Although the US presidential election is more than a year away, it is already election season in the US, and would-be candidates out there raising their profile and as much money as they can.
With campaigning comes campaign promises, which are generally worth the paper they are written, no matter which party the candidate is from. That said, several of the Democrats have been floating proposals for health care reform. The contention is that the US health care system is broken, and needs fixing desperately. The candidates differ in how they think it is broken, where it is broken, how badly it is broken, and how to fix it. The popular press is already infiltrated with the usual fluff pieces intended to serve as background material - much of which criticizes the US health care system while heaping praise on its alternatives. One of the most popular alternatives is the British model (the National Health Sevice or NHS), which has its own combination of strengths and weaknesses. But no health system is perfect. Worse, centrally controlled government health care systems retain complete control of the data they generate, allowing them to have near complete control of their image: the data that is made available to outsiders, how it is presented and analyzed. This problem is compounded by the usual difficulty associated with collecting accurate data in any modern health care system. Trust me: I understand this one from direct personal experience. If the people abstracting charts or gathering data for such report cards don't know what they are about, they will not ask for help. They will produce complete rubbish and call it a report card.
It has long been known that predicting long term demand (5 or 10 years into the future) in health care is tricky. It is likely somewhere between difficult and impossible. In the US, the law of supply and demand tends to minimize shortfalls in the availability of health care for the vast majority of its citizens. In Great Britain's NHS, this translates into a substantial mismatch between resources and demand, which has in turn translated into long waits for some kinds of service. It is also likely that this problem is further aggravated by systematic under-resourcing of health care. That this is a problem is now explicitly acknowledged by the NHS, and they publicly track the wait for a variety of services:
http://www.waiting.scot.nhs.uk/
Interestingly, participants in the NHS are not especially realistic about the wait times, all of which are far longer than typical US waiting times:
What is the effect of all of this? Well, it deserves a book, but I have neither the time nor the resources to write one. One consequence is that people will deteriorate and even die while awaiting care. Everyone knows that this is a problem, but, as mentioned above, there are a variety of reasons why measuring the effects of waiting times would be challenging even in the presence of eager cooperation. That said, perhaps the question is: What is the body count associated with these waiting times? Well, this is a news account of one estimate:
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from the www.dailyrecord.co.uk
4 June 2007
462,000 DEATHS CAUSED BY NHS
Failings are revealed
By Natalie Walker
POOR NHS treatment has led to almost half a million Scots dying in the last 30 years, a new study has revealed.
Doctors at Glasgow University found that between 1974 and 2003, a total of 462,000 people died in Scotland as a result of health service failings
It means Scotland has one of the highest avoidable death rates in western Europe.
The study examined the number of deaths caused by a lack of "timely and effective health care".
The vast majority of people - around 250,000 - who died due to inadequate or delayed treatment were heart or stroke patients.
Another 7300 had cancer and slightly more than 2000 were pneumonia patients.
The study revealed that avoidable deaths among men in Scotland over the time period was 176 for every 100,000 people.
This compared with 159 in Portugal, 129 in Austria and 100 in Italy.
Rates for women were 123 per 100,000, also higher than every other European country investigated.
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Roughly speaking, this translates to about 15,000 people dying while waiting in Scotland every year - population about 5 million. Scaling up to England - population 50 million - you could extrapolate that 150,000 succumb from delayed access a year. For a similar system in the US - population 300 million (give or take a few tens of millions of uninsured immigrants), the body count from a replica of England's NHS would be on the order of about a million people a year. This number is staggering, and vastly greater than even the wildest body count attributed to the failings of the US system.
The above provokes a few questions:
1. Is the Scottish data
accurate? I have no idea. As I mentioned above, my direct experience
has left me skeptical of all such data.
2. Is it appropriate to
extrapolate in this manner? Appropriate or not, extrapolation like
this is epidemic in health care policy discussions. I enjoin all
readers to regard all such statistics (including the body count from
medical accidents in the US) with skepticism. Twain was famous for
'lies, damned lies, and statistics', and I can only imagine how he
would describe modern policy wonks and their creative use of
information.
3. Would a system modeled on the NHS represent a
substantial improvement over our current system? The answer is not
self-evidently yes or no, but if the Scottish data both hold up under
scrutiny and generalize, then the answer would be a resounding NO.
4.
Who dies awaiting care? Not the wealthy - they take money out of their
pockets and procure their care in a timely fashion. These medical
tourists can and do go all over the world to get their care. Why is
this important? Because without this benefit from the law of supply and
demand, the body count from Britain's NHS - whatever it may be - would
be higher still.
5. Can the NHS fix this problem? Not without the
infusion of far more resources than they presently command, and not
without a more efficient way of allocating them...
6. (appended 5
July) What would be the results of a similar accounting in the US?
