• Priceless: Chapter 5 – ctd.

    For reasons that will become clear next week, I’m totally swamped. Therefore, I will not be able to keep up with Austin’s relentless pace through Priceless. I feel compelled to comment on one  thing in chapter 5, however.

    It’s a common trick to cherry pick one study, one year, one country, or one statistic where we shine and declare that we have the best health care system in the world. Or, to declare that because you fond a way to make the US look good, it’s “up for debate”.

    With the amount we spend, it’s crazy that we can even have a discussion. We should unequivocally be number one. We’re not. The way we get to say we are is by picking one country (Canada!) where “wait times” are an issue. Or, more commonly, we pick on survival rates.

    I’ve written about this over, and over, and over again. And still, people ignore what I’ve written and cite survival rates. They also do it in the same cancers (breast, prostate, colon), where they know we over-screen, and they know we focus.

    That’s cherry picking.

    We do not have the outcomes we want. There are any number of reasons for that, more than I have time for today.

    If you want to have a debate, fine. I’ve heard you. I’ve read what you’ve written. You have cited survival rates in certain cancers. I have written my replies to these citations and explained why we are cherry picking. I’ve shown what I think are better metrics. I have not talked past you, but engaged you and your arguments. I’ve thoughtfully considered them, and responded to them in detailed point by point analysis.

    Your turn.


    • Survival rates are excellent, but as Aaron says there is no one way of looking at things. I agree, but when one presents an alternative method other variables should be excluded. John did just that. On page 90 of his book he provides a before and after of mean life expectancy; before and after fatal accidents are removed. Suddenly the US looked great. I am not saying that is proof, for proof of any one issue would require an entire book. John just demonstrates the fallacy of some of the observations that have been used and exploited.

      These difficult issues have been discussed in many settings and when does in depth work one finds that survival rates are demonstrating a lot more than others would like to admit. Number manipulation and selection is common with other methods so one has to make sure of what the study is actually studying, health care systems or societal problems, etc. This type of number manipulation was used to show the US in a bad light with regard to infant mortality, but if one looked at the specifics one would note apples and oranges were being compared. Small example: Some nations don’t count the lowest birth weights as mortalities rather they count them as miscarraiges. Of course the number of infant mortality deaths might be reduced when they leave out the sub group that has the highest mortality rate. 

      One last issue. Healthcare is not just about improving lifespan or curing specific diseases. It is also about making life more comfortable. It is not comfortable waiting on line for a year or more to have gallbladder surgery when one is having intermittent excruciating pain. Talking about pain and comfort this country spends a fortune on it and most of it I guess is spent in the out patient setting. Some would like us to live and die like Spartans. That is not our lifestyle. We spend a fortune on entertainment, TV’s lattes, cars etc. Why can’t we spend a similar proportion on health care making our lives more pleasant?  

      • You should really read Matt Welch’s piece on health care in france. Matt is one of the senior editors of the libertarian Reason online magazine. Read this, and I thin you can better understand what Aaron means by cherry picking. John picks the countries with the worst wait times to make his case. However, we are pretty lousy on a lot of wait times also compared to quite a number of other OECD countries. IIRC, Japan actually has the shortest wait times. As Matt knows, wait times are shorter in France. He also notes how much easier it is to navigate their system. At least weekly, we get calls from patients who have not been able to successfully make it through the paperwork and complexities of our insurance system. We have had to deal with issues at our hospital where nurses accidentally ran up huge bills thinking they were seeing a provider that was in network when they were not. At any rate, read Matt. He is not a fire breathing libertarian loony. Have read him for years. (Disclaimer. I am a believer in positive liberty.)



        • Steve,

          Aaron says, “The way we get to say we are is by picking one country (Canada!) where “wait times” are an issue.” And then you go and pick France.

          One of the problems we always have is that many people cherry pick infant mortality and life expectancy as indicators of a nation’s health care system, when they clearly are not. In fact they say next to nothing about the quality of the health care system since both are mostly about other socio-demographic issues (education, income, drug abuse, violence, etc).

