Monday, March 30, 2009

Liberals vs. conservatives - Answers to Liberal Litany on U.S. Health System "Crisis"

In my upcoming book, Obama, Doctors, and Health Reform, I have a chapter called “The Litany.” The Litany refers to the off-repeated but seldom countered complaints about the U.S. health system – that it costs too much, covers too few, creates too many bankruptcies, and leaves in its wake miserable health care statistics.

These U. S. statistics, compared to other industrialized nations, include: shorter life expectancies, higher infant mortalities, more uninsured. and more rapidly rising cost. Many of these statistics stem from the simple fact that one of every five Americans in now an immigrant or a close relative of one and that these immigrants are often beyond the reach of the health system.

Tone of Criticism

The general tone of critics’ complaints is: as a civilized nation, we ought to be ashamed of ourselves. Our health system is “in crisis,” and our old, poor, disabled, and sick are dying in the streets for want of care.

In response to these litany of complaint. John C. Goodman and Devon Herrick of the National Center of Policy Analysis, Linda Gorman of the Independence Institute, and Robert Sade of the Institute of Human Values in Health Care, have prepared a 20 page rebuttal “Health Care Reform: Do Other Countries Have the Answer?” they back their rebuttal with 87 references.

1. Does the U.S, spend too much on health care? Other countries, they say, “ aggressively disguise costs” and treat long term care, out-of-pocket spending, overhead costs differently than in the U.S.. Per capita, the U.S. uses fewer physicians, nurses, hospital beds, physician visits, and hospital days than median OECD nations. The average growth of our spending per capita is below that of over nations (3.7% vs. 3.8%) and has been so over the last four decades (4.4% s. 4.5%). Further, our waiting times for procedures are far shorter than other countries.

2. Are U.S. outcomes better or worse than those of other countries? The authors argue that U.S infant mortality varies enormously in the U.S. across racial and ethnic groups by factors of 2 – 3: 1 across cities and states for reasons that have little to do with health care. U.S. infants, once born, have high likelihood of survival. Five year survival from cancer in higher in the U.S. than in Europe. Our rates of hypertension and hypertension control are greater. And our rate of adverse events in hospitals is less. Our waiting lists for dialysis, hip replacement, knee replacement, bypass surgery and cataract surgery are much less. The authors comment, “It is not clear whether the U.S. spends too much on health care or other countries spend too little.”

3.Is the large number of Uninsured in the U.S. a crisis? The authors say that uninsurance is often transitory, that 83% to 86% are insured, and that our unprecedented influx of immigrants causes uninsured 2 ½ times that of the native born population. Of the 46 million uninsured about 12 million are illegible for Medicaid and other public programs. 17 million of the uninsured live in households of $50,000 or more, and more than half of these earn more than $75.000.

4.Does lack of health insurance cause premature death? The consensus of economic studies is that “insurance has a relatively small effect on health.” The authors argue that it is not known how much mortality and morbidity is due to lack of health insurance. They also point out that creating universal coverage by having people enroll in Medicaid may cause them to drop private plans, which may cause worse health outcomes.

5.Are medical bills causing bankruptcy? They cite a series of economic studies indicating that only 17% of ‘Medical bankruptcies” are actually so, that there are few statistical links between bankruptcies and health problems,

6.Are administrative costs higher for private insurance than public insurance?

Here is their comment, “The Congressional Research Service has estimated the administrative costs of Medicare at 2% of total program costs, compared to 10% of private insurance and 12% for HMOs. Some single payer advocates have uses this estimate as an argument for a universal Medicare program. These estimates ignore hidden costs shifted to the providers of care, and the social cost of collected takes to fund Medicare. A Millikan & Robertson study estimates that when these costs are included, Medicare and Medicaid spend two-thirst more on administration than private insurance spends on administration: 27 cents, compared to 16 cents, respectively for each dollar of benefits.”

7.Are low-income families more disadvantaged in the U.S. system? In Britain, the National Health Service, despite its 60 years in existence, has done little to equalize health care access. In Canada, the wealthy and powerful have much greater access to medical specialists than the poor. In Canada, low-income Canadians are 22% more likely to be in poor health than their U.S. counterparts. In all OECD countries, higher income people use the system more intensively than at higher costs than lower income people.

8.Can the free market work in health care? The portrayal of the US. as a more market driven system may be more perception than reality. In the U.S. 13 cents of health care money is spent out of pocket, and in OECD countries the average is 20 cents. In the U.S,. cosmetic surgery and corrective visual out-of-pocket costs have declined 30% over the last decade. Retail clinics have proliferated. They post prices, keep EMRs, and prescribe electronically. Systems operating outside of 3rd party payments and constraints have lower costs and better quality. Wal-Mart is and Target are offering $4 prescriptions for generic drugs, and more than 10 million of U.S. families are managing their own care through health savings accounts, and many countries, such as Singapore, South Africa, and Switzerland rely on private insurance mandated by government.


The authors conclude,” Support for government regulation of health care financing and delivery has been based on a narrowly selected data, while all but ignoring contrary data. We have attempted to correct the record by discussing some specific gaps and suggesting the U. S. health care reform would benefit greatly from a careful examination of the current success and future potential of market-based reforms.”

If I may summarize,

Be careful before accepting the prevalent liberal litany,

that the U.S health system should live in eternal infamy

that United States health statistics are uniformly poor,

compared to other nations with coverage door to door,

and that the market is for the few and not for the many.

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