First, let me state that vying political agendas would make it
impossible to collect reliable data. The stakes would be so high that
it would be impossible to execute or complete the study. I would have
a hard time believing any data that was published.
That said,
my guess is that the quality and timeliness of service for indigent
patients in the US is almost certainly superior to the performance of
the NHS for the kinds of care that Medicaid covers. That is to say, if
you were to compare any large public hospital in the US (e.g. Cook
County Hospital) to the NHS, you would likely conclude that the US
system performs far better than its critics contend. Once again, this
is my opinion, but likely concordant with the experience of those who
provide this service. The care rendered to medicaid patients at
non-public hospitals - such as the one I work at - is vastly more
timely than the NHS. If you were to compare peformance on more
elective procedures (hip replacements, knee replacements, expensive
cancer therapy), the NHS would be vastly better, as these services are
not generally made available to medicaid recipients at either public or
private hospitals.
The UK physician/bomber cadre adds another aspect to this matter. The NHS has maintained low barriers to entry for foreign physicians because MD compensation is so miserable in the UK; the better players come to the states or Canada, where a living wage can be had, but entry criteriae are much more restrictive. Every political unit in the world has the same problem; allocation of scarce medical resources. Some must go without some things. I am in favor of age and quality of life related allocation, i.e. no heart transplants for severe senile dementia. If this is seen as discriminatory to disabled, so be it. Now we discriminate against the near indigent (the truly indigent get medicaid) How we effectively implement allocation (RATIONING) is the problem. As long as the elderly vote and the young do not, the system will not change without governmental obfuscation of what they are really doing.
Posted by: mkeamy | July 04, 2007 at 11:41 AM
There's a problem with conflating single payor and the sort of system the British have. There's no "equal sign" between them. Having countless insurers in the US taking money out of the system while providing no actual service is getting more and more indefensible. I've been posting on it over on my blog, which is usually more devoted to what it's like to be in the OR; something about which you already know a thing or two.
Posted by: Sid Schwab | July 06, 2007 at 09:30 AM
this link was posted at left, right and center which bears on your post:
http://www.timesonline.co.uk/tol/comment/columnists/article2039584.ece
Posted by: mkeamy | July 06, 2007 at 08:38 PM
That's a good link: the comments are equally as important as the subject post. Thanks.
Posted by: Sid Schwab | July 09, 2007 at 08:26 AM
Large organizations have enormous difficulty tracking data. Most are very good at tracking money. Even this can be more difficult than it appears at first pass, as is evidenced by the growing practice of 're-statement of earnings' in both the public and private sectors.
In theory, socialized health care can be more efficient because no participant is extracting a large percentage of the resources from the system, and smart leadership can avoid duplication of resources at every level. In practice, every socialized health care system expends an exorbitant amount on bureaucracy compared to the US healthcare system. My understanding is that there are systems in Europe that expend the majority of their resources on administration. With the NHS, it is not clear that the entirety of the cost is captured when it is calculated. Do they count the cost of training their physicians, nurses, and other medical personnel? Highly doubtful, and this is likely a major outlay. Do they count lost income from excessive wait times and avoidable death? Once again, if these numbers are correct, that cost would be staggering, and no accounting of the NHS could remotely capture its cost to the country if it was not included. It seems quite plausible that the US system, highly imperfect as it is, might be more efficient than any of its alternatives.
Flip side here? If there are really 45 million uninsured US citizens, and their wait times are on par with those in England, then there could be a body count in the US which rivals that I guestimated for England. As I stated previously, my belief is that wait times at county hospitals in the US are likely substantially better than those in the NHS, and thus our body count from wait times is likely lower.
Dr Schwab has contended that a single payor system would be different than the NHS. He is correct. That said, a highly regulated single payor system might perform identically to the NHS. All solutions are political and social in nature. Each alternative has both strengths and weaknesses. No solution might be preferable - strongly preferable over the long term - to many of the alternatives under consideration. My view? Any solution which minimizes regulation and central planning is preferable. Free and open markets, which utilize the law of supply and demand, are the most efficient way to provide health care, period.
Posted by: Mike O'Connor | July 09, 2007 at 03:58 PM
Hi. read Krugman in Monday NYT, here's the link if you get times select
http://select.nytimes.com/2007/07/16/opinion/16krugman.html?hp
hmmmm.
Posted by: mkeamy | July 15, 2007 at 08:50 PM
I have always been pretty happy with the health care system in the Netherlands and I think it is better than the UK system. Around 2000 we also had problems with long waiting lists, but the waiting lists have decreased by more than 90% since.
Basic explanation of the system: http://www.justlanded.com/english/netherlands/tools/just_landed_guide/health/healthcare
Performance report: http://www.rivm.nl/bibliotheek/rapporten/260602002.html
Especially interesting is the graph at page 15 of the report on the cost effectiveness of health care internationally.
Posted by: Wouter | July 31, 2007 at 04:39 AM