          Personally, I think the whole discussion of a “health care system” is misguided. We never talk about our “transportation system” or our “housing system,” or our “food system.” Why? Because none of them are really “systems” in any meaningful sense of the word. As a thought experiment, try to diagram our “transportation system” some time.

          What we do talk about is the problem some people have in accessing transportation, food, or housing and what can be done for those people.

          IMO, this is why discussion of health care are so often futile. We talk past each other. When I say “transportation” you may think about the traffic on the Interstate, while I may think about the frequency of trains coming into my station, and someone else may think about how dirty the taxi cabs are in their city. One person might say “transportation sucks” and someone else might respond, “No, it’s actually pretty good.” Both might have statistics and studies to support their view. How is it possible to have a reasonable discussion?

      • British Columbia wait-times (health care is a provincial responsibility)
        Cholecystectomy in all facilities: 50% receive tretment within 5.3 weeks. 90% within 21.6 weeks. Website has stats by hospital and by specialist. http://www.health.gov.bc.ca/swt/faces/Home.jsp;jsessionid=f16010b187769ca23bfaae6abea9

        BTW, what is the American wait-time for gall bladder surgery for an uninsured person who can’t afford the cost of the surgery and qualifies for neither Medicare nor Medicaid? Do American wait time stats include these patients?

        • Thank you. Well said. The debate of wait times is a bit specious when one considers an uninsured person’s wait time is indefinite.

          An under-insured person with an HSA might stress about incurring the unaffordabke out -of-pocket expense if he has the operation, or the physical complications if he does not. how do we measure that wait time?

          The carnage in the real lives of the uninsured and underinsured — how much is that factored into the analyses? No, we do not proceed irrationally. But if we do not allow the carnage on the ground to define our intentions, then what’s the point?

          Talking about what we would do in the event of a level 5 hurricane, and actually having to take action in the middle of one because our lives depend on it would yield two very different responses, I think.

          • Art writes: “The debate of wait times is a bit specious when one considers an uninsured person’s wait time is indefinite.”

            If you are asking how long the wait time is for treatment of an emergency or urgent hospitalization in the US I think I can answer that. The same length of time as the insured person  [citation EMTALIA Act 1986]

            • I am not talking about the ER. Cute.

              An uninsured person does not get equal access to necessary medical care. The wait is indefinite unless the condition becomes so critical the ER cannot dismiss the patient because he is not “stabilized.”


              Pick a story. They represent many millions. I’d be happy to talk about the realities of the so-called treatment in ERs and the “wait” that some people endure.

            • Re EMTALA: Nothing is perfect and neither are any systems across the world, but the high ticket acute and urgent problems requiring hospitalization are mandated to be treated without concern of financial payment. The penalties for breaking the law are large.

            • I am familiar with the links you posted and the laws regarding the emergency room. Of course that brings up all the inefficiencies of people waiting until they are so sick they must use the ER as first resort for medical care which is a whole other topic and not what my post was about .

              To ask why a middle-aged widow, for example, uninsured for 18 years unnecessarily loses the eyesight in one eye because she could not access healthcare in a timely manner, well….you get my point.

              (She even had a friend who would co-sign for the hospital bill. The hospital said, “No, too many do not pay. You’ll need cash or insurance.)

              This is a pretty typical example of a “wait time” — indefinite — imposed by our current system for those many millions who have “fallen through the cracks.”

              Just keepin’ it real…which is not to say the cat fight with Priceless isn’t entertaining as hell.

            • Art, most outpatient care isn’t that expensive, but of course some are caught in the cracks. However, is the answer first dollar care if we have a Medicaid safety net? First dollar coverage can increase costs tremendously making premiums go sky high and that also reduces the number of insured. Surely that is not what we want. Maybe we need to help the less afluent pay for their high deductible policies and perhaps even help them with their deductibles which would permit the market place to function making health care more efficient. 

