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Tilting at Windmills

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July 27, 2007
By: Kevin Drum

CANCER AROUND THE WORLD....Over at TNR, Jon Cohn provides us with the latest dope from the Annals of Oncology. Exciting! The question at hand is whether the United States, with its awesome private healthcare system, is better at delivering new cancer drugs to patients than Europe, with its array of feeble and feckless public healthcare systems. At first, it looks like the United States is the winner, but when you dig a little deeper it turns out that this has a lot to do with the fact that the study includes lots of countries that have very low healthcare spending, like Great Britain and Eastern Europe. So what happens when you do an apples-to-apples comparison?

If you really want to know how universal health insurance per se affects the diffusion of cancer drugs, a much more logical comparison would be between the U.S. and some of the countries that more closely resemble us in terms of economic development — and that don't spent quite so little money on their own medical care systems. And guess what happens if you do that? A very different picture emerges: We may be atop the world when it comes to getting new cancer drugs to our patients, but we're hardly alone on that perch. Three other countries — Austria, France, and Switzerland — are right there with us.

....Admittedly, the paper is vague on one key point: It doesn't indicate whether, among those four world leaders, the U.S. stands out as the best. If it did, the argument against universal health care might still have some small merit. Fortunately, Jonsson and Wilking have e-mail addresses. And they were kind enough to respond when I contacted them. "Overall," I asked, "was one country significantly and consistently better than the other three?" Wilking's response: "Not really."

I suppose you're all getting tired of hearing this, but the conclusion here is pretty much the same as it is every time you look at the U.S. vs. Europe: the differences are almost entirely about money. If you have a national healthcare system but you spend way less than the United States (as Great Britain does), you can provide good but not great service. If you spend modestly less than the United States (as France does) you can provide healthcare every bit as good as ours — and cover every single citizen in the bargain.

And what if you actually spend as much as the United States — but you have to put up with our ragtag private delivery system? Then you get healthcare about as good as France's, except that it doesn't cover everyone, it bankrupts large companies, and it goes away anytime you get laid off. And all for only about 40% more than anyone else in the world pays. Pretty good system, eh?

Kevin Drum 1:57 AM Permalink | Trackbacks | Comments (36)

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I'm not tired of it. The fact-free discussions of this topic drive me wild. Here's another study comparing our healthcare system to those of other countries--in this case, the UK, New Zealand, Australia, and Canada.

The study looks at healthcare in these five countries on 21 quality indicators and finds variation across indicators. That is, no country is superior across all indicators; all have strengths and weaknesses.

The results are useful to medical professionals because they point to specific things that can be improved, but they're also useful politically because they show, as if we needed to be shown once again, that we are not better than all those commie countries that provide healthcare for all their citizens at less cost than we do.

Posted by: THS on July 27, 2007 at 2:12 AM | PERMALINK

The AMA jumped in bed with the insurance companies/lawyers! Who got fucked? We did!

Posted by: jay boilswater on July 27, 2007 at 2:30 AM | PERMALINK

But you must be wrong. America is the greatest country on earth, now or ever in history. It's right there in the Bible, goddammit.

Posted by: craigie on July 27, 2007 at 2:31 AM | PERMALINK

Must be Satan`s fault

"When a true genius appears in the world, you may know him by this sign, that the dunces are all in confederacy against him." - Jonathan Swift

Posted by: daCascadian on July 27, 2007 at 3:37 AM | PERMALINK

Kevin, you're ignoring the WSJ article referred to by Cohn in the TNR article. The article points out after the Universal Health Care initiative was passed last year in Massachusetts, there has been a giant leap in the waiting time in Massachusetts to see your family doctor . It now takes on average 7 WEEKS just to see your family doctor.

"On the day Ms. Lewis signed up, she said she called more than two dozen primary-care doctors approved by her insurer looking for a checkup. All of them turned her away."
"For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year's survey."
"The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year."

I don't think the American people would stand for a socialized health care system which results in a SEVEN YEAR waiting time just to see your family doctor for a simple cold.

Posted by: Al on July 27, 2007 at 3:47 AM | PERMALINK

The smoke and mirrors about long wait time is nothing more than a hollow argument. I saw my Dr. yesterday for a routine appointment that I had made last week. The scheduled time was more convenient for me and I could have been seen much earlier. The Dr. decided I needed to see an opthamologist for a routine screening and offered to make the referrel and appointment for me. By 2pm I had the appointment for today. Hardly long waits for routine visits.
The time is long past for universal healthcare for everyone.

