blog on quality of of US health care. Unfortunately for you, those post have already refuted both your examples.

            • Steve H “those post have already refuted”

              Do you not recognize the difference between opinion, fact and a study?

              Do you not realize that on this list you have essentially read only one or a very few person’s opinions on this subject which is inadequate for a conclusion to be drawn?

              The CONCORD study itself is evidence. Where is your evidence? You don’t have any so you didn’t post any. Not good.

              I would be the first to admit that I can poke some holes in almost any study, but its hard to poke holes in this study that refutes the implication of the above title, “Best in the world! (at crappiness)”.

              As far as infant mortality is concerned all one has to do is look at the statistics when birthweight is compared. There is very little dispute regarding these numbers and they show the US to be best in the world at treating the very low birth weight infant. Ask the neonatologists.

              I will await some proof from you. Simply repeating another’s opinion and then generalizing it the way you have marginalizes the opinion of the one initially making it.

            • I don’t think CONCORD provides convincing evidence since
              the metric for comparison is survival and not mortality

            • From this blog: The zombie infant mortality explanation
              Which quotes from a study finding, “The high rate of adverse birth outcomes in the United States does not appear to be a statistical artifact, such as a difference in coding practices for very small infants who die soon after birth (MacDorman and Mathews, 2009). Indeed, country rankings remained identical even when Palloni and Yonker (2012) recalculated the rates to exclude preterm births (less than 22 weeks of gestation).”

              Or why survival rates are not an appropriate measure of health care performance. “Survival rates are really problematic when you’re trying to discuss improvements in mortality, or compare systems.”

              As concerns LBW, Emily wrote: “As far as infant mortality is concerned all one has to do is look at the statistics when birthweight is compared. There is very little dispute regarding these numbers and they show the US to be best in the world at treating the very low birth weight infant.”

              Treating LBW newborns is undoubtedly an area, like treating gunshot wounds, where the US health care system performs better than other countries. That’s not exactly something we should be proud of since, like gunshot wounds, a great deal of our expertise is due to the fact that we have more LBW births than almost any other developed country in the world. (Surprisingly, <a href="http://www.oecd.org/els/family/CO1.3%20Low%20birth%20weight%20-%20updated%20081212.pdf"Japan’s rate of LBW is the same as ours, but their infant mortality rate is much lower, which may mean they have the best health care in the world!)

              Of course, a real health care “system” would do more to systematically prevent LBW births since that would save money and lives. But, I suppose, that would be socialism.

              Likewise, asking why the US has such a high rate of people who are wounded or killed by guns and what could be done to reduce that problem rather than treating people after the fact would be more useful. But that may be socialism too.

          • Medicaid is what I referenced in my reply so I separated this comment from the comment on outcomes directly above. I don’t think many disagree that Medicaid is not good insurance. Because of the ACA, all sorts of rules and regulations, etc. we will probably end up seeing a lot of people lower on the economic ladder lose their insurance which provided good health care. They will be placed into Medicaid through no fault of their own.

            In my mind this is a terrible development and unfair to them and to others trying to better themselves that are on Medicaid. Medicaid is totally subsidized so I would like them to have the opportunity, if they like, to use that subsidy like cash to purchase a better policy.

            • You mean an approach like the Arkansas plan for the
              Medicaid expansion? I am interested to see how that goes. I hope it
              proves to be a significant improvement.