              What should we do with the large number of uninsured that have assets and refuse to pay? Sue them and collect just like other businesses do. We don’t cover their gambling debts in Vegas and we don’t have to cover them here.

      • I’m confused by the Table on page 90. I can understand how the US life expectancy rises if people who die (prematurely) from accidents are not counted. Our gun and car culture may have something to do with that.

        But how can a country have a *lower* life expectancy if people who die from accidents are not counted? This appears on the Table to describe Switzerland, Norway, Canada, Iceland, Sweden, Japan, Australia, France, Netherlands, Italy, UK (slightly), Finland, Spain, and Greece.

        Does this mean that in these countries elderly people have disportionately higher rates of fatal accidents than younger people?

        John cites a American Enterprise Institute study that his footnote acknowledges was disputed by a Wall Street Journal blog. The WSJ blog reported that the AEI authors backed away from the study.

        The WSJ blog cites a footnote to the OECD Economic Survey: United State 2008, which reads, in the relevant part, the OECD says the statistics are wrong:

        “It has been claimed (Ohsfeldt and Schneider, 2006) that adjusting for the higher death rate from accident or injury in the United States over 1980-99 than the OECD average would increase US life expectancy at birth from 18th out of 29 OECD countries to the highest. In fact, what the panel regression estimated by these authors shows is that predicted life expectancy at birth based on US GDP per capita and OECD average death rates from these causes is the highest in the OECD. The adjustment for the gap in injury death rates between the United States and the OECD average alone only increases life expectancy at birth marginally, from 19th among 29 countries on average over 1980-99 to 17th. Hence, the high ranking of adjusted life expectancy at birth mainly reflects high US GDP per capita, not the effects of unusually high death rates from accident of injury.

    • You lost me here: “We should unequivocally be number one.”

      Compared to the rest of the OECD, we eat substantially more, we drive more (presumably we walk less), we injure and kill ourselves more frequently, etc., etc. And we are far more diverse.

      I agree that we spend entirely too much on healthcare for what we get, but even if we had far and away the best healthcare in the world, it isn’t clear to me that we’d have the best health outcomes.

      • RC, I believe you to be correct and it is difficult to see the difference in outcomes, but part of that might be due to the reliance of some on mortality statistics which do not take into account fatalities that you mention, genetics, social problems like drug abuse, etc. When studies are actually done on these things our outcomes substantially improve. But not only that our comforts improve as well.

        For years much of the western world was relying upon NTG to relieve angina while we were putting in stents. They yelled our mortality statistics weren’t good enough. Now, for some reason they too are putting in stents that they said were a waste of money and along with that their health care costs are rising.

        (ed. note — Per the policy, comments that make factual assertions, such as those in this comment (in bold), require evidence. This is your only warning. Subsequent comments with evidence-free claims will not be approved.)

      • Fun fact. It is a commonly held belief in Australia that we have overtaken America as having the highest rate of obesity in the world. I was going to point this out to RC, because it’s the type of news you wouldn’t hear about in American newspapers. But it looks like America might still hold the obesity crown.

        Here’s an example of the type of news articles we were getting in Australia:

        The report (“Australia’s future fat bomb”–what a title!) seems to have some serious flaws. The report also chose to compare their obesity rate for Aus (26%) with the Gallup data for US obesity rate (25%) rather than the JAMA or CDC rates (>30%). Maybe this is valid for some reason…

        Either way, you guys better watch out. We are after that title.

    • I agree with Al. I think both the left and the right ignore that comfort and convenience are in some ways just as important as living a few months longer. I have never been in a European hospital, but I understand them to be very spartan in nature. Look at the hotel industry. The standard that people use to evaluate a hotel is not just whether you can get a good night’s sleep. You can sleep just as well at a Motel 6 as the Four Seasons, but most people would rather stay at the Four Seasons. I think the US health care system falls into the Four Seasons category. We have fancy out patient clinics and high paid doctors, because such thinks make people feel comfortable. People like it that their doctor was the smartest guy in college. Does that mean that the doctor can make people live a day longer than some civil service doctor in England, who makes half the money? Probably not, but people do not want to take the chance. People in this country want the best and they will pay for the best. People do not want civil service doctors and spartan insitutional hospitals..