Posted by: t on July 27, 2007 at 4:49 AM | PERMALINK

How does Universal Healthcare, exactly, stop us from having Cancer Centers (like we do now) where people pay extra to get the most expensive and experimental care out there? ...Like we do now?

Posted by: Crissa on July 27, 2007 at 5:36 AM | PERMALINK

"For those residents who can get an appointment with their primary-care doctor, the average wait is more than seven weeks, according to the medical society, a 57% leap from last year's survey." "The dearth of primary-care providers threatens to undermine the Massachusetts health-care initiative, which passed amid much fanfare last year."

So... They don't have enough doctors to see everyone?

Why is this an indictment against universal healthcare? Because... If they can't do it now, when it's not an emergency...

...What would they do if it was?

This has nothing to do with universal healthcare, Al.

Posted by: Crissa on July 27, 2007 at 5:42 AM | PERMALINK

And all for only about 40% more than anyone else in the world pays.

My understanding is that countries like France and Germany spend 40% less than we do. So if you turn around and use them as the baseline, we spend 66% more than they do!

Posted by: low-tech cyclist on July 27, 2007 at 6:00 AM | PERMALINK

Al: to take what Crissa said one step further, the article you cite simply demonstrates the extent to which we've been rationing health care all along under our privately-run system.

We've been rationing by access to health insurance: those who have it, or can otherwise afford the bills, get to see a family doctor, but those who lack insurance and can't pay the bills on their own, don't get such care.

Now that that rationing has been removed in Massachusetts, all of a sudden there aren't enough doctors.

The truth is there weren't enough doctors all along, but cost/access rationing hid this fact from those of us who have access to decent health insurance.

Now Massachusetts will ration via inconvenience until the market rights itself by increasing the supply of family doctors to meet the demand. Since it takes awhile to produce new family doctors, that's going to be a slow process.

The good news is that things almost certainly aren't as bad as they look in Massachusetts. This is almost surely what the economists call "pent-up demand" - there are undoubtedly a lot of people who've been putting off seeing doctors for years for various ailments because of cost, and are now all trying to get treatment at the same time for those years' worth of problems. Once this backlog gets dealt with, demand for doctors' services should settle in at a level that was higher than what it used to be, but a good deal lower than what it is now.

Posted by: RT on July 27, 2007 at 6:16 AM | PERMALINK

My doctor here in Paris doesn't have anyone working with him in his cabinet -- no one is needed to deal with the insurance companies. When the visit is through, he writes me a prescription, if I need one, then I hand him my national insurance card and my debit card and he runs them through a little machine on his desk. That's as close as either of us come to dealing with an insurance company. It sure cuts out a lot of waste. Remember, the prime weakness of the U.S. system is that the insurance companies have a financial incentive -- i.e., pure profit -- to deny care. As long as that is the case, it's going to be a mess.

Posted by: Livin' in Paris on July 27, 2007 at 7:09 AM | PERMALINK

Here in Oakland, if you make an appointment to see your Kaiser doctor for a "physical", it can take months to actually get seen by that doctor. On the other hand, if you have an "urgent care" problem, you can be seen by somebody, but probably not your own doctor, that day. The point is that "waiting times" depend on who and what you're waiting for and, yes, we have long ones here for some things. And why the hell would you go to a doctor to be treated for a cold anyway?

Posted by: LMichael on July 27, 2007 at 7:53 AM | PERMALINK

Here in Australia I've had cancer & extensive cancer treatment (surgery, hospital stays, radiotherapy, chemotherapy etc.) Upon diagnosis all treatment was (terrifyingly) immediate & NONE of it has cost me a cent. As follow-up since then I see my preferred oncologist for checkups twice a year, at a time of my choosing, also for free. My treatment was, and is, world class, state-of the-art & thankfully, because of that & good genes/good luck, my aggressive cancer hasn't recurred. While cancer's toll on my career & family was brutal, it wasn't ever, remotely, financial. I think that's also a large part of why I survived a type of cancer with a very scary prognosis: I didn't have imminent financial ruin as an added stress to a clearly looming mortality.

