Beware Health Care System Rankings

Advocates of more government involvement in health care often rely on a World Health Organization (WHO) report to make their case. They point to dubious claims that the performance of health care systems in countries like Canada and France rank much higher than the U.S. system.

Now, the Cato Institute has published a critique of the WHO report and finds it flawed in a number of ways.

Here are two key findings from Cato’s paper, WHO’s Fooling Who?:

“To use the existing WHO rankings to justify more government involvement in health care is to engage in circular reasoning because the rankings are designed in a manner that favors greater government involvement.”

“Media reports”¦neglect to mention the margins of error”¦an 80-percent uncertainty interval for each country.” “”¦the U.S. rank could range anywhere from 7 to 24″¦France could range from 3 to 11 and Canada from 4 to 14.”

Read the Executive Summary, or the entire 12-page Cato paper to learn why you shouldn’t believe everything the World Health Organization tells you.

WHO’s Fooling Who?

The World Health Organization’s Problematic
Ranking of Health Care Systems

by Glen Whitman
February 28, 2008

Executive Summary

The full 12-page paper:
WHO’s Fooling Who?


Steve Buckstein is Senior Policy Analyst and founder of Cascade Policy Institute, a Portland-based think tank.

Share
  • eagle eye

    Some good points in the report especially about the error bars on the rankings. But the U.S. ranking looks like nothing to be proud of, especially given how much we spend. Ditto for U.S. life expectancy and other health indicators.

    The U.S. health system is headed for big changes. Conservatives who defend the status quo are simply burying their heads in the sand. They better come up with alternatives soon and get the adopted, otherwise the other side is going to do it for them.

  • Friends of Meatpuppet

    Nothing against the author but Who cares? We are going to get health care shoved down our throats by the next regime. It is now one of the most volatile subjects available. And once we are forced to have it we will see the end of medicine as we know it.

  • dean

    Steve…I couldn’t get into the full report, but basically agree with what EE says above. Cato is just not a reliable source for this critique, because they start from an ideological basis that assumes free markets are always superior. The WHO data assumes nothing either way, it just compares results.

    Yes, we on the left will cite the WHO data to point out where our present mixed system is failing. But to try and cast doubt on the data in order to what…prop up our belief in our failing system? What is the point of that? Conservatives need to either put realistic, politically passable proposals on the table or make the argument that our wobbly system is fine as is. Otherwise my side gets to set the terms of the debate.

    • Anonymous

      You might take the time you’re spending arguing and read the whole report. Then maybe you have something relevent to say

    • Steve Buckstein

      Dean, dismissing the source (Cato) without looking at its arguments doesn’t get us very far. Both the WHO report that you so frequently cite and the new Cato study that faults that report are complex documents. But sometimes it’s hard to accurately assess health care system information without digging into the details. This is one of those times.

      Without boring readers too much, let me summarize one problem that the Cato author has with the WHO rankings. Basically, the WHO rankings are based on five factors, one of which it labels “Financial Fairness (FF).

      “The FF factor penalizes a country for each household that spends a larger-than-average percentage of its income on health care. BUT IT ALSO PENALIZES A COUNTRY FOR EACH HOUSEHOLD THAT SPENDS A SMALLER THAN AVERAGE PERCENTAGE OF ITS INCOME ON HEALTH CARE.” [Emphasis added]

      “Put more simply, the FF penalizes a country because some households are especially likely to become impoverished from health costs—but it also penalizes a country because
      some households are especially unlikely to become impoverished from health costs. IN SHORT, THE FF FACTOR CAN CAUSE A COUNTRY’S RANK TO SUFFER BECAUSE OF DESIRABLE OUTCOMES.” [emphasis added]

      Cato outlines a number of such problems with the WHO rankings.

      I’m not challenging the WHO rankings to try and “prop up” the U.S. system, and nothing in the Cato report tries to do that either. But, it’s important to understand that WHO rankings are not the end-all and be-all of comparisons between different country’s health care systems. Otherwise, we could improve the U.S. ranking while actually making our system, and our citizens, worse off rather than better off. Hopefully no one wants to do that.

