Editore"s Note
Tilting at Windmills

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August 2, 2007
By: Kevin Drum

SICK....My review of Jon Cohn's Sick, a critique/history of the American healthcare system, is now available at the Columbia Journalism Review site. I basically praised the book, which is very good, but then added this:

The format of Sick almost begs for narratives about overseas health care systems. The book is basically a tour around America, with each of its eight chapters named after the place in which its story unfolds. So why not include chapters on Manchester, Malmö, and Marseilles, each of them highlighting in narrative form both the good and bad points of the British, Swedish, and French systems?

....In an increasingly globalized world, the war on terror has sobered us to the dangers of crippling the foreign reporting and institutional memory of all but a handful of national newspapers. Health care may be about to remind us of this in an entirely new context. Anyone for reopening that Stockholm bureau?

I wrote this before Michael Moore's Sicko was released, and was delighted to find out that going overseas was exactly what Moore had done. But I'd still like to see someone do the more wonkish book version of this.

Kevin Drum 2:58 PM Permalink | Trackbacks | Comments (18)

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The phenomena of medical tourism is very quickly going to radically change the American health system. Our physicians are WAY WAY WAY overpaid, and those in Thailand or Germany, who charge MUCH MUCH less, will be taking cases away from the US. After all, if you can get the hip replacement AND a two-week trip in Thailand for 1/2 the cost of the replacement in the US, there are gonna be a lot of takers.

The US health care system is simply ripe for the takedown in off-shoring, and it will soon be. Our physicians, who think that they are kings or something, are gonna lose a lot of business to Thailand, and many jobs will be lost. Costs MUST come down, and the easiest way to do that is to REMOVE the profit component of the health care system. That's when the whole system began to go down the tubes.

Posted by: POed Lib on August 2, 2007 at 3:04 PM | PERMALINK

While I liked Sicko and particularly its framing of the problem, there's nothing wonkish or (par usuel) balanced about it. A serious but readable (and media-ready) examination of comparative merits of various G8 healthcare systems would be tremendous boon to all of us who think the most important issue of the day is fixing our ridiculous system.

Posted by: Eric E on August 2, 2007 at 4:48 PM | PERMALINK

http://content.nejm.org/cgi/content/full/354/22/2314

Rep. Louise Slaughter wrote an article for the New England Journal of Medicine,
not a lefty publication, by the way, a medical journal-- that describes how Medicare D was pushed through by Republicans who sought to benefit drug companies and corporations, not the American people.

Posted by: consider wisely always on August 2, 2007 at 5:55 PM | PERMALINK

Art Levine's piece (in the "news & opinion from our contributing editors") makes it clear that efforts to reform American healthcare will probably go nowhere.

Some years ago, one analyst blamed the lack of reform on a widespread American belief that even if you were uninsured, you could always go to the emergency room, and you'd be cared for (which is exactly what President Bush said recently). That folk belief is probably breaking down, but I think it might take another decade ago, maybe until Readers Digest starts printing horror stories about what happens to the uninsured.

Come to think of it, does anyone read RD any more?

Posted by: David Martin on August 2, 2007 at 5:56 PM | PERMALINK

Readers Digest? Are they still around? Loved their condensed books when I was 10.

Posted by: fafner1 on August 2, 2007 at 6:21 PM | PERMALINK

I'd like to hear more about the Swiss healthcare system. I've heard that the market there for medical insurance has been structured such that there is far more consumer choice, far more competition and thus considerably lower cost.

There are roughly 7.5 million Swiss and I'm told they have nearly 90 companies offering health insurance. If the same ratio was applied to the 30 million of us here in California, we'd be able to choose among 340 insurers instead of the couple of dozen currently available. Think of what that would do to costs.

Posted by: jm on August 2, 2007 at 7:14 PM | PERMALINK

No one ever talks about the Japanese healthcare system. There is universal coverage, complete freedom of choice, no waits, and the longest-living population on the planet. They must be doing something right besides eating all that sushi.

Posted by: Zak on August 2, 2007 at 8:01 PM | PERMALINK

The interest I have in choosing among 340 insurers is roughly the interest I have in comparing electricity rate plans or postal rates.

The only weak spot of Moore's otherwise excellent movie is that he avoids looking at how national insurance schemes overseas compare to EACH OTHER -- i.e. their relative failings and successes. (French health care, for instance, relies on a kind of "top up" complementary health insurance that goes along with what the state provides; UK health care doesn't.) If he had done so, though, his movie would have been about four hours long. But he's moved the ball up the field quite a ways, and I agree with Mr. Drum that we now need good analyses of all these plans' pluses and minuses in the context of an American system.

Posted by: Tracer Hand on August 2, 2007 at 8:09 PM | PERMALINK

[The Japanese] must be doing something right besides eating all that sushi.

They are also killing whales, which is an obvious result of having universal health care....

Posted by: Disputo on August 2, 2007 at 8:11 PM | PERMALINK

I think the public policy potential of stories like these is pretty high:

So what does it mean that Americans are now among the shortest and fattest people in the industrialized world? If a number of studies out in the last two months are any indication, the stagnating height and expanding girth in the United States are not only related, they may be a sign of a decline in the overall health of Americans—particularly children.

...

Today, Americans don’t even break the top 10 in terms of tallest nations. The average American is shorter than the average of citizens of Belgium, Germany, the Scandinavian countries and Canada, according to Social Sciences Quarterly. This surprised researchers because historically height has been related to a nation’s wealth. Prenatal care, nutrition and the way childhood diseases are treated are usually better in nations with higher per capita incomes—and all these factors can affect height. But the wealth-health equation doesn’t always hold up. The Netherlands, whose gross domestic product (GDP) ranks 16th globally, according to the World Bank, is taller than the United States, which has the highest GDP in the world. And the average Czech is taller than the average American, despite the fact that their nation’s per capita income is less than half that of the United States.

