Shooting for Sweden, Hitting Venezuela

Great Debates
181

Being larger is generally considered an advantage. Its called the “internal economics of scale” Admittedly it does not have any huge effect in healthcare, but it is not a disincentive. There are no difficulties scaling from the size of Iceland to Australia to Germany for example.

Yet if we look at other countries which are unhealthy, in terms of obesity, alcohol consumption, etc, we find the US lags them too. Among developed nations, New Zealand is next after the US on obesity, followed by the UK. They both have higher rates of alcohol consumption as well. Yet New Zealand has a life expectancy of 81.6 years, the Uk of 81.2 and the US 79.3. If you rank countries, there does not in general seem to be a connection between healthy living and lifespan.

Why do you suppose that is?

"Cognitive bias" ? I’d say it looks like something else. An understanding of maths, maybe, or a sense of proportions.

There are about 55 million pupils in the US. Paying 2400 more per student is an overpay of about 132 billion. There are about 320 million people in the US. Overpaying by 5000 per year costs 1.6 trillion. About 9 % of GDP. Now, to put that into some sense of proportion the US military expenditure is generally considered to be very large. It is 3.3 % of GDP.

So I’d say considering an overpay of 1.6 trillion to be a disaster, and an excess of 132 billion not to be, seems entirely reasonable.

And the US getting better results than Canada? No.

Having lots of systems without much in the way of standardization is a large part of what wastes those 1.6 trillion. Excess bureaucracy. There is a lot to be said for doing it by state, but it’d take some pretty firm regulation and standardization at the federal level.

Other people have pointed out that this is wrong. But I wanted to actually look at it a bit more, because its more than just wrong. Its amazingly wrong. Its a statement from another planet.

The US, by the latest numbers spent 10 300 $ per person. Switzerland spent 8 000. Norway spent 6600. In terms of GDP, the US spends 18 % on healthcare. Switzerland is 12.5 and Norway 10.5. So its about a military budget down to the expenditure of Switzerland and almost two down to Norway.

You know, a lot of the stuff Europeans get could probably be fitted into two military budgets.

Now, let us look at the results they get for that spending. Lifespan in years, US 79.3, Switzerland 82.6, Norway 81.9, Canada 81.9. The US is, according to the CIA World Factbook near the bottom of the first world. Infant mortality, Norway 2.5, Switzerland 3.6, Canada 4.5, the US 5.8. Bottom of the first world.

Healthy life expectancy, Switzerland 73.1, Canada 72.3, Norway 72.0, USA 69.1. Thats at the bottom of the first world rankings. Maternal mortality per 100 000 births, Norway 5, Switzerland 5, Canada 7, United States 14. Bottom of the first world.

Mortality amenable to health care, Switzerland 55, Norway 62 , Canada 78, USA 112. Ranking… well I think you can guess now. Near the bottom of the first world countries.

So yes, the US spends amazingly much more than the runners up, and gets very poor results.

Note that when I use the term “first world countries”, that is western Europe, Australia Japan etc. I do not include what used to be called the second world of South America or the old Warzaw Pact states where most of the population grew up in totally different systems. The US is not a standout among Eastern European nations and may in fact be a little above the middle.

I can see why you’d think numbers stupid. However, the reason large overarching measures are chosen when comparing healthcare systems is to make countries fungible. Rather than cherry picking single areas like cancer. It is not at all uncommon to see developed countries compare each other and decide that “We need to learn from what those guys are doing”. The US resistance to learning form others is a cultural trait, not a measure of any difficulty in doing so.

As for Singapore… well I’d find their system excessively coercive myself. But not excessively cheap all things considered. See, there is a lot of countries out there to look at when examining how healthcare scales. And what we see is that the total population isn’t all that important, theres some economies of scale but not massive, but population density is absolutely important. The lower the population density the more expensive it gets. And a nation small and dense enough to cover the entire population from one hospital can realize some amazing savings. Its not compulsory, but most do.

Singapores mixed financing with compulsory savings costs them 5 % of Gdp. San Marinos Bismarck style system costs 6 % of Gdp, Andorra is also Bismarck and spends 8 % of Gdp, Luxembourg spends 6 %. The city-state sized nations spend vastly less on healthcare compared to larger nations, regardless of system.