  • Chris McMullen

    Dean sputtered: “The WHO data assumes nothing either way, it just compares results.”

    BWAHAHAHAHA!! Yeah, an arm of the anti-U.S., socialist-leaning U.N. “just compares results.” That’s gotta go down as one of the end-all stupidest comments ever made.

  • Jerry

    I am of the belief that the best health care is available in Zimbabwe. It is very affordable, too.

  • Bob T.

    “BWAHAHAHAHA!! Yeah, an arm of the anti-U.S., socialist-leaning U.N. “just compares results.” That’s gotta go down as one of the end-all stupidest comments ever made.”

    Are you talking about the UN-IPCC report dean blindly adorns?

    🙂

    • dean

      Steve…No social science based ranking system can be complete or perfect, so I have no doubt faults can be found with what the WHO chose to measure and how they did so.

      But at the end of the day, one has to wonder 2 things. First, since the US has the most free enterprise oriented health care system in the developed world, and since the Cato argument is against socialized insurance or delivery systems (which all the other developed nations have to one degree or another,) why are these measures even necessary? In other words, if markets are superior, we should be far infront of all these socialized nations by just about any measure. But clearly we aren’t. Maybe we are 37th, maybe we are 20th or even 10th. Any way you slice it we spend a lot and don’t get a very good return.

      I suspect the answer is fairly simple. Health insurance is simply not effiently done through private markets. And I think the reason has to do with the pool. A private, profit oriented health insurance company has 2 perverse incentives: 1) keep sick people out of the pool and 2) deny as much health care as is possible to everyone in the pool. This leaves the poor, sick, and elderly out, and we then have high public costs to care for them.

      All these nations that have socialized insurance figured this basic point out years ago, and they now deliver as good or better care for far less money and serve many more people.

      Chris….I did not realize that I “sputtered.” Thanks for pointing that out. I’ll check in for a tune up next week.

      The corner you and Bob T are painting yourselves into is that you can’t accept ANY data that contradicts your core beliefs. There must be some great socialist conspiracy out there making all this stuff up so the US looks bad. Apparently every other nation on earth might rely on WHO and the IPCC, but we can just opt out of reality, and make up whatever suits us.

      • davidg

        A recent report showed that government pays for 46% of all health care spending in the country, and will soon be 49%.
        https://www.cbsnews.com/stories/2008/02/26/health/main3876569.shtml

        I would hardly call ours a free market system. It is certainly failing more and more as governments’ role continues to get greater and greater.

        • dean

          Davidg….cause or effect? Each year fewer Americans get health care through their employment. And each year our population ages, so more people sign up for Medicare. That is government’s fault?

          If we had an entirely free market system, what private insurance company would insure 80 year olds? And at what price?

          • davidg

            Every statistic I have seen shows that 84-85% of Americans have health insurance. That is not an indication of an emergency. It certainly is not a justification for creating a national health insurance pool. Some people are hungry too. They get food stamps. But we don’t create a national food stamp program for everyone when only a small percent even need it.

            I don’t know what 80 year olds pay for health insurance. I am sure there are many in that 84% total. Ask them what they pay. And also ask yourself: how many 80 year olds are there? Certainly not enough to justify nationalizing health care for everyone.

  • Bob T.

    Well there it is.
    dean the pot calling the kettle black.
    Who more than dean has painted himself into a corner by denying all data that contradicts his core beliefs?
    His blind allegiance all things UN a perfect demonstration of core beliefs perpetuating ignorance.
    It is dean who avoids and then dismisses the genuine and two sided study of issues.
    All the while tossing out one strawman pitch after another.
    Clinging to the liberal party lines is dean’s core.
    His irrational reliance on UN “concensus” provides all the reality he needs.
    Even while the IPCC AGW case withers into the comical farce it is dean trumpets the UN stature and pretends it is he who recognizes the best science. That’s hogwash of course and later when dean comes along into real reality, he’ll continue with more of his ignorance as he lectures us on how skeptic were premature in their condemnation of the IPCC. And that only when he finally arriive at where the science already is will the case be sufficient to reconsider IPCC.
    Of course he’ll then be spending much of his chin rubbing time advising us on the uncertainties of it all while insisting we still need to adopt all of the policies attributed to global warning.