      • In August 2000 I spent 3 days in Johnston-Willis Hospital in Richmond, VA. It seemed every bit as “Spartan” as any hospital room I’ve been in in Canada, even with a private room.

        There was nothing wrong with it, but I’d be hard pressed to find any significant differences.

      • You seem to assume that it’s all one dimensional. The smartest guy in college might also be the one with the people skills of a gorgon. In other nations where they may place less emphasis on book smarts and focus less on the financial returns to medicine, they may get physicians who have other skills that are, perhaps, even more important (especially now that IT like Watson may de-emphasize memorization, recall, and patterning as key skills).

        Since my daughter’s had multiple surgeries, I can testify that describing the food, bed, room decor, customer service and more in many hospitals as like the “Four Seasons” would get you a big lawsuit for libel and defamation from the Four Seasons.

        No one denies (except John and his labor theory of value) that we pay much. much more. On the base quantity measures, we don’t get more (hospital days, doctor visits, prescription drugs, etc.). On the simple outcome measures, we don’t get more. On the more detailed data of the mitigating factors (like health behaviors) and outcomes/quality, I think an honest appraisal says, at best, that the evidence is mixed–the mitigating factors explain some of the difference, but nowhere near all of it; the quality/outcome measures show some areas where we do better, some where we do not.

        Now, I realize I haven’t provided citations, but I do think that’s a reasonable summary of the consensus. And, in science, I think the burden is now on those who claim that we don’t spend more and/or do get more and/or have other factors that explain the mismatch between spending and outcomes to keep trying to provide further evidence. Thus far, they have not proven their case.

    • RC says above: You lost me here: “We should unequivocally be number one.” Compared to the rest of the OECD, we eat substantially more, we drive more (presumably we walk less), we injure and kill ourselves more frequently, etc., etc. And we are far more diverse. I agree that we spend entirely too much on healthcare for what we get, but even if we had far and away the best healthcare in the world, it isn’t clear to me that we’d have the best health outcomes.”

      Cost more – unequivocally questions:
      (1) Relative to other countries included in the comparisons, is it clear that the difference in cost is mostly attributable to income differences in terms of physician compensation, hospital income, and incomes for other providers (Rx manufacturers, medical device manufacturers, etc.)?

      (2) Relative to other countries included in the comparisons, don’t Americans have a much higher rate of utilization of services, perhaps in part because of availabiltity?

      When I evaluate investment options as a fiduciary for my 401(k) plan, I use an attribution analysis (stock selection, etc.) to identify the variances from, say a stock index fund. Can you direct me to any comparable analysis for cost effectiveness comparisons regarding health care?

    • To achieve equitably efficient healthcare by our nation’s healthcare industry, it will first need to be justly accessible. I cite maternal mortality data to indicate the pervasive nature of this problem. See: World Health Organization, TRENDS IN MATERNAL MORTALITY: 1980 TO 2008, 2010. Between 1990 and 2008, the Maternal Mortality Rate for the 43 developed countries of the world improved by 0.8% annually. By comparison, the world-wide maternal mortality rate improved by 2.3% annually. For our country, it worsened by 3.7% annually. In 2008, for our country to rank within the best quartile of the 43 developed countries, our maternal mortality rate would have to have been reduced by 75%. Finally, four states in 2008 had already achieved a maternal mortality rate that was 75% better than our nation’s average of 13.1 . Among the 50 states, the best state had a 1.2 MMR and the worst was 20.9 The MMR for our nation was 13.1 .

      I continue to wonder why these numbers are not frequently cited in the public arena of knowledge. I suspect that the “economic mandate” for universal insurrance can not be solved efficiently without first solving the “social mandate” to arrange justly accessible, enhanced Primary Health Care for each citizen. The “social mandate” representing the only means to reliably reduce our nation’s maternal mortality rate.