I’ve left out the Vatican due to exceptionally lopsided demographics and Monaco which I think is included in Frances system.

182

Absolutely true, but when it comes to health care, the adverse selection inherent in health insurance is absolutely the primary problem. It’s the iceberg. Everything else are the tips.

Every industrialized country that has specifically targeted the issue of universal insurance (which is most of them) has largely brought this problem under control. I’m not saying they’re all perfect but perfection is unattainable.

183

I am under no such impression and made no such statement. I might also add that clinics are generally for-profit enterprises in Canada, too, and that hospitals are independent non-governmental entities, and sometimes – as in the case of the famed Shouldice Hospital in Toronto – are private for-profit entities. You have completely misunderstood the second statement I made. When I say “access to health care”, I am referring specifically to health care coverage and how it’s financed and the financial obstacles to accessing health care, which have been explicitly eliminated in Canada (by the principles of the Canada Health Act) and in all first-world nations except the US, where financial obstacles to health care remain tragically onerous.

You are just simply factually wrong about adverse selection being the only problem with private health insurance. I’ve already itemized the major issues in post #174 and referred back to them once before, yet you still don’t get it. The major issues with private insurance include the following:

[ul]
[li]The huge complexities, administrative overhead, and paperwork it introduces into the system, and the consequent enormous costs. Talk to anyone who has moved from Canada to the US about that. I have.[/li][/ul]

[ul]
[li]Insurance companies meddling between the doctor and the patient, denying treatment or approving only cheaper alternatives, sometimes driving even well-insured patients into medical bankruptcy.[/li][/ul]

[ul]
[li]A fragmented, unregulated system in which it’s impossible to systemically control costs.[/li][/ul]

[ul]
[li]Risk-based rather than community-rated premiums, which is the one and only illustration of your “adverse selection” theory.[/li][/ul]

[ul]
[li]The extraordinary costs and inefficiencies introduced by artificial patchwork solutions like Medicaid and EMTALA laws, which are basically very expensive failed attempts to make up for the absence of UHC in the US. That, and the unnecessary complexities of Medicare, result in the US spending more public tax dollars on health care per capita than other countries spend in total on universal coverage, while still relegating most of its citizens to the ravages of private insurance companies.[/li][/ul]

Yes, it is, and I never said otherwise. Again, I was pretty clear in making the distinction between health insurance and health care services. If health insurance is funded as a public service, it’s obviously possible for it to be underfunded or otherwise mismanaged, and that would affect the availability of resources. This is a self-evident fact. The difference between the outlook of most countries’ citizens and conservative Americans is that the former trust their government to fund their health care system appropriately, and their expectations have generally been met – as indicated, for instance, by Canadians’ general level of satisfaction with their health care system.

Bullshit. I’ve been posting on this board on health care issues for nearly five years. I have never “changed my argument” or made any claim other than the one I’m making here and now. If at any point my argument wasn’t clear that’s on me. If you misunderstood my argument despite its clarity that’s on you. But my central point has never changed: market-driven private insurance as the basis for medically necessary health care is fundamentally wrong, inappropriate, immoral, and leads to tragically undesirable outcomes.

184

Define what you mean by market-driven private insurance.

Most people in America get their insurance through the government - medicare, Medicaid, VA, S-Chip - or through their employer. Then, there are some that get a private plan on the ACA exchanges.

Do you consider that “market-driven private insurance”? If so, why?

185

Yes it is “market-driven private insurance”. Private doesn’t mean that a person must shop for it personally. The insurance one gets through one’s job has been chosen by the people from Purchasing, but it’s provided by a private company which is interested in getting maximum profit.

186

That statement is categorically false. Most people in America have private insurance through their employers – about 60%, and another 9% buy individual plans directly. This does not count those who have some degree of government help but also utilize private insurance. Employer plans and anything bought on ACA exchanges are all private insurance. Medicare is only for those over 65, Medicaid only for the very poor, the VA only for veterans, and CHIP (not called SCHIP any more) is only for low-income families with children. Most of these government programs are sadly inadequate, essentially by design, since Republicans, especially, reject on general principle the idea of federal government involvement in health care.

