The World's Greatest Healthcare System For Dummies

Prof. Krugman:

The United States spends far more on health care per person than any other nation. Yet we have lower life expectancy than most other rich countries. Furthermore, every other advanced country provides all its citizens with health insurance; only in America is a large fraction of the population uninsured or underinsured.

You might think that these facts would make the case for major reform of America’s health care system — reform that would involve, among other things, learning from other countries’ experience — irrefutable. Instead, however, apologists for the status quo offer a barrage of excuses for our system’s miserable performance.

So I thought it would be useful to offer a catalog of the most commonly heard apologies for American health care, and the reasons they won’t wash.

Excuse No. 1: No insurance, no problem.

“I mean, people have access to health care in America,” said President Bush a few months ago. “After all, you just go to an emergency room.” He was widely mocked for his cluelessness, yet many apologists for the health care system in the United States seem almost equally clueless.

We’re told, for example, that there really aren’t that many uninsured American citizens, because some of the uninsured are illegal immigrants, while some of the rest are actually entitled to Medicaid. This misses the point that the 47 million people in this country without insurance are an ever-changing group, so that the experience of being without insurance extends to a much broader group — in fact, more than one in every three people in America under the age of 65 was uninsured at some point in 2006 or 2007.

Oh, and finding out that you’re covered by Medicaid when you show up at an emergency room isn’t at all the same thing as receiving regular medical care.

Beyond that, a large fraction of the population — about one in four nonelderly Americans, according to a Consumer Reports survey — is underinsured, with “coverage so meager they often postponed medical care because of costs.”

So, yes, lack of insurance is a very big problem, a problem that reaches deep into the middle class.

Excuse No. 2: It’s the cheeseburgers.

Americans don’t have a bad health system, say the apologists, they just have bad habits. Overeating and teenage sex, not the huge overhead of America’s private health insurance companies — the United States spends almost six times as much on health care administration as other advanced countries — are the source of our problems.

There’s a grain of truth to this claim: Bad habits may partially explain America’s low life expectancy. But the big question isn’t why we have lower life expectancy than Britain, Canada or France, it’s why we spend far more on health care without getting better results. And lifestyle isn’t the explanation: the most definitive estimates, such as those of the McKinsey Global Institute, say that diseases that are associated with obesity and other lifestyle-related problems play, at most, a minor role in high U.S. health care costs.

Excuse No. 3: 2007 is better than 1950.

This is an argument that baffles me, but you hear it all the time. When you point out that America spends far more on health care than other countries, but gets worse results, the apologists reply: “Sure, we spend a lot of money on health care, but medical care is a lot better than it was in 1950, so it’s money well spent.” Huh?

It’s as if you went to a store to buy a DVD player, and the salesman told you not to worry about the fact that his prices are twice those of his competitors — after all, the machines on offer at his store are a lot better than they were five years ago. It is, in other words, an argument that makes no sense at all, yet respectable economists make it with a straight face.

Excuse No. 4: Socialized medicine! Socialized medicine!

Rudy Giuliani’s fake numbers on prostate cancer — which, by the way, he still refuses to admit were wrong — were the latest entry in a long, dishonorable tradition of peddling scare stories about the evils of “government run” health care.

The reality is that the best foreign health care systems, especially those of France and Germany, do as well or better than the U.S. system on every dimension, while costing far less money.

But the best way to counter scare talk about socialized medicine, aside from swatting down falsehoods — would journalists please stop saying that Rudy’s claims, which are just wrong, are “in dispute”? — may be to point out that every American 65 and older is covered by a government health insurance program called Medicare. And Americans like that program very much, thank you.

So, now you know how to answer the false claims you’ll hear about health care. And believe me, you’re going to hear them again, and again, and again.

Ezra Klein at The American Prospect:

Earlier this week, Rudy Giuliani released a radio ad directly engaging the health care debate. "I had prostate cancer five, six years ago," begins the ad. "My chance of surviving prostate cancer, and thank God I was cured of it, in the United States? Eighty-two percent. My chance of surviving prostate cancer in England? Only 44 percent under socialized medicine."

Unsurprisingly, Giuliani's statistics are a straight lie resulting from a basic mathematical error. The Annenberg Fact Check Project wrote, "We tracked down the source of that number, which turns out to be the result of bad math by a Giuliani campaign adviser, who admits to us that his figure isn't 'technically' a survival rate at all. Furthermore, the co-author of the study on which Giuliani's man based his calculations tells us his work is being misused, and that the 44 percent figure is both wrong and 'misleading.'" The Giuliani campaign, demonstrating their traditional fidelity to truth and accuracy, have said they will continue using the statistic.

