Activism

Thoughts on Healthcare

 

Recently I have been interested in the healthcare debate that has been going on in many developed nations, but specifically the United States. As most people probably know, the United States is the only developed nation in the world without some kind5), despite the U.S. paying a substantially larger sum of money for its system (WorldBank, 2014). Obviously, the degree to which state control is in place varies country by country, but you get my point being that most other countries are able to do something the majority support; [1] that being a single-payer healthcare system or just a more state-run system. Now I personally have not developed my opinion fully on this issue, hence why I’m looking into it and just plan on going over my understanding of the debate and offering some possible policy suggestions.

This post is mostly going to be centered around arguments I’ve heard defending the United States healthcare system, of which I was very pleased to see because it was not until recently that I had even heard of such a thing as defending the U.S.’s healthcare system, given how openly it just dismissed as horribly inefficient and expensive. As many on the right have pointed out, the U.S. leads in most areas of cancer survival rates when compared to other developed nations such as Canada, Sweden, Denmark, etc. From this, they often conclude that single payer system is inferior because cancer treatment is a very difficult process, and one can easily use it to judge a country’s healthcare efficiency given that more efficient systems should have higher survival rates for such a complex procedure.

This is a very common argument given by the staunch defenders of the U.S. system that I take issue with. It is true that the United States has very good cancer survival rates, [2] however this comes at an enormous cost. As Soneji and Yang (2015) have pointed out, [3]

“Compared to Western Europe, for three of the four costliest U.S. cancers—breast, colorectal, and prostate—there were approximately 67,000, 265,000, and 60,000 averted U.S. deaths, respectively, and for lung cancer, there were roughly 1,120,000 excess deaths in the study period. The ratio of incremental cost to quality-adjusted life-years saved equaled $402,000 for breast cancer, $110,000 for colorectal cancer, and $1,979,000 for prostate cancer—amounts that exceed most accepted thresholds for cost-effective medical care.”

So, what does this all mean? Well, we see that from 1982 to 2010, the U.S. spent $435 billion, $325 billion and $434 billion more than Europe on care for breast, colorectal and prostate cancer. [4] Now, defenders of the system may say that at least our extra spending is helping people live longer, but such a conclusion is short lived when you factor in lung cancer, which kills almost as many people as breast, colorectal and prostate cancer combined.

Although lung cancer mortality rates in the U.S. have dropped over the past few decades, those rates remain higher than Europe’s. Soneji and Yang estimate that there have been 1,120,000 more excess lung cancer deaths in the U.S. than in Europe from 1982 to 2010. During this same period, the U.S. spent $406 billion more on lung cancer care, adjusted for population size, than Europe did. Soneji and Yang calculate that for every extra $19,000 spent on a lung cancer patient in the U.S. compared to Europe, that patient loses a year of quality-adjusted life. Americans die more frequently than Europeans of lung cancer even though Europeans have higher smoking rates (WHO, 2016).

Another point I wanted to bring up is regarding wait times. People often go on and on about how wait times are much higher for medical care in countries other than the United States. Now, while this is true to an extent and is one of the main reasons I don’t support a fully single payer system, the issue is a bit more complicated than it seems. First off, as Viberg et al. (2013) shows, the methods by which wait time data is collected in varying countries are all over the place and there is a general lack of good data on the subject as a result of this.

Despite the lack of hard data on the subject, I was able to find a study by the OECD (2013) which Viberg et al. actually recognized as one of the few case studies that is up to code with good data. What they show is that this lack of data on wait times actually has been a real problem for the governments of countries that have single payer systems. Canada, for example, had a very difficult time in the early 2000s dealing with their long wait problems because different clinics in different provinces kept collecting and storing the data differently or sometimes not at all.

But what the OECD reports are that the data situation has been under better control in the years following 2004, and the Canadian government has been able to implement wait time guarantees that have been quite successful in reducing wait times. Similarly, in the case of Sweden, the OECD report states,

“The last two decades display a pattern of temporarily reduced waiting times due to the guarantees. However, the current guarantee, designed in 2005, seems to have had a more positive, long-term effect on waiting times. More patients than before are receiving treatment and surgery within 90 days.”

They attribute this success to the economic incentives the government gave individual clinics to reduce wait times by giving more money to those which met the requirements of The Queue Billion which mandated certain wait times. This trend of governments finding their own paths to reducing wait times through more effective methods of data gathering, reporting, and taking action to be a common trend throughout all countries with single payer systems. So while yes, they do tend to have longer wait times, this isn’t something that can’t be fixed. My personal recommendation would be a system still largely state-controlled, but with more economic incentives and independence to individual clinics in order to reduce wait times and improve quality.