    And the beat goes on.

  • Anonymous

    I’m getting bored with deans arguments against common ssense

    • dean

      I should have added that another cause of our increased government paid health care is the Iraq war. We now have 90,000 seriously wounded veterans, many of whom will be recieving expensive treatment (well earned I might add from our only truly socialized medical delivery system, the doctors and nurses of the VA) for many many years. Does anyone know of any private insurance agencies who will cover and care for our wounded veterans?

      Bob T…not the time and place to re-litigate global warming. I’ll just say that your statement that I have a “blind alegiance to all things UN” is not based on any fact or knowledge you have about me. I accept the IPCC findings in large part because they are supported by ALL of the major scientific instututions of the United States: NOAH, NASA, the American Science Foundation, and so forth. I don’t know of a single one that does not support the IPCC.

      As for what policies we should adopt, the price of gasoline is now approaching $4 a gallon, the Iraq war & occupation is in its 6th year, and Saudi Arabia and Iran are the 2 largest repositories of remaining oil. Even without global warming as an issue, energy conservation and alternative energy development make good sense, don’t you agree?

      I take the WHO data for what it is, the most relied upon comparative international statistics on health that happen to be available. Beyond that I don’t have any other UN study or data that I have ever relied on or cited on this site or elsewhere.

      Anonymous person…in this day and age there are so many entertainment venues available to you. There is no excuse for boredom really. I encourage you to take personal responsibility for maintaining an active mind.

  • dean

    Att eh risk of boring everyone further, if you don’t like the WHO analysis, try the Harvard Commonwealth Foundation.

    https://www.commonwealthfund.org/publications/publications_show.htm?doc_id=640980

    They recently analyzed “preventable deaths” prior to age 75 among 19 industrial countries. This is a broad measure of the overall effectiveness of health care that has been used for many years. The US ranked dead last. And while other nations (France, Canada, New Zealand, etc) with more socialized insurance systems were improving dramatically over the past 10 or so years, the US is flat lining. Near zero improvement.

    • eagle eye

      I agree that the WHO analysis is debatable — what analysis isn’t? — and would say further, probably highly questionable at the end of the date.

      But then I have to ask what kind of analysis of data would paint the U.S. system in a favorable light. I don’t know about the Harvard Commonwealth study. Perhaps it is dubious too.

      OK, fine. What are some studies that paint the U.S. in a favorable light based on data?

      It seems to me that our life expectancy and other health indicators are a big yellow flag for the health care system here.

      • dean

        EE…those plus our overall health care spending, which is far higher than anywhere else by anybody’s calculations.

        The debate, such as it is, seems to be about whether a free(er) market health care system can or will deliver higher quality, reasonably priced services to us than our present mixed system with increased federal government involvement and funding. Cato is apparently worried that the debate has shifted far in favor of increased government intervention, so they see the need to challenge the assumptions that much of the critique is based on. This does not mean their critique is without merit.

        The fundamentals; highest cost, mediocre overall results, and the constant threat most of us face of loss of insurance with job or income loss, can’t be easily disputed since many of us live with these unfortunate facts day to day. I believe the most recent numbers are that we have 8 million more uninsured today than when Bush took office, yet by most measures the economy has grown, and unemployment is very low. We seem on a downward ramp.

        Where the US does good statistically is in high quality care for upper middle class and wealthy people, high pay for doctors, and high profits for some insurance companies. Three reasons we can’t change the system easily.

        • dean

          This is for Davidg up above. 80 year olds are all insured through medicare and/or medicad, paid for by you and me. Welfare recipients are covered through Medicaid, again paid by us working people and business owners. The growing number of uninsured are working people (many self-employed) with low paying jobs that don’t provide insurance, plus their kids, plus those with pre-existing conditions who can’t get insurance, plus some young healthy folks who take the risk of going uninsured even though they can afford it.

          EVen those who have insurance through work are finding they have to pay a larger and larger share due to the escalating prices.