But the basic question Giuliani poses should be central to the presidential campaign: How good is American health care? The developed world is full of alternative models, fully functioning structures that can be viewed as little experiments, the outcomes of which should inform our policies. If our system outperforms its competitors, than we should amplify what sets us apart and pushes us ahead. If we under-perform, we should take a hard look at whether our model really is superior. And luckily, we have the data.

Indeed, we have brand new data. The Commonwealth Fund just released a broad survey collecting health care attitudes and experiences from patients in Australia, Canada, Germany, the Netherlands, New Zealand, the United Kingdom, and the United States. Here are summaries of some of the findings:

1. We spend the most. We spend more than any other country in the world. In 2005, our per capita -- so, per person -- spending was $6,697. The next highest in the study was Canada, at $3,326. And remember -- that's "mean" spending, so it's the amount we spend divided by our population. But unlike in Canada, about 16 percent of our population doesn't have insurance, and so often can't use the system. These facts should set the stage for all numbers that come after: Every time you see a data point in which were dead last, or not leading the pack, remember that we spend twice as much as any of our competitors.

2. We don't pay doctors according to the quality of their care. One of the first questions is "percent of primary care practices with financial incentives for quality" -- in other words, how many doctors are paid, in part, according to the quality of the care they deliver. In the United Kingdom, the number is 95 percent. In Australia, it's 72 percent. The U.S. scores lower than anyone else, at 30 percent. Similarly, electronic medical records -- which both increase the quality of care and lower its cost -- have 89 percent penetration in the U.K., 79 percent in Australia, 98 percent in the Netherlands, and 28 percent in America. On both these metrics, we perform miserably.

3. Our wait times are low because many of us aren't getting care at all. It's true, Americans do have short waits for non-elective surgeries. Only 4 percent of us wait more than six months. That's more than in Germany and the Netherlands, but considerably less than the Canadians (14 percent) or the Britons (15 percent). But our high performance on the waiting times only account for individuals who get the care they need. Our advantage dissipates when you see the next question, which asks how many patients skip care due to cost. And here, America is far worse than anywhere else.

In just the past year, a full 25 percent of us didn't visit the doctor when sick because we couldn't afford it. Twenty-three percent skipped a test, treatment, or follow-up recommended by a doctor. Another 23 percent didn't fill a prescription. No other country is even close to this sort of income-based rationing. In Canada, only 4 percent skipped a doctor's visit, and only 5 percent skipped care. In the U.K., those numbers are 2 percent and 3 percent. Few of our countrymen are waiting for the care they need, that much is true. But that doesn't mean they're getting it quickly. Rather, about a quarter of us aren't getting it at all.

Indeed, 19 percent of Americans were unable, or had serious problems, paying medical bills in the last year. Comparatively, no other country was even in the double digits. This is part of why we perform well on the waiting-times metric. In other countries, the disadvantaged wait longer for their care, and so show up in the data tracking wait times. In our country, they disappear from that measure, because they never get the care at all. You don't wait for what you're not receiving. So their wait times show up as "zero," when they should really be something akin to infinite. And would you prefer to wait four months for your surgery, or never get it at all?

4. Most of us don't have a regular physician. One might expect, given what we pay, that our care would at least be more central and convenient. But it's not so. Of everyone surveyed, Americans were the least likely to report a doctor or general practitioner they routinely saw. As a result. Americans are the most likely to say their doctor doesn't know important information about their medical history, which has obvious implications for care quality, medical errors, etc.

5. Our care isn't particularly convenient. Nor is medical service more convenient for Americans to access. On such questions as whether your doctor has early morning hours, evening availability, or weekend slots, we're not trailing the pack, but we're not in the lead, either. On evening hours, for instance, we lag behind Australia, Canada, Germany, and New Zealand. On same day appointments, Only 30 percent of Americans report that they can access a doctor on the very day they need one, as opposed to 41 percent of Britons and 55 percent of Germans. And a full 67 percent of Americans -- more than in any other country -- say it's difficult to get care on nights, weekends, or holidays with resorting to the emergency room, where care is costlier and, if your injury is not grievous, less efficient.

6. Our doctors don't listen to us. But maybe the amount we're paying comes in customer service -- maybe our doctors spend more time with us, are more reassuring, are more attentive to our cases. After all, we basically like the care we get. Our overall self-evaluation of the treatment we receive is solidly in the middle of the pack, with 70 percent expressing satisfaction -- which means we're less satisfied than the Canadians, Australians, and New Zealanders, but 5 percent above the Britons, and well above the Germans or Dutch. But when you ask for specifics, we do a bit worse.

