ThanksJoe. I was only responding to the claims that health in the US weren't worse than elsewhere. By the way, it isn't the diverse population that accouints for the bad performance. Health bahaviors among the US population are among the best. You can control for all sorts of individual characteristics and stratify for SES and race and you still get the relatively bad health figures. For example, survival from breast cancer in US is worse than in Canada and it isn't due to differences in incidence. Let's face it: the systen is a bad one and merely providing insurance will not fix the problems.
Barbara
----- Original Message -----
From: Joe White <[log in to unmask]>
To: Starfield, Barbara; [log in to unmask] <[log in to unmask]>
Sent: Wed Jun 10 17:05:40 2009
Subject: RE: Apparently, the United States has the world's best health care system
Hi Barbara,
I think people were mostly responding to the question as I posed it. I assume you're referring to your big article on primary care. Aside from the fact that that article is presented as a brief for primary care, it isn't especially relevant to the political issue because:
a) Many of the variables you discuss are not what the fear-mongers talk about. Neither they nor the public in general are interested in ratings of, e.g., primary care as to "person-focused care over time" or "family orientation and community orientation" nor the policy variables of "universal or near-universal coverage" or "professional earnings of primary care physicians relative to those of other specialists." The Macinko, Starfield and Shi (HSR 2003) dependent variables are a bit more relevant, but in that article you only present national scores for your primary care scales. Which is not what any average voter will care about. And, by the way, any argument that starts from the premise that the U.S. would improve if it had more HMOs will be popular with health policy types but not with anyone else.
b) Even if you had presented national data on the mortality for particular disease figures, that is basically available from the Nolte and McKee article. And such data still do not address questions of access to what individuals might consider needed care, e.g. "waiting lists."
c) And figures such as premature mortality and mortality for particular disease figures still do not address the possibilities that U.S. worse performance in those areas, on average, are due to particularly bad results for certain populations.
So it makes sense to argue that the dependent variables that the conservatives emphasize are not as important as they (and their target public) think. But that's not a likely way to win the political battle. I'd prefer not to tell the people who asked me about the asinine WSJ article, "It asks the wrong question, the right question is access to primary care." Because that will be taken as meaning the critics are right on the grounds they've identified, and I don't think it is remotely wise to try to frame the political issue as, "we the reformers don't think you need access to specialists." If you read the Frank Luntz memo, that's exactly the frame the opponents of NHI are trying to impose on the advocates!
Best,
Joe
-----Original Message-----
From: Starfield, Barbara [mailto:[log in to unmask]]
Sent: Wednesday, June 10, 2009 3:50 PM
To: [log in to unmask]; [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health care system
It is sujrprising that the community of readers of this list serve seems not to be aware of the very large comparatibe studies of the US health care systen and many measurers oif health outcome.--the US is almost always last. Even the 'white papers cited in Ciongressional committees cite it.
See for example the review paper by Starfield et al in Milbank Quarterly. Published in 2005, it is reinforced by several studies since then, eg, see Banks et al in JAMA.
If you need and can't access the MQ paper, let me know.
----- Original Message -----
From: Anglo-American Health Policy Network <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Sent: Wed Jun 10 12:00:02 2009
Subject: Re: Apparently, the United States has the world's best health care system
The issue isn’t “best performing.” I think it’s fair to say that, assessing across a wide range of variables, the U.S. performs quite poorly. Our performance on access and cost is so poor that our quality would have to be amazingly good to offset that. And our quality is not that good.
Nor is the issue “health system” as opposed to “medical care system.” Actually, American conservatives are quite happy to argue that social ills explain our low life expectancy, etc., because, in their version of the explanation, you can’t expect good, upstanding citizens to pay extra for all those people who shoot each other and take drugs and drink too much and don’t take care of their children properly and eat junk food so get fat and get diabetes and heart trouble. If you go back to the exchange between Clinton and HHS Secretary Sullivan in NEJM in 1992, Sullivan makes the “health” argument in order to say health insurance is the issue. You can see that also in the 2008 Republican platform. Jim Morone gives a great example from a debate in which he participated in 1994, in which his opponent said, “Look, professor, you can’t expect the hardworking people of suburban Cook County to go into the same health care alliance as the crack heads in the city of Chicago.” Liberals may think talk of “health” allows talk of community, equality, etc instead of emphasizing the medical-industrial complex. But outside the public health schools, the “health” argument plays, in American politics, as an argument for separating healthy and virtuous “Us” from unhealthy and sinful “Them.” I’ve attached the chapter that I assign for my health policy class, which is based on Jim’s book, Hellfire Nation, just in case anyone’s interested. At any rate, talking about “health” instead of medical care is not helpful in this policy fight.