          80 year olds who can afford it pay for supplimental insurance that gives them a bit better coverage than they get through straight Medicare.

          My point was that without government funded Medicare 80 year olds, except for very wealthy ones, would not be able to get any private insurance. I doubt even Cato would dispute this.

          But you are right. Its not a true “emergency.” Its more like a disgrace, when compared with what the rest of the developed world is able to do.

          • davidg

            Ok, so you acknowledge that the poor and the elderly have programs now that they can use now. So they don’t need a new program. From the demographics you identify (your source?), many of the people without insurance coverage have chosen to be without and/or are in a low risk category where insurance coverage just may not be very important to them anyway.

            Since 84-85% of the population has coverage now, and since many of the people without insurance have chosen that status or are in a low risk category, why is it necessary to create a new system that everyone must join? If there is a problem, address that problem. Any attempts at a universal system are clearly overkill for the scope of the problem as you have identified it.

            Medical practices in other countries may be more efficient than what is done here. That doesn’t mean that government in the USA is capable of replicating that. The study I cited above shows that government presently controls 46% of all medical expenditures in the USA. If we could anticipate effective programs from our government, then just reallocating existing dollars should be more than sufficient to create a marvelous system based upon a European or Canadian model, assuming those systems really work as you and WHO say. We shouldn’t need more money to do that.

  • Carol

    Where the US does good statistically is in high quality care for public employees and elected offficials.

    Their lack of feeling the painful cost of healthcare feeds the rising costs. Then they contribute to the liberal entitlement machine that inists on causing further pain for the working private emplyees by forcing them to fund free insurance for others.
    The lavish benefits packages that public emplyees have insulates them from and distorts the free market.

    • dean

      Davidg…yep, the non-working poor and elderly are covered. But I think you misread the demographics of the non-covered. Most are working families in teh service and retail industries. 10 million are kids. Many have pre-existing conditions, and are clearly high, not low risk. They cannot find affordable insurance plans that will have them.

      The estimates I have seen suggest about 15 million out of the 50 million presently uninsured are low risk younger folks who probably could afford a policy.

      The present proposals from leading Democrats do not create a single system that “everyone must join” as you put it. The Clinton plan does have a mandate that everyone must join something, but there are a lot of choices within that. The Obama plan says everyone with kids has to sign their kids up for something, but adults can choose to remain uninsured.

      Your number on present government health expenditures is higher than mine, which is 29% (mine might exclude spending on veterans, which could explain the difference). But either way, is it sufficient? If it were we would not have this problem to discuss.

      And even if it were sufficient it is not static. As the baby boomers reach 65 and retire they go from private insurance coverage to Medicare coverage, so the soup will get very thin if we don’t put more carrots and beans into the pot.

      Carol…yes, you are right on your first point. Most public sector employees have great health benefits, comparable to employees of many large private enterprises (not including WallMart).

      But I don’t get your second point. Are you suggesting we drag them down to a lower level in order to what…incentivize them to pass legislation that lifts all boats equally? Or are you suggesting stripping insurance down to a bare bones package for everyone so we all would pay more out of pocket, and then use less?

    • eagle eye

      Like dean, I don’t see where you’re going. Are you saying that only public employees have a good system? Since they’re a small minority of the population, that would seem to mean that the rest don’t have such a good system. Doesn’t seem like a very rousing defense of the current system. What then do you suggest — taking away the public employees’ benefits? Is that really supposed to fix things for the vast majority? I don’t think that is going to fly very far, with either the public employees or all the rest.

    • carol

      WHOA NELLY!!! Do we have another Carol in our midst? One who doesn’t know how to end a sentence with a period?

  • Anonymous

    I think anyone that wants to buy their own insurance should not have to pay for universal insurance of others. The supporters of universal insurance can form a pool that is sustainable and the private sector supporters can form their pools of supporters.

    I choose freedom and choice over mandates!

    It seems the supporters of Universal health care want to have it their way only and take away our choices. I don’t see how you can do that if we live in a free society.

    We also seem to have a lot of people that think we are too stupid to make our own decisions.