What do I mean by market-driven private insurance? Clearly I’m mainly talking about the private health insurers, and we all know who they are: the Blue Cross organizations, Unitedhealth, Wellpoint, Kaiser, Humana, Aetna, HCSC, Cigna, etc. Essentially the organizations listed here. But it’s actually worse than that because, perversely, even Medicare adopts some of the same policies, though mercifully not all of them.

So perhaps the most productive answer is to focus on the key defining characteristics of what I regard as unacceptable health insurance practices associated with market-driven insurance or systems that are modeled on them. As a general statement, it means any system that treats coverage of medically necessary health care as a business rather than as a patient-focused public service; in effect, treating human health care like auto insurance rather than like social security. The salient factor here is that health care coverage and therefore access to health care can be denied if the person cannot afford a suitable coverage plan, or can be denied for arbitrary policy reasons. This is routine in the insurance business. It is utterly unacceptable in health care.

More specifically, my thesis is that any system with one or more of the following attributes is fundamentally inhumane and has no moral right to insure human health care:

[ul]
[li]Any system whose rates are set based on actuarial assessment of individual risk or risk for a specific cohort.[/li][/ul]

[ul]
[li]Any system that routinely scrutinizes individual claims for conformance with extensive and complicated contractual terms, and therefore any system that is capable of arbitrarily denying claims, the consequences of which can include withholding critical medical care and/or financial ruin; in a word, the consequences can be death and/or personal bankruptcy.[/li][/ul]

[ul]
[li]Any system that places arbitrary limits on payouts, whether annual, lifetime, or per incident, such as preset limits on the length of a hospital stay, the consequences of which are the same as stated above, including the practice of ejecting a patient from a hospital despite still being in need of medical care.[/li][/ul]

[ul]
[li]Any system that places arbitrary restrictions on what doctors or hospitals are covered, or leaves the patient liable for exorbitant costs for “out of network” services.[/li][/ul]

[ul]
[li]Any system that excludes for any reason coverage for any generally approved and available procedure that a doctor deems to be medically necessary.[/li][/ul]

187

What I said was true. The majority of people in America get their insurance through the government or their employer. That’s a fact.

It’s not really a market. When I buy a car, I have many choices, many options, and I know (within reason) what the price will be. When I buy food, there are choices in where to buy, what to buy, and the price. Those are markets. With health insurance, that’s not the case.

I agree that we have private health insurance (which is not immoral at all). We also have public/govt-based insurance, which is also not immoral. And we have a very tiny sliver of people who buy private plans on the exchanges, which in some states, it’s sort of a market.

America has issues we need to fix. We have 29 million without insurance, and that needs to stop, and it could be stopped of our politicians had the willpower. But calling our system market-driven is laughable, and doesn’t strengthen your argument.

188

The insurance workers in the US get through employers is private. That’s a fact.

189

Moving on down the Wall of Wrong…

You do realize that the US probably has both the least fixed prices and the greatest shortage of physicians, though?

The reason for this great gulf between how you believe things should work and how they actually work is that your understanding of economics seem incomplete and focused on supply and demand. The thing is, in a market the actors will always aim towards the greatest profit. Which on the supply side is forming a cartel or otherwise getting a monopoly. Especially in cases where there is low price elasticity, ie. the customer cannot refuse to purchase the product. Like health care. It helps if there are barriers to entry. Like health care. And if there is a significant asymmetry of information. Like in health care.

Not that supply and demand are entirely innocent. One of the reasons for the GP shortage in the US is that being a specialist is much more lucrative. (And I’m not saying that the US educational setup selects for physicians who are inclined to go for extra qualifications to earn more money, but…)

“Every incentive” kind of assumes that the only motivation of a physician is financial don’t you think?

Average time in Sweden is 22,5 minutes, Norway 18, Finland 17.5, Switzerland 17, France and Canada 16. So it doesn’t look like fee for service is making that much of a difference, really. It is however true that the US is among the nations with the longest doctors visits, behind only Sweden (who is fee for service)

But that neglects that the US has among the fewest numbers of doctors visits per year. The US average 4 doctors visits per year. In the first world, only Sweden has markedly fewer visits, interestingly. Canada has 8, Germany 10, Japan 13. Admittedly, time spent per patient in Germany is significantly shorter. But maybe its reasonable that if you visit the doctor twice as often each visit is shorter.