The issue is protection from illness once it occurs. So that is whether people in the U.S. who currently have decent health insurance would be worse off, IF THEY GET SICK, if the U.S. had a system “more like other countries.” It is surely true that we pay too much for the care people do get. But the average voter doesn’t get much of the bill directly. It is also true that many of the well-insured can’t be sure they will stay well- insured. That is one reason the public is open to change. But if care for the well-insured might get worse with a system more like other countries’, a rational voter might choose to take the economic risk (of what the market might do to them) rather than the political risk (what the government might do to them).
So that’s why direct comparisons of care for specific treatments are useful. Anecdotes about waiting for a particular service need to be answered at that level: receipt of particular services.
Any further cites to specific studies would be greatly appreciated!
Thanks for all the thoughts and ideas,
Joe
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Thompson, Ken (SAMHSA/CMHS)
Sent: Wednesday, June 10, 2009 11:06 AM
To: [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health care system
Following along these lines- isn't the best performing health care system an overall social effort expanding beyond clinical and even public health interventions to promote, protect and recover the populations health in an efficient, just and equitable fashion, with the capacity to continue to improve in all these arenas? Here measures of morbidity and mortality mix with measures of capability and capacity/fitness, inclusion and exclusion. .
Seems to me a more restricted view- limited particularly to clinical services- could leave an excellent clinical service in the midst of a society that is generating pathology for the clinical services to try to mend- a task they can only partially do, even at best.
Ken Thompson
Pittsburgh
________________________________
From: Anglo-American Health Policy Network <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Sent: Wed Jun 10 09:13:46 2009
Subject: Re: Apparently, the United States has the world's best health care system
Dear Tim et al,
There is no best performing health care system in the world. Some countries do best on some things, other countries do better on others. There are always trade-offs. The US might more sensibly look at Germany and the Netherlands for political/institutional reasons, not because they are necessarily any ‘better’ than the single payer systems. On the flip side, the US already has one of the biggest single payers in the world in Medicare (which’d probably perform better if it didn’t farm much of its administration out to the commercial sector), and it also of course has the single paying VHA, arguably the best performing sector of American health care.
Best,
Adam
________________________________
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Jost, Timothy
Sent: 10 June 2009 13:32
To: [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health care system
I actually think the Nolte and McKee data is pretty good, and shows that the US performs quite poorly. The data you see most often in right-wing attacks is 5 year cancer survival data, where the US is tops (although Cuba does better with breast cancer). But 5 year survival rates are a factor of time of diagnosis, the earlier you diagnose cancer, the more likely you are to survive 5 years. Actual age-adjusted cancer death rates are not much better in the US than elsewhere. The Nolte and McKee data, moreover, show that cancer is the only place where the US does better (at least than france and Germany). On everything else we do worse.
I also would not dismiss the fact that these comparisons always look at Canada and the UK. No offense, but these are not the best performing health care systems in the world. The conservatives are monolingual and much more interested in making a point than in learning anything. The Commonwealth fund data show that the US does better than Canada in access to specialists, worse in terms of financial burden, and about the same in everything else. compared to the other countries Commonwealth looks at, however, we do worse by lots of measures, including access to primary care.
Tim
Timothy Stoltzfus Jost
Robert L. Willett Professor
Washington and Lee University School of Law
(540) 458 8510
fax (540) 458 8488
[log in to unmask]
________________________________
From: Anglo-American Health Policy Network [[log in to unmask]] On Behalf Of Joe White [[log in to unmask]]
Sent: Wednesday, June 10, 2009 8:02 AM
To: [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health care system
Chris and all:
Thanks, Chris. The Nolte and McKee data is in the Commonwealth Fund charts. But I should tell the reporters about the article.
The Commonwealth data is, e.g., http://www.commonwealthfund.org/~/media/Files/Publications/In%20the%20Literature/2007/Nov/Toward%20Higher%20Performance%20Health%20Systems%20%20Adults%20Health%20Care%20Experiences%20in%20Seven%20Countries%20%202007/Schoen_2007intlhltpolicysurvey_chartpack%20pdf.pdf
The problem is, much of the U.S. disadvantage in any aggregate data is surely due to the portion of our population that doesn’t have insurance, or has inconsistent or lousy insurance. Politically, the problem is that the well-insured worry that in order to do better overall, they will have to accept worse insurance for themselves – e.g. waiting lists, etc. “like in Canada” (or like in the UK). And there ARE waiting lists in Canada and the UK.