I disclose all this to let Americans know what they should expect as a basic standard for citizens of an advanced Western economy. Australian healthcare rates somewhere around fair-to-middling for OECD countries. It ain't France, it ain't perfect, but compared to the US it's incredibly equitable, accessible & high quality. In terms of healthcare outcomes it's also provably superior & at far less cost to the nation (as % of GNP).

And Al, as far as your belief that "socialized health care system results in a SEVEN YEAR waiting time just to see your family doctor for a simple cold" - you honestly couldn't be more wrong. Under Australia's semi-socialized, universal care system if I have anything minor wrong I ring my local GP who sees me within 24-48 hours depending on what's convenient for both of us. I see her (for free) she diagnoses & prescribes medicine that is subsidized by the Pharmaceutical Benefits System & therefore costs around $7-12 a prescription. That's it. No waiting list. No delay. No cost for consultation. Low cost for medicines. Simple, immediate world-class healthcare for free. Why on earth would you be frightened of, or alarmist about, that?

Posted by: DanJoaquinOz on July 27, 2007 at 7:58 AM | PERMALINK

I suppose another (specious) argument against Universal Health Care is that it increases unemployment. Doctors have no need of employees whose sole purpose is to get the insurance companies to pay for services rendered.

Posted by: lMichael on July 27, 2007 at 7:59 AM | PERMALINK

Ah Kevin,

Cancer treatment doesn't lend itself well to simple metrics. Survival rates, life expectancy, etc. do not take into account quality of life.

You may live longer in France but you spend most of that time getting slow infusions of toxic drugs, taking pills, and trying not to throw up. In the US many patients quickly figure out they can not afford treatment and are able to spend weeks or months of quality time with their family before the cancer catches up.

Maybe we should spend a little more time in cancer prevention than cancer treatment. The US is still number one in combined cancer (male and female), breast cancer, prostate cancer, and female lung cancer.

Posted by: Ebgert on July 27, 2007 at 8:26 AM | PERMALINK

Actually, here in MA my waiting time quadrupled.

Last year I had a problem and called my doctor's office first thing in the morning. Two hours later, I was seeing him.

This year, same thing; but he couldn't see me until 4 in the afternoon.

Al must be right!

Posted by: thersites on July 27, 2007 at 8:49 AM | PERMALINK

I think it is important in these discussions to distinguish between "universal coverage" plans such as Massachusetts which keep the insurance companies involved, (with all of their job-making and profit-making inefficiencies) and single payor systems such as in Europe or Australia which allow a doctor to not have to deal with endless paperwork and rigmarole.

Posted by: Ruth on July 27, 2007 at 9:09 AM | PERMALINK

I think it is important in these discussions to distinguish between "universal coverage" plans such as Massachusetts which keep the insurance companies involved, (with all of their job-making and profit-making inefficiencies) and single payor systems such as in Europe or Australia which allow a doctor to not have to deal with endless paperwork and rigmarole.

Posted by: Ruth on July 27, 2007 at 9:09 AM | PERMALINK

I think that it is a mistake to include the issue of access to the latest drugs into the unversal health care debate. With some cancer drugs like Rituxin costing over $1K per treatment, it is highly unlikely that we will be able to afford that at least initially.

Universal health care should focus more on access to basic medical services.

Posted by: gregor on July 27, 2007 at 9:46 AM | PERMALINK

There's obviously a base cost that a price has to reflect. If the price goes beneath that, people lose money. It can't be that hard to figure out to what level certain medical procedures cannot fall beneath before it becomes unprofitable. Why the health care debate doesn't center around that is beyond me. My guess is, if my comments aren't completely off base, is that it'd turn the debate into something about allocation of resources, which is what the Republicans don't want.

Why hasn't there been more comparison of the costs and how they are created between the different systems? How much, for instance, would it cost to maintain the current salaries for doctors, and then increase their salaries accordingly, in a universal system? How were the salaries of doctors affected once the government of France, for instance, mandated universal coverage? If there's work done on these points and others like them, please tell me where I can find it. If not, it should be done, because it'll help us defeat the Republican talking points.

Posted by: Brian on July 27, 2007 at 10:00 AM | PERMALINK

Pretty good system, eh?

It creates & reinforces some glaring class distinctions-- guess it's comforting to have some means of determining who's worthwhile in our society & who's not. Let's not underestimate how valuable that sort of thing is to the right.