    Please stay out of my choice to have a private company take care of my health care , I’m Happy with the choice I picked.

    If your not happy with your choice, then don’t drag me to universal health care because you are unhappy with your choice.

    fix your problem but don’t create one for me!

    • Steve Buckstein

      Anon, one proposal that might satisfy your desire to stick with your choice, while letting the “universalists” have what they want is Stephen Gregg’s “Bridging the Ideological Divide.” The short version is at: https://www.cascadepolicy.org/pdf/health_ss/200610_bridging_the_ideological_divide.pdf

    • dean

      Anonymous person…the current Democratic proposals do what you want. If you have an insurance program at your place of work you are happy with, it won’t change a thing. If you are not in the upper 2% or so income bracket, you would not have to pay any more than you are already paying to subsidize insurance coverage for others, primarly the elderly, veterans, and Indian tribal members living on reservations (a treaty obligation we inherited from our great-grandparents).

      No one is saying you cannot or should not make yor own decisions. Except possibly the decision to have NO insurance at all. And the rationale (like with mandatory car insurance) is that uninsured people end up costing us sooner or later at the emergency room.

      “Universal” health insurance is not the same as a “Single Payer System (Canada,) and does not mean loss of choice. It just means no one is denied insurance because they are too sick or too poor. Everyone pays something into the pot, everyone gets a minimum level of coverage. Its that simple.

      • eagle eye

        dean, I don’t believe for a microsecond that the Democrats’ plan is going to be as cheap as they say. That’s what was being said about Medicare over 40 years ago, that it wasn’t going to cost much at all. Now it’s about the upset our financial apple cart for the rest of the century.

        The Democrats, in one way or another, if they can, are going to enact, step by step, an enormously costly plan, with health care rationing for all but the superrich, and vastly higher taxes, with much less freedom of choice than we have now.

        That’s why I hope others will get their heads out of the sand and put better alternatives.

        The Republicans had their hands full from 2000-2006, but still, I blame them a lot for wasting all that time. Alll they did was add on the enormously costly prescription health benefit. Great.

      • Anonymous

        The income tax was first put on the richest of the rich making over around $10,000 dollar a year, this program will be the same. They will forget to index it to inflation or need to tax more and more people to keep it solvent.

        It is a really bad idea unless it is voluntary.

  • davidg

    You sound like Santa Claus: nobody pays more except the very rich (top 2%); everybody gets the same or a better deal than they had before; everyone else gets coverage at some wonderful level of benefits. Basically what you are saying is: the top 2% of the people will finance the cost for the approximately 15% of the people who don’t have insurance now and for the increased benefits everyone else gets.

    There is an old saying that surely applies here: if it sounds too good to be true, don’t believe it.

    Just for good measure, why not throw in some benchmark cost goals, which, if not met, trigger a sunset to the program?

    • davidg

      #12 is a response to Dean at #11.2.

      • dean

        I agree with EE that the present proposals probably understate the costs over the longer term, especially if efforts to moderate health care costs are unsuccessful.

        Davidg…the higher taxes on the upper 2% or so are only part of the financing package. Another part is requiring all large businesses (not sure what the “large” cutoff is) to either pay or play, meaning they either chip in for their employees health insurance or they pay a tax so the government can step in.

        Many of those without insurance will be required to pay something, a percent of income, to buy in, so the taxes at the top do not provide 100% subsidies.

        A number of reputable non-partisan health care adn finance experts have reviewed the Clinton and Obama proposals and validated their figures. What actually ends up passing is another matter.

        And remember that our 50 million (and growing) uninsured are already costing you and me. We pay higher insurance premiums (a hidden tax) to pay for the hospital beds the uninsured take up once they check into the emergency room. Unless the richest nation in the world chooses to start letting its citizens die in the gutter in front of hospitals, we have to find some way to get everyone access to medical care and that has to be paid for.

        EE is right in that the Republicans have had majority control of Congress from 1994-2006 and the White House for the past 7 years. Instead of creating a “free market” system that would actually deliver, they all but ignored the issue, allowing it to grow worse and worse. So the Democrats, who appear likely to increase their majorities in both houses and win the Presidency, will have the ball in their court, for better or worse.

