Well said Barbara- in my view the public health shift from smoking to obesity is just another example of how that community -at least in the northern hemisphere manages to construct public issues (societal/structural determinants) as private irresponsible behaviour.
Jennie
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]] On Behalf Of Starfield, Barbara
Sent: 11 June 2009 11:27
To: [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health care system
Frankly, I do noit consider obesity to be a matter of individual choice. It is not easy to have a healthy diet in the US and the same ius becoming the case elsewhere for the same reasons.
----- Original Message -----
From: Anglo-American Health Policy Network <[log in to unmask]>
To: [log in to unmask] <[log in to unmask]>
Sent: Thu Jun 11 05:00:18 2009
Subject: Re: Apparently, the United States has the world's best health care system
Health behaviours in the US are among the best?
Obesity??
-----Original Message-----
From: Anglo-American Health Policy Network [mailto:[log in to unmask]]
On Behalf Of Starfield, Barbara
Sent: 11 June 2009 02:50
To: [log in to unmask]
Subject: Re: Apparently, the United States has the world's best health
care system
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%20Li
terature/2007/Nov/Toward%20Higher%20Performance%20Health%20Systems%20%20
Adults%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
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Please access the attached hyperlink for an important electronic
communications disclaimer:
http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
Please access the attached hyperlink for an important electronic communications disclaimer: http://www.lse.ac.uk/collections/secretariat/legal/disclaimer.htm
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