Americans are the least likely to report that their doctors explain things in ways they understand (though the spread on this question is rather small) or say doctors spend enough time with them (56 percent of us say they do, as compared to 70 percent of Germans). We're the most likely to report that test results or medical records were unavailable during our scheduled appointments and, along with the Germans, the most likely to say that our doctors ordered tests that we'd already had done. On the bright side, 78 percent of us say our regular doctor was "informed and up-to-date" about follow-up care after a hospital visit.

7. We have high rates of chronic conditions. Aside from the surprisingly unhealthy Australians, Americans have the highest rate of chronic disease. And this isn't only a comparative problem; our high rates of chronic disease are a massive cost-driver, attributable, according to the research of Ken Thorpe, for about 2/3rds the rise in health spending over the past few decades.

8. … But we're not treating them properly. So given the high prevalence of such diseases, and the pressures they exert on our system, you'd hope our system had evolved so as to treat these diseases more effectively.

Not so. One of the big issues with chronic disease is coordination of care. Illnesses like diabetes and kidney failure have so many manifestations, and require so much maintenance, that it's critical for care providers to have a full picture of what treatments are being received, what the patient's medical history is, what therapies they will and will not follow, etc. And for that reason, it's critical for the patients to have a single medical home – a regular care center where their case is understood, tracked, and treated. Sadly, we're tied with the Canadians for the lowest percentage reporting a single "medical home."

Worse,we're far and away the likeliest to report spending more than $500 out-of-pocket on prescription drugs annually. That's a problem, as higher out-of-pocket costs mean more of us going without prescriptions, which means less maintenance of conditions and, thus, more cost when our chronic illnesses balloon into catastrophic health events. Indeed, 42 percent of Americans with chronic conditions -- the exact same percentage who report paying more than $500 for drugs -- report skipping care, drug doses, or doctor's appointments due to cost. That's cheaper for them in the short-term, as they can spend some of the money on food or rent. It's more expensive for us, however, as we pick up the huge bill when they end up in the hospital in full cardiac arrest.

9. We're frequent victims of medical, medication, and lab errors. Along with Australians, Americans are the most likely to report a medical, medication, or lab error, with 20 percent saying they've experienced one of the above over the past year. For those of us with chronic diseases, the rates are even higher. There are many reasons for this, ranging from our low adoption rate of electronic medical records to our splintered care system. But the effects are bad for our health and, needless to say, bad for our insurance rates. Conservatives make a huge deal out of medical malpractice claims, but studies show that our high rate of lawsuits is due to our high rate of medical error. The crisis isn't just in the courtrooms, it's on the operating tables.

10. Most of us are dissatisfied with our current system. In health polling, happiness with the system is generally measured through a three-answer question: Does your system merely need minor changes, as it works pretty well? Does it need fundamental changes? Or does it need to be rebuilt? Of all the countries surveyed -- including the supposedly dystopic U.K. and Canada -- Americans are the least likely to report relative satisfaction, and the most likely to call for a fundamental rebuilding. Only 16 percent of us are happy. In Canada and the U.K., that number is 26 percent. In the Netherlands, it's 42 percent. Meanwhile, 34 percent of Americas want to completely rebuild. Only 12 percent of Canadians say the same, and only 15 percent of U.K. residents want a new system. So paying more than twice as much as anyone else, we have the lowest satisfaction with our health care system. Lower than the countries with waiting lines. Lower than Germany, and Australia, and New Zealand.

And perhaps this shouldn't be a surprise. Is it any wonder that Americans who have to forgo care are less satisfied than Canadians who simply have to wait for elective surgeries? That our shorter doctor visits, more impersonal caregivers, higher rates of medical errors, and inability to find primary care after 6 P.M. have left us frustrated? And that our sky-high costs have, finally, left us aching for change?

There is no other area of American life where we collectively accept such a bad deal. We spend the more than any other nation on our military, but our military is unquestionably the mightiest in the world. We spend the most on our universities, but our universities are the best on the planet. But we spend the most on our health care -- twice as much as anyone else -- and our health system is mediocre-to-poor, with 47 million of us lacking the insurance necessary to easily access it. It's not surprising that Americans want change. But it should be shocking that opportunistic politicians like Rudy Giuliani feel safe to stand in its way. Maybe in this election that will change.