        • eagle eye

          dean, I of course agree with you about how the Republicans blew their chance. But don’t count on the big Dem blowout in November.

          On second thought, do count on it, complacency has been the undoing of many a Democrat these last years.

          • dean

            EE…not counting on it…not me anyway. By reluctantly nominating McCain the Republicans have given themselves a fighting chance to hang onto the White House. The math in the House and Senate (way more open seats to defend for the Rs) suggests strongly that the Ds will increase their majorities. In the past a McCain Presidency with a Democratic congress would logically lead to a focus on moderate, non-ideological problem solving that would be good for the country. But (in my view) McCain’s being forced to the right and his beligerance on foriegn policy drives me well away from him, as it probably will other relatively moderate voters. I probably would have voted for him in 2000. Not now.

            I do worry (a little) that the Dems could overreach with too much power, as your side did in recent years (in my opinion).

            To John E below…did you post this in the wrong arena?

  • John

    March 3, 2008 7:50 AM
    John E. Says:

    If dean wants to help keep up the local charade with Rex Burholder he’s supporting irresponsible or dishonest elected officials.

    His agenda is as transparent as it gets.

    https://www.heartland.org/Article.cfm?artId=22619

    Global Warming Skeptics attend International Conference in NYC

    100s of the world’s leading “skeptics” meet in NYC.
    100s of scientists, economists, and policy experts who dissent from the so-called ‘consensus’ on global warming.
    100s of scientists, many of them with distinguished careers and many appearances in the peer-reviewed literature, believe the Modern Warming is natural and moderate.
    They are being censored by the press and demonized by environmental advocacy groups.

    Will policymakers and skeptics ignore 400 or 500 ‘skeptics’ from around the world?

    100 Speakers Expected
    Plans for the conference include five keynote presentations and 25 panels of scientists discussing a wide variety of global warming-related issues. Approximately 100 experts will give formal presentations at the conference, with several hundred others expected to attend and share information in a more informal manner.

    Five tracks of panels will address paleoclimatology, climatology, global warming impacts, the economics of global warming, and political factors. Each track will consist of four or five panels composed of experts on some aspect of the general topic.

    Many of the presenters will provide written papers to supplement their presentations, which will be collected and edited for publication following the event. Other follow-up activities include planning for a follow-up conference in London in 2009, the launch of a scholarly journal, and publication of a rebuttal to the Intergovernmental Panel on Climate Change’s recently released Fourth Assessment Report.

  • Anonymous

    This post responds to dean’s post at #12.1.1.

    As I remember, one of the main reasons for the Democrats enthusiasm for health care “reform” was that the present system costs too much. But their “reform” program adds new costs to the wealthy (your 2% figure), requires those without insurance to contribute (they couldn’t afford it before but now we mandate that they pay (!??)), and puts some new unspecified taxes on employers. I would say these reforms are definitely going to cost more than the present system, and that is before we start seeing the immense cost overruns typical of government programs. If the present system is bad, then I am sure we can’t afford the effect these proposed reforms will have on it.

    Your confidence in cost projections provided by Hillary and Obama is a little amusing. Neither of these senators has any significant legislative accomplishments. They have both been around long enough to have actually proposed the legislation they only now envision. It is a little premature to say that a “concept program” from rookie legislators will solve any problems.

    Your attack on CATO also seems amusing in view of your unquestioned acceptance of what WHO says. WHO is part of an organization of world governments. Who should be surprised when WHO’s analysis of world health programs finds that government run programs are better than those which are not? If its findings were any different, WHO’s head would surely roll. I don’t think WHO’s analysis should be automatically be dismissed, and nor should CATO’s, just because each organization has its own bias. Each deserves to be analyzed, and its fair for CATO to point out WHO’s bias.