      See also a similar report by AMNESTY INTERNATIONAL USA, 2010.

      • Paul N., it is not a good thing to see maternal mortality in this country deteriorate. None of us want that and your numbers show this to be occurring. Many would like to do something and I am included. The problem I have is not the expenditure of resources rather making sure that the resources are used in the right place especially since we have so many different programs targeted to maternal mothers and children.

        Let’s assume we spend more money on healthcare. If access to healthcare was not the cause, but drugs, family breakdown etc. were then we really haven’t helped solve the underlying problem. That would be disturbing. It would be like calling for major resources to treat bullet wounds to children when placing a police officer in the right spot would prevent the problem in the first place and the many deaths that occur despite the increased focus on healthcare.

        Can you tell us the other things that have caused an increase in maternal mortality and show us why  primary care for each citizen, in whatever way you believe, will solve this problem better than solving the underlying social problems?

    • ” The penalties for breaking the law are large.”

      That may be true on paper. In the real world it’s irrelevant . The anecdotal evidence that repeats itself over and over tells quite a different story.

      • Art, what you say is easy to say, but hard to prove. Let us hear proof where those cases were actually taken to court and litigated showing the law was not upheld. I am not saying it or anything else is perfect, just that the penalties are high and hospitals can be excluded from the Medicare system. There have been claims made that hospitals have sent patients to other hospitals, but that is permissible if the hospital doens’t have the required services.

    • RE: by Al on October 1st, 2012 at 21:39

      I’m finding now that the conversation is moving into “the others.” This is something that I encountered for 5 months when I stood with portraits and signs in front of the Supreme Court and Capitol in DC.

      I was never an activist before I started investigating this subject by studying people’s real lives, interviewing them at length and painting their portraits — from the tea partier and hedge fund manager comfortably insured — oh so “right” about the others — to the young uninsured pregnant woman whose fully employed husband took her to one hospital (ER care) where she was treated for a headache and sent home. Husband then went to a second ER. He lied and said he left his insurance card home. That hospital admitted the woman and couldn’t release her because she was officially “unstable.” A million and half dollars later mother and child were dead.

      Heart strings. Absolutely not. Hard “flesh” data that might not inform the conversation enough.

      Why does this happen? Because the safety net (Medicaid) is very selective and varies state to state. The ACA addresses this if states will jump on board.

      And the free market has worked beautifully. It’s managed to extract as much profit as possible from every premium dollar to the point where insurance companies are touting those cost-shifting devices called HSAs as terrific opportunities. They are an unmitigated disaster for the average person and should be sold by financial planners.

      Statistics correlate to real lives. Our system has turned people into liars, forced marriages for health insurance reasons, and encouraged every kind of deception so people can find a way to access care if they are an “other.” And statistics say there are tens of millions of them.

      As a former owner of two businesses, at one time an employer of 32 people and avowed capitalist, I see that free market forces have disenfranchised and killed way too many Americans when it comes to healthcare. I keep looking for that piece of information that will show me what I’m missing. Not there. I’m liking single-payer more and more. Links to your writings on this subject would be appreciated.

      Thank you for this conversation. I feel a new resolve to continue connecting the issue to real life first ,inundating my senses with this problem of accessing healthcare as it plays out on the ground, and THEN bringing all my intellectual creativity to bear on the problem.

    • Al,
      In the complete world of numbers that’s the way it’s supposed to work. I have one foot in policy and the other in the field. I get it.

      There are all kinds of proof. Contact me anytime to get the “proof” of people’s lives. There are all kinds of evidence.

      The challenge is to have ALL the various kinds of “evidence” challenge us intellectually not just the evidence to which we ascribe certain boundaries.

      Your statement says that people of moderate means are supposed to take on a system to “prove” what they’ve experienced so it fits into your model.

      They have the proof of their lives.

      Take one of my subjects who agreed to be interviewed by ZDF, German tv about my research through art. (It’s the link that starts with “Amerikas” It’s in German…ugh!) She is not going to take on the system. She’s trying to save her eyesight .In your paradigm she’s supposed to what? With what means?

