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Monday, July 02, 2007

Bad Medicine 

For some reason, I'm thinking about health care a lot these days (No, I'm fine, thank you for asking: except for needing to lose a few pounds to get to race weight, I've never been better).

I was over hanging around Darren Barefoot's comment on the new film Sicko. This is roughly what I said there:

Nobody wants to say it so much, but as bad as the health care system in the US is (for a minority of its citizens, it should be said, as opposed to the well-covered ones), no country’s medical care system (at least the parts where the US differs substantially from the rest of the world) makes much of a difference.

What separates the developed world life expectancies from undeveloped-world life expectancies is mostly stuff like child immunization, clean drinking water, and effective treatments for diarrhea (ORT, which is pathetically cheap and incredibly effective).

What separates Cuba (and other nations, mostly in the “developing” category) from the US is probably the availability of enough, but not too much food (and not a lot of meat). Thus the average Cuban is on a calorie-restricted but not starvation diet.

The average American or Canadian or European diet? Not so much. Or rather, too much.

Meanwhile, the health care spending makes people healthier in relatively marginal ways: the rare young cancer patient benefits if we can extend their life by 30+ years, but they are rare. We can give you knee surgery and hip replacements, but those don’t make you live longer, they just make you able to play golf at age 60.

Unfortunately, all these marginal treatments are really pricey. As has been noted in the field, the last six months of a patient’s life are often the most expensive, medically speaking. This is because, well, we can’t always be sure they’re going to die, but without medical intervention we’re pretty sure they will.

Then they do, and all we have to show for our dramatic medical intervention is a lot of public health expenses.

Regarding the issue of the value of marginal spending on health care, see this slightly leftish discussion and this rather libertarian discussion. Both lean heavily on a government-supported RAND study that took a sample group of 7700 uninsured Americans, and gave them one of five types of insurance, ranging from free care, to HMO-style care, to a group that had a 95% co-pay with a capped maximum annual out-of-pocket cost (in essence, the subject would have been sheltered from catastrophic medical costs, but would have to pay virtually all of their routine doctor-visit costs).

There was almost no difference in their health outcomes. The free-care group showed a bit better control of hypertension, and had better vision (I suspect this means they kept their eyewear prescriptions up to date). Marginal value of health care and all that.

A serious examination of modern health care systems needs to be clear-eyed about what they can and cannot do for the money.

Comments:
Dang, I thought I posted a comment here, but it doesn't seem to have stuck. I'll try again:

but as bad as the health care system in the US is (for a minority of its citizens, it should be said, as opposed to the well-covered ones)

"Sicko" mostly isn't about the uninsured in America, it's about the insured who discovered that their coverage wasn't nearly good enough.


What separates the developed world life expectancies from undeveloped-world life expectancies

Interesting tactic! most comparisons of the US health care system are with other developed countries and how there are significant differences in health outcomes regardless. (Yes, even if diet, genetics, etc are factored out.)


We can give you knee surgery and hip replacements, but those don’t make you live longer, they just make you able to play golf at age 60.

This is a breathtakingly blase way of dismissing quality of life issues. I disagree quite strongly; quality of life ranks a very close second -- or even tied with first -- with quantity of life.

Also, it's hardly just being able to play golf; it may come down to living independently vs assisted care. (This factor is also why even in an age with dialysis, we perform kidney transplants.)


A serious examination of modern health care systems needs to be clear-eyed about what they can and cannot do for the money.

Fair enough. I will agree with that, but not with the unstated implication that quality of life is an unimportant metric.
 
Andrew: there are differences between the US and the rest of the free world. But these are measured in years, at most. I went to the WHO website and poked "Canada" and "USA" into the tables. I read off the simplest number, life expectancy at birth (both sexes), data as of 2005.

Canada: 80.5 years
USA: 77.9 years

Okay, two more.

Sweden: 80.9 years
Cuba: 77.2 years

The reason I compared the US system to undeveloped-world systems is to illustrate the magnitude of the differences. The US has slightly shorter life expectancies than those in places like Canada. UK is 78.9, which is also a tetch better.

It would be interesting to say that if Canada has a Swedish-style medical system, the US has a Portugal-style medical system (78.2).

Life expectancies in the developing world start around a decade shorter than those in the US, and Mali (a more or less random example) has its life expectancy at 45.9. Much of Africa seems to experience life expectancies in the forties.

So with these raw numbers, with most of the lifestyle stuff left in (and I think we mutually agree that the lifestyle stuff favors Sweden, and probably favors Canada), show slight differences between life expectancy outcomes among various developed countries including the US.

They show huge differences between those countries and countries with actual healthcare crises.

Now, as to the quality of life issues, I am open to hearing how these are better in Canada than the US, albeit with the perspective that I'm going to bring up Chaoulli v. Quebec, medical tourism by Canadians, and all the other things that suggest that quality-of-life issues are very hard for our system to deal with. In short, this is because they cost a lot and generally get shuffled to the back of the line in preference to people who are dying.

That's the right prioritization, but the prioritization alone suggests that people are not getting all the medical care they want.

Note that I'm making parallel arguments here: Canada and the USA both have systems that could use improvements. But they're both already world-class!

Perhaps we should both move towards a Swedish-style healthcare system. You know, user fees and parallel private-care systems!

It's interesting that if you read that link, even more than the pros and cons of the Swedish system, what stood out to me is that the Swedes are also trying to re-engineer their system.

I don't know if the results will be good or bad, and maybe nobody will know for a decade. Maybe we're all dissatisfied that doctors have not yet shown us the path to cheating death.

I know I'm so despondent about this fact, that I'm going to go to the local Kwik-E-Mart (2 miles from my house) and have a donut with sprinkles and pink frosting.
 
They show huge differences between those countries and countries with actual healthcare crises.

Those countries _aren't outspending even other developed countries, per-capita by two-to-one_.

It is very important to consider that you can get turfed from a hospital to a shelter in the United States _because your insurance ran out_. Insured patients! Does that happen anywhere else in the developed world? It might not be a crisis to you because it's not you getting turfed, but it matters... particularly because, again, per-capita the US healthcare expenditure is _double_ most comparable countries and yet the outcomes are barely keeping pace.

medical tourism by Canadians

That's mostly mythical, as I blogged over a year ago. (But if the topic concerns you so much, consider that it's a growing field among American patients.)


I'm going to go to the local Kwik-E-Mart (2 miles from my house)

My closest one is 0.8 miles away as the Google Map flies... =) But it'll be open till end of July and I heard the initial rush has already consumed all available Simpsons-style donuts.
 
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