    I frequently hear it, but I don’t fully understand your argument about the uninsured and emergency room service. At one point you suggest that we are letting the uninsured die in the gutters in front of hospitals, but then you acknowledge that that does not happen at all because they can always get free care at the emergency rooms. The proper conclusion seems to be that we are already providing care even for the uninsured. No one is left dying on the street as you fear. Granted that this is a clumsy way to provide a charity service for those who can’t afford anything else. But it negates the argument that service is always unavailable to the uninsured. You have already argued that it IS available to them and that we are paying for it now. You can’t have it both ways. The problems with all of the Democratic reform proposals is that they are gross overkill. Creating a program to target those who need it doesn’t require a national program that everyone must participate in.

    • davidg

      Post #14 is mine, if you couldn’t tell already. In my last two posts I have been a little careless in working with the posting system. I must need a nap.

      • dean

        WHO’s on first? Just kidding.

        Yes…I would take WHO’s analysis with a grain of salt and oay attention to what they choose to measure. But lots of other analyses seem to support their basic findings. In a statistical comparison with other developed nations, the US system costs the most, leaves the most without regular health care, and has poor results on key indicators like life expectancy. Cato’s critique of the WHO analysis is fine as far as it goes. But it does not change reality.

        I don’t have confidence in the Clinton and Obama cost projections. I have some confidence in the independent analyses of these projections.

        No…I suggested that an alternative to us sharing the cost of emergency room care for the uninsured is to just let them die in the gutter, either in front of the hospital or elsewhere. I did not suggest this is happening now, though we are not far from it.

        Yes…some care is available to everyone now. I am not trying to have it both ways. In my view, the richest nation in the world ought to be able to provide a basic social safety net for its citizens, and we do that, though less well than many other nations.

        The broad questions are:
        1) do we stay with our present, expensive, deteriorating system with no changes?
        2) do we reform it in the direction of a freer, less regulated market? 3) do we reform it in the direction of a more regulated market with better access (at the front door, not the emergency room) for everyone?

        Everyone has to participate in a lot of programs we may not individually use, want or like. SSI, spending on natonal defense, spending on wars we don’t support, etc…

        Its a cost of being a citizen of a republic. If your side loses the election, the other side gets to establish what you will participate in, whether you like it or not.

  • davidg

    As to the overall quality of medical care in the US, neither you nor Steve Buckstein seem willing to acknowledge that the main problem might not be with financing, but with what passes for medical care here. US medical practice is much more inclined to use high tech surgery and drugs for every possible condition. This is expensive – and not necessarily effective. You might be interested in a book by Nortin Hadler, The Last Well Person: How to Stay Well Despite the Health Care System. There are a lot of interesting authors and medical practitioners who encourage “lifestyle medicine” and other simple practices which have been shown to be amazingly effective. You and Steve glommed onto that recent (bogus) study saying prevention is not cost effective. You will probably never be able to convince those of us who have experienced otherwise.

    There are “independent” analyses to legitimize the Clinton and Obama plans, plans which are still basically on the drawing boards? You may have more faith than Obama has of hope.

    As to your broad questions:
    Number 1 seems a little bit moot. Change is inevitable. Congress will always be tinkering with everything it gets itself into. That includes health care. We always have change, but not necessarily for the better.
    Number 2: thank you for recognizing the question! I really haven’t seen enough discussion on this alternative, not even from CPI, but it surely deserves more thought.
    Number 3. I am not sure why you think effective reform of our insurance-industry/government-program dominated system is possible. Most everything I see indicts the entire system. So Hillary and Obama want to cobble new appendages on a system that no one likes. How ugly does this monster have to get before we kill it?

    • Steve Buckstein

      davidg, I don’t think I’ve stated that the “main problem” with medical care in the US is financing. It’s a complicated issue and sometimes we deal here with pieces of it. Granted that other factors may be as or more important, and that’s why discussions like this can be so useful – to bring such issues up.

      To your assertion that high tech surgery and drugs are expensive, I have to ask, compared to what? Drugs in particular can actually save costs if they keep people out of much higher cost hospital stays, more expensive surgery, etc. (see Myth 6 on page 15 of “First Do No Harm: Why American Health Care Policy is Failing, and How to Fix It” at
      http://www.cascadepolicy.org/pdf/health_ss/I_121.pdf

      On prevention, I’m not trying to convince you or anyone else that prevention is not a good and cost-effective thing in your own life. It probably is. But system-wide, efforts at prevention by themselves are likely not cost saving because providers will react to maintain their income. When a politician claims that emphasizing prevention will help us save a lot of money that we can then use to cover the uninsured, I simply urge you to be skeptical.