I know all the counter-arguments, I think. The first is, “what about the countries that don’t have waiting lists? What about France, Germany, etc.?” But “well, France doesn’t” is not a good answer because, well, it’s France. Not English-speaking, not a neighbor, etc. “How do we know we’ll get France instead of Canada” is not an argument I want to get into. Even though the basic design’s being talked about are a lot closer to France than to Canada or the UK.
The second is, “there’s lots of waits in the U.S., they just don’t show up as ‘waiting lists.’ Which is true. I could tell you stories about my mother. But, to the extent services are denied or delayed because the docs don’t suggest them, that doesn’t show up, to patients, as “the government interfered with my doctor.” And there ARE lots of situations in which services are done quickly, probably more quickly than they would have been done in Canada or the UK. See the waiting list figures in the Commonwealth data.
The third is, “look, the Canadians and UK would have no waits if they just split the difference between what we and they spend, in order to improve capacity.” So long as it was invested slowly instead of being spread to the wind like Alan Maynard would say some of the UK money has been. The trouble is, if their governments have squeezed “too much,” how could U.S. voters be sure our government would not squeeze “too much”?
The fourth is, “we can save from eliminating wasteful services.” But, first, we don’t actually know how to do that. And, second, that is played politically as “the government interferes with our medical care. Who knows better, the government or your doctor?”
So that’s why I’m particularly interested in comparisons of care for particular diseases. There are some in the OECD study from 2003. There were scattered ones back when I wrote my book: GAO had a good one on bone marrow transplants (U.S. was pretty bad, Germans were actually worse, French were great) and on a couple of cancers (U.S. slightly better than Canada in first year; slightly worse over five – I suspect continuity of insurance strikes again). But does anyone know of other studies?
All the best,
Joe
From: Chris Ham [mailto:[log in to unmask]]
Sent: Wednesday, June 10, 2009 1:42 AM
To: Joe White; [log in to unmask]
Subject: RE: Apparently, the United States has the world's best health care system
Joe
Ellen Nolte and Martin McKee’s Health Affairs paper on mortality amendable to health care uses one relevant aggregate measure and suggests the WSJ may have meant worst rather than best.
Chris
Chris Ham
Professor of Health Policy and Management
Health Services Management Centre
University of Birmingham
Park House
40 Edgbaston Park Road
Birmingham B15 2RT
0121 414 3212
07767 321 356
Read my new paper with Jo Ellins and Helen Parker, Opening up the Primary Care Market, in the BMJ, http://www.bmj.com/cgi/section_pdf/338/mar31_1/b1127.pdf
Read my editorial in the BMJ on the 2009 Budget and the NHS http://www..bmj.com/cgi/content/full/338/apr29_1/b1760 <http://www.bmj.com/cgi/content/full/338/apr29_1/b1760>
Read my editorial in the BMJ on the Conservative Party's policies on health http://www.bmj.com/cgi/section_pdf/338/jun01_1/b2198.pdf
________________________________
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Joe White
Sent: 10 June 2009 02:38
To: [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health care system
Actually, I got asked by a news network contact about this article, a few hours ago. The question was, among other things, what I could suggest in terms of quality measures that might contradict this. Off the top of my head (a lot of my stuff is in my university office) I suggested the Commonwealth Fund reports for overviews, and the OECD 2003 report on “A Disease-Based Comparison of Health Systems” for some of the fairly rare examples of disease-based comparisons. My memory of such reports is that, on the whole, they usually show the U.S. doing pretty well on specific diseases, but not consistently at the top. But what might some of you suggest for measures?
Cheers,
Joe White
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Jost, Timothy
Sent: Tuesday, June 09, 2009 6:26 PM
To: [log in to unmask]
Subject: Apparently, the United States has the world's best health care system
No less an authority than the Wall Street Journal tells us so
OPINION
• JUNE 9, 2009
Canada's ObamaCare Precedent
Governments always ration care by making you wait. That can be deadly.
• By DAVID GRATZER
Congressional Democrats will soon put forward their legislative proposals for reforming health care. Should they succeed, tens of millions of Americans will potentially be joining a new public insurance program and the federal government will increasingly be involved in treatment decisions.
Not long ago, I would have applauded this type of government expansion. Born and raised in Canada, I once believed that government health care is compassionate and equitable. It is neither.