I just brought up quality because this is something I wanted to finish on. Despite the U.S. leading in areas like technological advancement in medicine, cancer survival rates, and the potential for high-quality care, most Americans simply don’t receive it (AHRQ, 2012) and this is something many American policymakers have been concerned with for a very long time, (Brook, 2011) not some liberal conspiracy. Some studies (McGlynn et al, 2003) suggest that the average American only receives about 50% of their recommended health care services. As Woolf and Aron (2013) [5], in their amazing book I highly recommend you check out, note:

“Although the United States does well in providing access to many specialists, access to primary care physicians and a regular health care provider is more limited than in many other countries (OECD, 2011b; Schoen et al., 2009b, 2011; Starfield et al., 2005; World Health Organization, 2008b). According to the OECD, only 12.3 percent of U.S. physicians engage in primary care, the lowest proportion among 15 peer countries providing data: see Figure 4-1.10 Macinko et al. (2003) applied 10 criteria to rank the primary care systems of 18 high-income countries (including Canada, Australia, Japan, and 14 European countries). The United States had the weakest primary care score of all the countries in 1975 and 1985 and the third weakest in 1995 (Macinko et al., 2003). Continuity of care from a regular provider, which is important to effective management of chronic conditions (Liss et al., 2011), may be more tenuous in the United States than in comparable countries. Only slightly more than half (57 percent) of U.S. respondents to the 2011 Commonwealth Fund survey reported being with the same physician for at least 5 years, a lower rate than all comparison countries except Sweden (Schoen et al., 2011). In another Commonwealth Fund survey, U.S. patients were more likely than patients in other countries except Canada to report visiting an emergency department for a condition that could have been treated by their regular physician had one been available (Schoen et al., 2009b).”

Ending with that, I think it’s safe to conclude that the U.S. healthcare system is not among the most efficient, and should certainly not be praised. That said, it should also be noted that the single payer systems of Western Europe and other developed nations should also be criticized for their inefficiencies, but I believe that my analysis helps show that a system closer to single payer is more desirable than the current U.S. system. Thanks for reading!

Notes:

[1] As Kiley (2017) notes: “A majority of Americans say it is the federal government’s responsibility to make sure all Americans have health care coverage. And a growing share now supports a “single payer” approach to health insurance, according to a new national survey by Pew Research Center.”

[2] This has been confirmed by numerous studies, most notably Coleman et al. (2008)

[3] You can find a critique of Soneji and Yang’s article here and a critique of that critique here.

[4] In a discussion with John Horgan, Soneji notes that: “In 2010, the National Cancer Institute estimated the cost of US cancer care was $126 billion (see p. 31, http://progressreport.cancer.gov/sites/default/files/archive/report2011.pdf). For the 12 selected cancers we studied, we estimate the U.S. spent an additional $569 per capita in cancer spending in 2010.  Or equivalently, if the U.S. and Western Europe were the same population size, the U.S. spent an additional 80.7 billion dollars in cancer care of the 12 most common cancers in 2010.”

[5] For all of Woolf and Aron (2013)’s references, see their bibliography starting on page 293 of their book.

References:

AHRQ. (2012) National Healthcare Quality Report

https://archive.ahrq.gov/research/findings/nhqrdr/nhqr12/index.html

Brook, R. (2011) Health Services Research and Clinical Practice

http://jamanetwork.com/journals/jama/article-abstract/896883

Coleman, M., et al. (2008) Cancer survival in five continents: a worldwide population-based study (CONCORD).

https://www.ncbi.nlm.nih.gov/pubmed/18639491

Greenberg, J. (2015) Bernie Sanders: U.S. ‘only major country’ that doesn’t guarantee right to health care

http://www.politifact.com/truth-o-meter/statements/2015/jun/29/bernie-s/bernie-sanders-us-only-major-country-doesnt-guaran/

Kiley, J. (2017) Public support for ‘single payer’ health coverage grows, driven by Democrats

http://www.pewresearch.org/fact-tank/2017/06/23/public-support-for-single-payer-health-coverage-grows-driven-by-democrats/

McGlynn, E., et al. (2003) The Quality of Health Care Delivered to Adults in the United States

http://www.nejm.org/doi/full/10.1056/NEJMsa022615#t=article

OECD. (2013) Waiting Time Policies in the Health Sector WHAT WORKS?

http://www.fcass-cfhi.ca/sf-docs/default-source/on-call/2015-05-19-siciliani2013waiting-time-policies-in-the-health-sector.pdf?sfvrsn=2

Soneji, S., Yang, J. New Analysis Reexamines The Value Of Cancer Care In The United States Compared To Western Europe

http://content.healthaffairs.org/content/34/3/390.abstract

Viberg, N., et al. (2013) International comparisons of waiting times in health care – Limitations and prospects

http://www.sciencedirect.com/science/article/pii/S0168851013001759#bib0135

WHO. (2016) Prevalence of Tobacco Smoking

http://gamapserver.who.int/gho/interactive_charts/tobacco/use/atlas.html

Woolf, S.H. and Aron, L. (eds.) (2013) U.S. Health in International Perspective: Shorter Lives, Poorer Health

https://www.nesri.org/sites/default/files/US_Health_in_International_Perspective.pdf

WorldBank. (2014) Health expenditure, total (% of GDP)

http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS


 

screenshot-econsynthesis.wordpress.com-2017-10-20-11-50-19-937.jpeg

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