      • dean

        Davidg…your larger point is well taken. We all can and should take more responsibility for our own health. But there are times when even otherwise healthy people need costly high tech medical intervention. A case in point is a friend of mine with a daughter who has cystic fibrosis. No amount of “lifestyle medicine” is going to help her cope with this genetic condition. She was basically kept alive through high tech methods for several years while awaiting a lung transplant, which she had and is now a healthy young person with hope of a future.

        No matter how healthy we keep ourselves we are only postponing the inevitable. We age, maybe we get Alzheimers or another chronic condition, and we become expensive to care for. That is what the study you cite found, not that living a healthy life is useless.

        The proposals of Clinton and Obama are reasonable adjustments to a very imperfect system that the ‘health care industry” won’t let us demolish and rebuild from thje ground up. They can solve a few festering problems, but neither gets at the root issues. Our hodgepodge regulated private insurance through employment system is badly designed, way too inefficient and expensive, too discriminatory, and is more focused on denying care than on keeping people healthy.

        I don’t have “faith.” I trust in good analysis from reputable researchers.

      • davidg

        Steve, thanks for the link to the very well written and reasoned Pozdena article. I certainly agree with his conclusion that the solution to the problem of the cost of healthcare: put the patient back in control of spending health care dollars.

        Pozdena didn’t address cost escalation caused by poor medical practices. You asked: surgery and drugs may be expensive, but compared to what? As one example, Hadler discusses bypass surgery in his book I cited above. Hadler shows how advances in medical theory on the causes of heart disease make bypass surgery obsolete. Yet hundreds of thousands of these operations are performed yearly in the US at a cost of $30-50,000 each – a staggering waste. You don’t have to believe Hadler. Any large bookstore has a half dozen or more books available making the same arguments as Hadler.

        Drugs aren’t exempt from the problem. Hadler basically says that the closest thing we have ever had to a magic pill is simple aspirin. It is one of the most effective and safest of the NSAIDs (non-steroid anti-inflammatory drug). Yet many people pay large sums for similar products, both non-prescription and prescription. A little education can go a long way here.

        Hadler gives other examples, and, as I mentioned, there are many interesting books available discussing the same issues. But even more exciting are the number of books available by doctors who are successfully treating the severe chronic diseases (diabetes, heart disease, osteoporosis, arthritis, and sometimes even cancer) with “lifestyle medicine” practices – with little or no drugs or surgery. The potential for cost savings are enormous, as discussed in Surgeon General Koop’s article I cited for you in a previous discussion. That recent article argued that we must all die of a chronic disease, and the later we die the more expensive that death will be. It is certainly true that we all will die, but there is no necessity that it will be by some debilitating chronic disease. That assumption was unproven in the article.

        Drugs and surgery of course have a large and valuable role to play in medicine, especially for acute problems. But they are greatly overused, and have only limited effects against the chronic diseases. Many doctors have recently demonstrated that their use can be all or substantially avoided in the treatment of chronic disease. That is the target goal that any national health plan should strive for. I see it as more of an educational role than any type of administrative or financial role.

        Dean, you make a good argument that the entire health care financing structure needs to be junked. I think Steve and I are in agreement with you on that. See the interesting Podenza article Steve cites for the direction Congress needs to go to do that.

        • dean

          Okay…I’ll check it out. The Netherlands study that suggested no savings from preventitive measures was based on a statistical model by the way. I don’t think it was intended as a final “proof.”

          Based on what I know (not much,) I would “junk” our system and replace it with the French system, which is single payer (tax supported) for the basics, with an option for individuals to buy a supplimental policy for extra servces. By all measures I am aware of, they seem to kick everyone elses butt on high quality delivery at relatively low cost (about 50-60% of what we pay).

          But…we can’t go there because too many well heeled doctors and insurance companies will kill it as “socialized medicine”. Cest la vis.