      It is my hope that the thinkers of the world like you and your readers allow what is really REALLY happening in the field be the catalyst for massive intellectual outpouring on a problem which is not just examined within the constructs of your world. Connection then solution.

      I will leave you with the last word and a gentle nudge….connection then solution.
      Kind regards,

      • Art (Theresa),
        Thank you for your reply. I believe we both wish the same things, but look at things a different way. We all recognize that we have to contend with budgets and that we will provide services to those truly in need. That is a given even if some might object. I’ll list a few potential differences we might have.

        1) We spend (government) IMO way too much on healthcare and that takes away funding for other things. An extra police officer might do more for health in a deprived area than the equivalent expenditure on health care. In fact it removes the need to remove many bullets from children and permits them to play in safety.
        2) You consider what we have today a free market. I don’t. In fact I think government has created an environment that is harmful to its citizens. Government promoted the HMO that sucked money out without providing an equivalent amount of care. I am not talking about a free market without some degree of government regulation and assistance.
        3) Direct government involvement IMO reduces quality and access while increasing cost.
        4) The patient with a headache more likely was sent home because the first physician didn’t recognize the problem, not because of insurance concerns.
        5) Medicaid may vary, but EMTALA doesn’t.
        6) Neither free markets nor government controlled markets kill patients. The incentives they create are responsible for the successes and failures.
        7) My desire is to see healthcare placed back in the market place where innovation and efficiency generally occur. I want government involved as a regulator and not one that can potentially team up with the provider because both have the same incentives. I want money saved so that capital can be invested to create jobs to eliminate poverty which by itself will improve the health of the nation.

        Kind regards as well

    • Al,
      In response to your points.
      1. Agreed, prevention will cut down healthcare costs. Addressing social ills is good. Then healthcare costs go down. As far as “taking away funding for other things.” No, defense spending takes away $ for other things. Better spending, smarter spending is necessary in healthcare. Safety nets need to be in place.

      2.I don’t consider what we have today a free market at all. That’s another long discussion. But one component of the free market is missing. Consumer clout. We can’t ever wield our power by boycotting. Watch a company change when you stop buying their products.

      3. Your statement. No meat there for discussion.

      4. Your conclusion. Incorrect. This isn’t an isolated incident. A woman, 7 months pregnant having had no pre-natal care, shows up in the ER, do you think she gets the same consideration as an insured woman with no pre-natal care (just for discussion sake) No tests, no screenings. The uninsured woman was “stable.” This situation just doesn’t fit with what you believe, it seems. But that’s why this issue of healthcare is so hard for people. I hear it all the time at my talks, “Naaaaah, that’s an aberation. That doesn’t really happen.” Wrong. Many hospitals walk that word “stable” line pretty darn close. And it all comes down to money.

      5. Incorrect. Your statement not supported by data collected “on the streets.”

      6. Yes! We agree. I’m a big fan of the incentives in the ACA to reward outcomes.

      7. Nice idea. The profit motive will always be to pay as few claims as possibles. Insurance companies aren’t Mother Teresa doing good deeds for the heck of it. When companies put up profits by incurring as few “medical losses” (claims) as possible, the motive will still be to pay as few claims as possible. And consumers will never be able to play the ultimate trump card. They can’t walk away from the product which will turn a company’s head so fast. So there is a kind of collusion that goes on. All the insurance companies know this so they all play the same game. Even the non-profits act like the for-profits. And their reasons. “We have to do it to compete.”

      The real game changer will be in states like Oregon and Vermont. The insurance companies are trying to subvert Vermont’s efforts to move to a single-payer. Real threat to them. I’m sure their lobbying efforts are in full swing. Oregon is setting up a health insurance co-op. These two models will really wake up the insurance companies. Let’s see if they then “compete.”

      Insurance companies “competing” with each other today isn’t true competition for the reasons I gave. They are just dividing the spoils.

      We could go on forever, I’m sure. Have a good one