There are days that I think we should just give everyone in the top couple of percent hereditary titles and have done with it.

Posted by: latts on July 27, 2007 at 10:01 AM | PERMALINK

Medicine for profit only short shifts patients. Medicine for profit leaves the needy out of the system. Medicine for profit bankrupts middle class families. Medicine for profit is unethical. -Kevo

Posted by: kevo on July 27, 2007 at 10:53 AM | PERMALINK

Kevin, when you write about health care, your attention keeps wandering away to peripheral issues like patients and health outcomes. That extra 40% we spend buys American doctors much nicer cars, houses, and vacations than French ones, and assures them a working day with refreshing paperwork breaks while French docs face a brutal assembly line regime practicing medicine on one sick person after another. It also supports a whole industry of insurance clerks and executives, not to mention lawyers (whose kids dress much better than French lawyers').
This constant attention to the health of people who have no important lobbying presence confuses
the whole discussion. Please stick to what's important here.

Posted by: Michael O'Hare on July 27, 2007 at 10:54 AM | PERMALINK

Drug costs have escalated in the past two decades. We've gone from medications costing tens of dollars/month in the 70's to hundreds in the 80's, thousands in the 90's and now tens of thousands of dollars/month for the medication alone.

This inflation is related to changes in patent law in the 80's (Dole-Bayh). Prior to this products developed under federal grants were in the public sphere. To encourage commercial development of these advances individuals and institutions Dole-Bayh allowed companies, universities and individuals to patent developments and even license or sell the patent to private companies.

Products developed to a major extent with public funds, such as imatinib (Gleevac) and bevacizumab (Avastin), have been taken private and the public then gets to pay whatever the drug company or developer wishes for the technology. The result of Dole-Bayh has been medical progress at a tremendous cost. Basic research has suffered as workers are continually looking for something to take privateakin to hitting the lottery. Were talking tens to hundreds of millions of dollars in fees to the individuals and the sponsoring university of such research. This has literally changed the landscape of medical research and not all for the better.

In reality most the new drugs while innovative have very modest effects on disease. Patients with advanced lung cancer, colon cancer, pancreatic cancer, head and neck cancer, ovarian cancer, breast cancer, brain cancer still die. With new agents their survival may improve a few months at best.

The price for these advances can be as much as $100,000/year for the drug alone. This is hardly cost effective care or sustainable,. Our system of private care with multiple conflicts of interest simply fans the flames. For example, doctors, drug companies, and hospitals with cancer centers benefit when patients are on therapy. Doctors often are consultants or paid researcher for the drug companies supplying the medication.

Meanwhile truly effective public health and disease screening measures are underutilized. Our system is really not a system.

Posted by: www.medicynic.com on July 27, 2007 at 10:55 AM | PERMALINK

I live in Switzerland and pay 287 Swiss Francs a month for my health care insurance. That is for a public ward aand has a 300 Franc deductible. It then covers 100 % of all prescription and doctor bills. Not too bad I think. Doctors here really over-prescribe tests so that if you go in for antibiotics for a sinusitis, they will ask you to have a blood test to ensure you really have a bacterial infection. I find that to be pretty needless.

Posted by: Michele on July 27, 2007 at 11:01 AM | PERMALINK

Ah Egbert,

As a cancer survivor I underwent exactly what you describe: "slow infusions of toxic drugs, taking pills, and trying not to throw up." Surgery & radiotherapy were similarly irksome except for the singular fact you conveniently ignore - these unpleasant treatments SAVED MY LIFE. You blithely suggest that American patients unable to afford life-saving cancer treatments have as consolation their unmedicated "quality of life". I hope neither you or your loved ones have to make do with dying a hastened, unmedicated death because you or they can't afford life-saving treatment. You comment:

"In the US many patients quickly figure out they can not afford treatment and are able to spend weeks or months of quality time with their family before the cancer catches up."

Dying because you can't afford the treatment to live is not "quality time". It's an obscenely preventable, premature, unnecessary death that should be completely unconscionable in the wealthiest nation on earth. That you would attempt to argue otherwise only confirms the utterly unfathomable depth of your moral bankruptcy. If you're a parody you're grotesquely unfunny. If you're not, you're unspeakably grotesque.