My views changed in medical school. Yes, everyone in Canada is covered by a "single payer" -- the government. But Canadians wait for practically any procedure or diagnostic test or specialist consultation in the public system.
Martin Kozlowski
The problems were brought home when a relative had difficulty walking. He was in chronic pain. His doctor suggested a referral to a neurologist; an MRI would need to be done, then possibly a referral to another specialist. The wait would have stretched to roughly a year. If surgery was needed, the wait would be months more. Not wanting to stay confined to his house, he had the surgery done in the U.S., at the Mayo Clinic, and paid for it himself.
Such stories are common. For example, Sylvia de Vries, an Ontario woman, had a 40-pound fluid-filled tumor removed from her abdomen by an American surgeon in 2006. Her Michigan doctor estimated that she was within weeks of dying, but she was still on a wait list for a Canadian specialist.
Indeed, Canada's provincial governments themselves rely on American medicine. Between 2006 and 2008, Ontario sent more than 160 patients to New York and Michigan for emergency neurosurgery -- described by the Globe and Mail newspaper as "broken necks, burst aneurysms and other types of bleeding in or around the brain."
Only half of ER patients are treated in a timely manner by national and international standards, according to a government study. The physician shortage is so severe that some towns hold lotteries, with the winners gaining access to the local doc.
Overall, according to a study published in Lancet Oncology last year, five-year cancer survival rates are higher in the U.S. than those in Canada. Based on data from the Joint Canada/U.S. Survey of Health (done by Statistics Canada and the U.S. National Center for Health Statistics), Americans have greater access to preventive screening tests and have higher treatment rates for chronic illnesses. No wonder: To limit the growth in health spending, governments restrict the supply of health care by rationing it through waiting. The same survey data show, as June and Paul O'Neill note in a paper published in 2007 in the Forum for Health Economics & Policy, that the poor under socialized medicine seem to be less healthy relative to the nonpoor than their American counterparts.
Ironically, as the U.S. is on the verge of rushing toward government health care, Canada is reforming its system in the opposite direction. In 2005, Canada's supreme court struck down key laws in Quebec that established a government monopoly of health services. Claude Castonguay, who headed the Quebec government commission that recommended the creation of its public health-care system in the 1960s, also has second thoughts. Last year, after completing another review, he declared the system in "crisis" and suggested a massive expansion of private services -- even advocating that public hospitals rent facilities to physicians in off-hours.
And the medical establishment? Dr. Brian Day, an orthopedic surgeon, grew increasingly frustrated by government cutbacks that reduced his access to an operating room and increased the number of patients on his hospital waiting list. He built a private hospital in Vancouver in the 1990s. Last year, he completed a term as the president of the Canadian Medical Association and was succeeded by a Quebec radiologist who owns several private clinics.
In Canada, private-sector health care is growing. Dr. Day estimates that 50,000 people are seen at private clinics every year in British Columbia. According to the New York Times, a private clinic opens at a rate of about one a week across the country. Public-private partnerships, once a taboo topic, are embraced by provincial governments.
In the United Kingdom, where socialized medicine was established after World War II through the National Health Service, the present Labour government has introduced a choice in surgeries by allowing patients to choose among facilities, often including private ones. Even in Sweden, the government has turned over services to the private sector.
Americans need to ask a basic question: Why are they rushing into a system of government-dominated health care when the very countries that have experienced it for so long are backing away?
Dr. Gratzer, a physician, is a senior fellow at the Manhattan Institute.
Shame on us for thinking we could do better,
Tim
Timothy Stoltzfus Jost
Robert L. Willett Professor
Washington and Lee University School of Law
(540) 458 8510
fax (540) 458 8488
[log in to unmask]
________________________________
From: Anglo-American Health Policy Network [[log in to unmask]] On Behalf Of Adam Oliver [[log in to unmask]]
Sent: Tuesday, June 09, 2009 5:52 PM
To: [log in to unmask]
Subject: NHS
Hi
I have two Russian dwarf hamsters (Larry and Ted). Unlike Syrian hamsters, dwarf hamsters are social animals, but I noticed that as their food supply diminishes, they fight more noticeably (so much so, that I had to separate them). Anyway, you might be interested in the following:
http://news.bbc.co.uk/1/hi/health/8091427.stm
Best,
Adam
Please access the attached hyperlink for an important electronic communications disclaimer: http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
!SIG:4a2fa199185365902092262!
Please access the attached hyperlink for an important electronic communications disclaimer: http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
|