All the nations with long visit times have a less than average number of visits per year. At a glance, it looks like the total time with a physician does not vary that much between nations, its mostly how many visits its spread over.

You are generalizing from a sample of one here. Canada doesn’t generally do well on waiting times, but it follows that doing better than Canada does not mean you are doing well. Insurance-based systems such as the US does tend to do well in this area, all three nations place above average or towards the top in waits. It doesn’t mean they are the only ones doing well or that not doing well is intrinsic to public systems. Denmark often comes in tops for some reason.

But waits are not even across all areas, which makes comparisons hard, and the US is often left out of studies because the lack of a central authority makes data gathering harder. However, the US tends to do badly on same-day or out- of- hours care, but once seen, Americans face shorter waits for specialists. The US does well on waits for elective surgeries, but not so well on non-electives, because other systems prioritize them harder. In effect Americans trade away fast service for vital surgeries in exchange for faster access to electives.

Of course none of this includes the uninsured or refused coverage fraction in the US who basically face infinite waits.

I live in Norway, and here is what I’d do if I needed a knee operation: I go online and look at the public portal for such things to pick the hospital I want. I am looking at it now. There is a hospital in Ålesund that has a wait of less than a week on that. I’d get an appointment with my doctor (or shoot her an email) and she’d book me in there. Assuming there are no complications I am unaware of. The flight would be covered, save a co-pay of about 50 $. Its a private hospital and after the operation they’d bill the government the agreed-upon fee for a knee.

I don’t disagree with you that waits are not Canadas best area. But I wanted to empathize that Canada is not representative of other nations or UHC systems in this area.

190

Yes. But they aren’t going to a “market”. Most companies provide almost no choices in their health insurance options. My company has only one option. It’s good insurance, and I like it. But it’s either that or nothing.

I’m not arguing against the label of “private”. But it’s not “market-driven” here in the USA.

Private and Market-driven are two different things altogether.

191

I had always assumed that the companies who purchase insurance for their workers review options, and compare and contrast. Maybe even negotiate, if they are large enough. Do not companies operate in a marketplace when purchasing?

192

The person who purchased the insurance did have options. When I purchase food for my family, is it not from a market with multiple options? I’ve got three small supermarkets, a traditional market (think Philly’s Central Market or LA’s Mercado) and multiple individual stores within 300yd of my house. That the purchases have been made by me and not by them doesn’t mean the food my relatives get isn’t from the market.

Hell, one of the worst parts of the insurance I got from my employer during my first three years of living in the US is that it changed every year. Every year, the company would choose a different policy from those available in the market, thus sending a lot of people back into pre-existing-condition-land (at least that one has sort of been removed).

193

This is nonsensical gibberish. Getting health insurance as a group policy from one’s employer is still private insurance that has all the fundamental reprehensible issues I itemized in post #186. Most of the time when employees get group health insurance it comes from private insurers like the ones I listed earlier, companies like Unitedhealth, Anthem, Kaiser, Humana, Aetna, HCSC, Cigna, etc. Most of these companies issue publicly traded stock on the NYSE; they compete in a competitive insurance marketplace where their customers buy health insurance as a commercial product in a price-driven marketplace; they are accountable for profits and revenues to a board of directors which is in turn responsible to the shareholders. You can’t get any more market-oriented than that, and from this basic fact, as I and others have tried to explain to you, arise all the problems with health care in the US, as summarized in the above-cited post.

If you think this is “laughable” then you don’t understand what “market-driven” means, and you definitely don’t understand the fundamental difference between health insurance as a business and health insurance as a universal patient-centric public service. You are spouting uninformed nonsense that shows you don’t understand the fundamental nature of health care economics, much as you did earlier in the other thread about Medicare where I simply had to cease trying to engage with you because it was pointless.

As for my point about immorality, running health insurance for medically necessary services as a profit-making business is immoral for the simple reason that many people die because of it, and many others are driven to financial ruin because of it. It’s just that simple. Your inability to understand this is not my problem.