Posted by: DanJoaquinOz on July 27, 2007 at 11:44 AM | PERMALINK

Doctors here really over-prescribe tests so that if you go in for antibiotics for a sinusitis, they will ask you to have a blood test to ensure you really have a bacterial infection. I find that to be pretty needless.

That's not such a great example of over-use of tests. From what I've read (in a medical textbook, but I'm not a doctor and this is not medical advice, etc.) antibiotics are effective (i.e. moreso than not prescribing them) in around 15% of sinusitis cases. It's a good idea to get some other indication of bacterial infection before prescribing antibiotics.

Posted by: me2i81 on July 27, 2007 at 11:55 AM | PERMALINK

DanJoaquinOz on Egbert: If you're a parody you're grotesquely unfunny.

That, he is. And a mean little fucker, to boot.

me2i81: It's a good idea to get some other indication of bacterial infection before prescribing antibiotics.

Absolutely. Over-prescribing of tests is much less a problem that over-prescribing of antibiotics, a popular US practice which is going to bite us in the ass.

Posted by: thersites on July 27, 2007 at 12:39 PM | PERMALINK

Already said, but, yeah, acknowledging that you don't have the money for treatment and going home to die doesn't exactly fit w/ the "pro-life" agenda that the people who oppose universal health care usually trumpet.

Posted by: THS on July 27, 2007 at 12:42 PM | PERMALINK

Whoops. ...less a problem than over...

Does this mean I can't beat up Orwell for bad writing today?

Posted by: thersites on July 27, 2007 at 12:42 PM | PERMALINK

Medicine for profit = one ailment for every man, woman and child, and two prescriptions to treat such ailments. That is the growth model for any business - expanding the market. Medicine for parfit is immoral. -Kevo

Posted by: kevo on July 27, 2007 at 12:45 PM | PERMALINK
I don't think the American people would stand for….results in a SEVEN YEAR waiting time…Al at 3:47 AM
Medical wait times for non-insured surgery at seven South Los Angeles community clinics. Cardiology: Nine months to a year Dermatology: Six months Ear, Nose and Throat: Six to nine months Endocrinology/Nephrology: Six to nine months Gastroenterology: Six to nine months Gynecology: Six to nine months Neurology: Six to nine months Oncology: Six to nine months Ophthalmology: Six to nine months Orthopedics: Six months to a year Podiatry: Six months to a year Rheumatology: Six months to a year Surgery: Nine months to two years Urology: Nine months to a year Posted by: Mike on July 27, 2007 at 1:29 PM | PERMALINK

As a cancer survivor I underwent exactly what you describe: "slow infusions of toxic drugs, taking pills, and trying not to throw up." Surgery & radiotherapy were similarly irksome except for the singular fact you conveniently ignore - these unpleasant treatments SAVED MY LIFE. You blithely suggest that American patients unable to afford life-saving cancer treatments have as consolation their unmedicated "quality of life". I hope neither you or your loved ones have to make do with dying a hastened, unmedicated death because you or they can't afford life-saving treatment..

Having lived through it with family members -- I have to say that, depending on the prognosis I would choose to forgo chemotherapy and no matter the prognosis will not undergo an allogenic bone marrow transplant. It's a personal choice. This says nothing about universal health care, although its obvious on the face of it that certain cancer treatments simply take too many resources to be widely applied.

I think Bill Gates has finally got something right with his approach to world health. If we move toward a better public health system in this country it would pay to follow his lead with better vaccines, better drinking water, better food quality regulation, etc.

Posted by: B on July 27, 2007 at 7:35 PM | PERMALINK

Cancer is most common in people OVER 65 and in the USA that means people who have MEDICARE, not private health insurance!!

Posted by: somebody on July 27, 2007 at 9:16 PM | PERMALINK

I don't understand -- Does the United States pay "modestly" more than France or does the United States pay "40%" more than France?

I'm having trouble reconciling these statements.

Posted by: David McNett on July 29, 2007 at 12:05 PM | PERMALINK

I've lived in France, seen a bunch of people who had to have surgery or other heavy treatment, and I never heard of any "waiting list". These people were diagnosed, and procedures scheduled promptly.

In fact, the only "waiting list" I've heard about is for organ transplants, for lack of donors.

Posted by: Fact checking on August 14, 2007 at 2:40 PM | PERMALINK




 

 

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