Why hasn’t America’s wealth brought better health—and height? Authors of the Social Science Quarterly report point to the American diet and the uneven distribution of health-care resources.


We spend more money that anyone else on healthcare, and all the evidence says we are getting increasingly poorer outcomes. But at least we don't have socialized medicine! That would drag us down into the gutter for sure.

Posted by: Martin Gale on August 2, 2007 at 8:33 PM | PERMALINK

The interest I have in choosing among 340 insurers is roughly the interest I have in comparing electricity rate plans or postal rates.
Posted by: Tracer Hand on August 2, 2007 at 8:09 PM

There is an opportunity cost involved with excessive "choices". Who the fuck has got the TIME to pore endlessly over various plans, fine print, etc.? I suppose there could be a new booming industry of 3rd party consultants who would crunch the plans for you and give you a synopsis and summary based on your income, age, etc., for an added fee. The Utopia of Choice is for the top 1% who can afford all the consultant in-betweens to make all their choices for them. The remaining 99% waste their time getting pinched.

Posted by: Doc at the Radar Station on August 3, 2007 at 1:10 AM | PERMALINK

"I suppose there could be a new booming industry of 3rd party consultants who would crunch the plans for you and give you a synopsis and summary based on your income, age, etc., for an added fee."

Heh. Like the industry that does the exact same thing for mutual funds, which are themselves in the same business) ensuring that every single american gets the exact same investment returns as Warren Buffet or the Yale endowment.

Posted by: jefff on August 3, 2007 at 12:43 PM | PERMALINK

Tracer Hand, Doc at the Radar Station and jefff,

Just curious, do any of you currently have health insurance, and if so, how is it paid for?

My wife and I currently pay $450/mo. for a high deductable crappyass policy from a company that has a reputatuion for denying claims. We did a lot of shopping around and this was the best available. Needless to say, this sucks hard.

Obviously, the California market wouldn't bear 340 insurers. Focussing on that number is missing the point. Increased competition would, presumably, lead to greater variety in types of service offered, such as incentive based policies that pay end of year rebates or dividends to subscribers who stay healthy. Another likely benefit would be lower prices across the board.

Given that single payer (something I'm in favor of, by the way), will be an extremely tough sell politically, why not consider other options while the debate is open?

Posted by: jm on August 4, 2007 at 11:19 AM | PERMALINK

jm, We need to push politicians to work toward a single payer plan. We need a serious candidate to step up and say that is what we need to work toward-to say that is what our GOAL is. Nobody is doing that. All they are offering thus far is half-measures (or less) that keep the insurance companies happy. We need some boldness, courage, and leadership here.

If you increase "competition" amongst private insurers you *might* get a slightly better price, but without more people willing to buy insurance policies that currently aren't covered you are actually going to *increase* the likelihood that when you get sick and make a claim that you will be denied coverage.

Changing your insurance company isn't like changing your long distance carrier. That's the crucial difference. "Whoops, You've now got a pre-existing condition!" In order to make increased competition "work" here you have to have the "power" to switch to a different company if it doesn't perform to your satisfaction. But... what about that $18K bill Company X won't pay in the meantime? And... why can't I find a Company Y to insure me now? And.. why in the hell do I have to spend so much time hassling with this instead of doing productive activity Z?

You can of course "solve" these problems and still keep private insurance front and center. You can regulate the industry with federal mandates that doesn't allow them to turn anybody away, they have to charge everybody according to a community rating regardless of what illness they have, etc., etc. What happens however, is the creation of a bureaucracy to regulate the insurers. If you are going to go to all that trouble, why not just have single payer in the first place?

There also has been a lot of talk about mandating that everybody be insured. That's the central feature of nearly all of the candidate's plans (R's and D's). The problem here is that you still have people that can't afford it, and others who are willing to suffer a tax penalty that don't want to buy it. There was someone here that posted about Massachussets' mandated coverage and the results weren't very impressive. You would expect that premiums would go down significantly as a result and I don't think they did.

I floated an idea here a few weeks ago about simply allowing people to "opt-in" to Medicare who reach 55 years of age and boost the Medicare payroll tax accordingly to accommodate them. You could progressively lower the age that you can opt-in until private insurers would simply be selling nothing but "gap" plans at some point in the future. That way the transition to single-payer would be smoother. The trouble with this is that it would encourage employer's to abandon covering their employers at a fast pace. So we're back to needing to solve this with single payer for everybody.. pretty much all at once.

Posted by: Doc at the Radar Station on August 4, 2007 at 12:43 PM | PERMALINK

Doc,

Comparing insurance plans is a fruitless exercise anyway because, as demonstrated in Sicko, you have no real way on the outside to evaluate the degree to which your insurance plan will try to screw with you.

Posted by: tc on August 4, 2007 at 12:46 PM | PERMALINK

Make that-"The trouble with this is that it would encourage employers to abandon covering their employees at a much faster pace."

Posted by: Doc at the Radar Station on August 4, 2007 at 12:49 PM | PERMALINK

tc, Exactly. I can't think of a more opaque industry than health insurance.

Posted by: Doc at the Radar Station on August 4, 2007 at 12:52 PM | PERMALINK

Kevin,

Seriously, am I supposed to think that you never read comments? I have mentioned this more than once, as you have made this complaint more than once. The World Health Organization did exactly as you asked in 2000:

http://www.who.int/whr/2000/en/

Posted by: Poéthique on August 5, 2007 at 10:28 AM | PERMALINK
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