194

However, this is a bit more like you buying food for a huge hippie collective with hundreds of people, or a prison. For the people living there, for the consumers of the food, is there a market for food?

60% of Americans are, at best, one step removed from the market, where their market power is reduced to complaining to HR about their choices.

195

I guess I would be wrong had I said that, but I didn’t. I don’t know who you’re arguing with, but as it keeps coming back to “the American system sucks,” a theory I certainly don’t disagree with and am not sure how it relates to my point, I guess we can agree on something.

That’s an odd claim, regarding a shortage of physicians; where is that from?

Obviously, less developed countries will almost all have serious shortages of doctors, far more so than developed countries. Sub-Saharan African countries - excepting South Africa, Botswana, and Namibia, whose economies are relatively strong - are famously doctor-starved. So I’d assume you mean only developed nations, but by what measure is the USA more short than others? The USA has more physicians per capita than Canada, according to all three sources I dug up just now (albeit by a small margin) or, to my admitted surprise, Japan, which I honestly thought would have a lot.

Of course, the sheer number of physicians might not be a good way of measuring this.

196

The US has a Primary Care Physician shortage. link

We’re doing a bang up job with specialists though. Not too surprising, since we likely have fewer routine visits than other countries, and good turn around on specialty service.

197

Oh, actually the American system is more like being in prison and having to pay for the food whether you like it or not, along with fees for using the bathroom, and for the toilet paper, and for washing your hands, and for the water, and for the soap…

But that the people choosing the food aren’t the same ones paying for it (it’s paid in part by the employees and in part by the company) doesn’t mean there isn’t a market. There is. And it blows, more in a BOOM way than an “oh yeah baby” way.

198

Nava addressed part of this but let me take a different tack. The analogy fails and therefore it fails to elucidate the main point I was making in the previous posts. Food is an end product but health insurance is not – it’s a means to the real end product, which is health care services. A more apt analogy is if what you were buying was not food, but the services of a food supply contractor, and one who operated in an environment of inefficiency and mercenary motivations to spend as little as possible on providing actual food.

As I and others have pointed out, the fact that health insurers operate in a competitive marketplace selling product which companies and individuals buy based on price and features is certainly indicative of a competitive insurance market, but that’s just a symptom of the fact that this is a market-driven approach to health insurance, and not the real problem. The real problem with insurance as a market-driven business is how the end customers are treated – how access to the real product, actual health care, is mired in vast and costly bureaucracy and essential health care is frequently denied or downgraded to satisfy the interests of the shareholders and the bottom line. For other forms of insurance, like car and home insurance, this is how a business has to operate. For health care, it’s fundamentally inhumane and immoral.

I tried to summarize some of those market issues in the bullet points at the end of post #186. The US market approach to health insurance has created a system responsible for the fact that thousands of people die unnecessarily every year for lack of access to necessary health care, including many who thought they were insured, and thousands more are driven to financial destitution.

199

Well, it was background knowledge but I did look it up again when you asked, and its still the case. Its normally measured in terms of physicians per 1 000 population. The US is up from 2.3 the last time I looked to about 2.5 today. Almost dead even with Canada. In the first world, Canada, Singapore and South Korea stands out as having less doctors than the US.

You are generally right about less developed countries generally having shortages. My keyboard is being defiant about links, but you can go here for a good link:

Second image down, pass the mouse pointer over the bars to get the number on each country. You can click it to highlight it.

200

I do see though that my original claim was “probably the greatest shortage of physicians” and this was clearly inaccurate. A more accurate statement should have been “one of the first world countries with the greatest shortage of physicians” or “one of the four first world nations with the greatest shortage of doctors”.

Anyway, onwards!

Pretty sure Nokia and Ericsson would have produced phones regardless of what the US government said.

Once again, this does not seem to match how things work in the real world. Large developed nations produce just as much biomedical research per person as the US does. They just spend less money on it for the same or better results. Like the rest of healthcare.

I think your analogy may be leading you astray. What happens in the real world is, government healthcare systems negotiate prices with the pharmas until they reach a price that is acceptable to both parts. Its known as capitalism. I don’t know what your car example is intended to illustrate but it doesn’t bear any resemblance to how these things are done.