Sunday, July 5, 2009

European vs. US Health Systems: Which one has the real drawbacks?

An Associated Press story that appeared in the New York Times on Independence Day, July 4, 2009 titled “Europe's Free, State-Run Health Care Has Drawbacks”, tries to be a cautionary piece about going too far with health reform. It starts:
“As PresidentBarack Obama pushes to overhaul the American health care system, the role of government is at the heart of the debate. In Europe, free, state-run health care is a given.
The concept has been enshrined in Europe for generations. Health systems are built so inclusive that even illegal immigrants are entitled to free treatment beyond just emergency care. Europeans have some of the world's best hospitals
and have made great strides in fighting problems like obesity and heart disease.”

Sounds pretty good to me. No problems yet. Then the warning:
“But the system is far from perfect.” We knew it. Let’s hear about those problems:
In Britain, France, Switzerland and elsewhere, public health systems have become political punching bags for opposition parties, costs have skyrocketed and in some cases, patients have needlessly suffered and died.”

Excuse me? These are supposed to be problems with Europe? These are also problems in the United States, the main differences being 1) scope – how bad and extensive these problems are (worse in the US than in Europe), and 2) intent – who are we trying to cover (them: everyone; us: some people. Certainly including the policymakers).

Let’s deal with these one at a time:

“Public health systems have become political punching bags for opposition parties…” Of course. Everything is. But in Europe, even those criticisms address the edges of the system; no significant political group in any of those countries is suggesting the abandonment of government-guaranteed to coverage and access to care. In the US, in contrast, the opposition (Republicans) has taken essentially no position except to say “no”. The Republican position on health reform reminds one of nothing so much as a 2-year old who can only utter that one syllable but is completely incapable of coming up with a positive suggestion. Of course, they have limited options since the administration and the Democratic leadership of the Senate have committed themselves to building the sacred for-profit insurance industry into their own health reform proposals. They can still oppose the public option (remember, there is nothing that they are actually for) and repeat the party-talking-points of “government run health care” and “government bureaucrats getting between you and your doctor” so often that they should be paid by the “Daily Show” for supplying Jon Stewart with some of his funniest clips. But as I discussed in my letter to Senator Brownback (June 24, 2009), this is nonsense. There is no way that government bureaucrats could hold a candle to insurance company bureaucrats, and at least in theory they are working for the public and have as their mission the funding of health care, not making profit. And no one is proposing government-run health care (although, despite occasional horrors like the VA urologist in Philadelphia, the VA and the military hold up pretty well to the private sector!), but rather government-financed health care. And government is pretty efficient about paying -- you know anyone who has complained about not getting their Social Security check lately? And – sadly to my mind – there will continue to be a grossly-subsidized “private option” that will be allowed to profitably skim the healthy people and leave the old and sick to the public sector.

“Costs have skyrocketed”. Yes. Costs have skyrocketed around the world, largely as a result of the increased availability of high-cost technological interventions. But nowhere have they increased anywhere near as much as in the US. The article states: “The U.S. already spends the most worldwide on health care. According to the Organization for Economic Co-operation and Development, the U.S. spent $7,290 per person in 2007, while Britain spent $2,992 and France spent $3,601.” Doing the arithmetic, the US spent, per capita, twice as much as France and two-and-a-half times as much as Britain. Which system has a problem with cost control? And, of course, something that cannot possibly be repeated too often, as it is the core, most important point of the discussion, those countries cover everyone and in the US we only cover some people – and every year that is both a decreasing percent and worse coverage for those who are left in. And per the World Health Organization (WHO), they have far better health outcomes than does the US,

“In some cases, patients have needlessly suffered and died.” A particular, and very serious example is given: “More serious problems in Britain's health care were reported last month, when cancer researchers announced that as many as 15,000 people over age 75 were dying prematurely from cancer every year. Experts said those deaths could have been avoided if those patients had been diagnosed and treated earlier.” This is indeed serious, but the issue at fault is not that the government controls health care, but rather that it would have cost more money. See above – Britain spends less than half of what the US spends per capita on health care. If they are to not have such health care deficiencies for their population, they are going to need to spend more, if nowhere near the amount the US spends. People need to understand the difference between how much is spent on health care (probably too little there, too much here) and how those funds are distributed (very inequitably here, much more equitably there). And, of course, there is no comparison to the US and no context. The BBC article presenting this news,, indicates that the calculations were done assuming the outcomes of Western Europe for those 75-84 and those of the US for people 85 and older. Note that this population of Americans are covered by a single-payer health care system: Medicare. By contrast, the Institutes of Medicine (IOM) of the National Academy of Sciences in the US, estimated in 2004 that there were 18,000 excess deaths in this country in people 18-64 (a group with a far lower death rate than those 75 and over) as a result of lack of insurance

Data from Britain and other European countries are population based, looking at the impact on all people. Too often, reports of “excellent” health outcomes in the US are severely skewed by looking only at the people who have had access to and received treatment. By excluding those who never get care, we grossly underestimate the horrible results of having a huge population without access.

Of course, this population does not, and will never, include those who make critical comments of systems that cover everyone. These comments are often specious and, even when true, are largely irrelevant. An excellent example is that from Dr. Alphonse Crespo, an orthopedic surgeon and research director at Switzerland's Institut Constant de Rebecque, quoted in the AP article: ''The minute you make health insurance mandatory, people start overusing it…If I have a cold, I might go see a doctor because I am already paying a health insurance premium.” This true, but scurrilous, assertion is flawed on two major counts. The classic RAND corporation study of health insurance done in the 1970s and published in 1982 demonstrated conclusively that people who have higher out-of-pocket costs, such as copayments do access care less often for minor problems, like colds, than those who do not. But they also access care far less often for major problems, like cardiac disease, diabetes and hypertension, which is much more significant, and has much more serious negative effects upon both cost and health, when these people end up receiving care at late stages of their diseases Lots of people, even those who know or should know that there is no effective treatment, go see doctors when their symptoms are bad enough, but all of them together do not account for a significant part of health care costs. These costs are driven by those with conditions most people who agree do need treatment. It is worthy repeating what Dr. Robert Ferrer noted in this blog on May 8, 2009:

The healthiest half of Americans accounts for only 3% of health care expenditures. Conversely, the sickest 5% account for 55% of expenditures and the sickest 10% for 70% of expenditures. So most health spending isn't folks with a cold or twisted ankle who run to the doctor. Most health spending is NICU babies and 20 year-olds with massive trauma from car accidents and cancer patients and old folks with congestive heart failure and 5 hospitalizations in the last year.”

Whatever the problems being confronted by European health systems, largely driven by underfunding and the rising cost of high-technology care, they pale compared to those in the US. For starters, and for finishers, they cover everybody. Until the US has a health care system that does, and does so equitably, it is not even on the same page. If we are to take the real lesson from this AP article, it is in the quote from Princeton health economist Uwe Reinhardt: ''These countries are in some way an inspiration for our reforms…All of these countries somehow manage to assess risk and compensate for it ... we could learn from that”

Yes. But the question is: Will we?

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