Universal health care means limiting access. A TNR debate, Day 1

Dear Jonathan,

Millions without insurance, rising health costs, uneven quality--on this, we agree: American health care is riddled with problems. It's enough to make a person look for a sweeping new proposal. In your book, you do just this, flirting with some type of government solution. Then, in an essay last week, you explained that countries with such systems "outperform" American health care.

I understand that argument. In fact, not that long ago, I shared your point of view. I was born and raised in Canada. There were three things I soaked up from my environment: a love of ice hockey, an ability to convert Celsius to Fahrenheit, and a belief that government-run health care was compassionate. But, unlike you, my faith in government wasn't exactly born of careful analysis--I wanted to be a doctor, and my interest was MCAT scores and admission rates, not stats on GDP spending. Still, growing up with socialized medicine, I couldn't imagine anything else.

Yet after getting into medical school and training in Canada's hospitals and clinics, I discovered how chaotic the system was. And I realized how cruel it could be. Far from the nirvana of your essay, I found people struggling to get basic health care--since practically every surgical and diagnostic test required some type of waiting. The stories I encountered were moving: a man waiting two years for a referral to a pain clinic; a woman with sleep apnea forced to wait three years for a sleep study; a professor--barely able to walk because of a spinal condition--told to wait six months for an MRI. The professor, by the way, was my father. Government statistics detail other shortages: Some 1.4 million Canadians in Ontario alone who are actively looking can't find a family doctor.


I concluded that government health care inevitably resulted in some type of rationing. With the "high tech, high expense" medical revolution changing health care across the West, governments decided to control costs by employing wage and price controls. Waiting and shortages were the inevitable result. No wonder, then, that, in some municipalities in Canada, lotteries are held, with the winners getting an appointment with the town family doc.

Of course, that isn't the conclusion that many would derive from your thoughtful piece. As you note, there is a rich literature suggesting otherwise. To summarize: It's not just that U.S. health care is feverishly expensive, it's actually not particularly good by international standards. Consider infant mortality statistics or life expectancy, you say, and we find that America trails other Western countries. The eventual conclusion: Do away with the pesky middlemen (like insurance brokers) and we'll all be insured and "end up healthier."

Let's start with the argument that single-payer systems perform better than American health care. This is a common argument: Comparing crude health outcomes, America lags behind. And life expectancy would seem to be a case in point. You don't cite numbers, but I will. Americans live 75.3 years on average, less than the French (76.6) or the Canadians (77.3) or basically any other Western European nation. But crude health measures reflect a mosaic of factors, such as diet, lifestyle, genetics, homicide rates, and cultural values. Health care--alas, it pains me as a doctor to say this--is just one factor.

Consider that homicide and motor vehicle accident rates in the United States are much higher than other countries (for instance, murder is eight times more common than in France). In their new book, The Business of Health, Robert L. Ohsfeldt and John E. Schneider factor out intentional and unintentional injuries from life expectancy statistics, concluding that this non-injury group of Americans outlive similar groups in other countries.

Or take infant mortality. Rather than looking internationally, let's consider the U.S. picture: According to the National Center for Health Statistics, Mexican American and white babies in the United States have a lower infant mortality rate (about six in 1,000 live births) than Native Americans (nine) or blacks (14). Yet Mexican Americans also have the least access to health insurance of any of these groups. In fact, it's even more complicated: A study in the Journal of the American Medical Association suggests that Mexican-American babies are twice as likely to be born outside a hospital as babies of all other groups.

Infant mortality statistics--like life expectancy--reflect a mosaic of factors. Dismissing American health care on the basis of such statistics is like declaring Cuban democracy stronger than America's based on voter turnout. In reality, if you measure a health care system by how well it serves its sick citizens, American medicine excels. In my book, The Cure, I focus on various types of care, such as heart disease, psychiatry, and cancer. I conclude that Americans come out on top.

Five-year survival rates for various types of cancers bear this out. For patients diagnosed with stage I colorectal cancer, survival is 90 percent in the United States, but just 80 percent in Germany and down to 70 percent in Great Britain. Breast cancer survival is better, too: at 97 percent for stage I carcinomas, versus 78 percent in Great Britain.

You explain these statistics by suggesting that American doctors are simply overly zealous, scanning everyone, turning up tumors in the aged, and then pushing patients into "early treatment of the disease [that] may do more harm than good." I'd offer another explanation: American medicine offers better, more state-of-the-art care. A study done in 2003 for Britain's National Health Service found that, long after its approval, more than 1,000 eligible British women with breast cancer were still not receiving Herceptin (and European access to cancer drugs is hardly more encouraging). Drugs like Erbitux, used to treated advanced bowel cancer, aren't available in Canadian hospitals. Forty percent of Britons diagnosed with cancer will never see an oncologist.


True, that doesn't necessarily reflect itself in overall death rates in every type of cancer--such statistics, like all national life-expectancy figures, tie into other factors like diet. But the big picture is impressive: U.S. cancer deaths have, adjusting for age, fallen 1 percent per year since 1991--a record unmatched in the Western world.

There are, though, international studies that suggest American health care is a dud. You write about a Health Affairs paper analyzing five nations. Add this to a growing list including a multi-volume WHO report and a widely-cited Harvard study. These studies reflect the bias of their authors: The World Health Oranization (WHO) report was more concerned with equality than timeliness of care; the Harvard study confused health and health care; the Health Affairs paper made questionable assumptions (like the supposition that longer hospital stays resulted in more efficient health care).

My central point: Don't measure a country's health care system by how well it promotes socialist goals or social engineering; judge a system by how well it serves people when they're ill. And, in this area, America is the best. That's why Arab princes come to our hospitals. And why patients from Niagara Falls, Ontario, with stage 4 colon cancer are sent by their government to Niagara Falls, New York, for treatment.

How unusual a position to be in. I've just written a critical book on American health care and now seem to offer up an unabashed defense of it. It's true that U.S. health care is riddled with problems. But government-run health care systems haven't managed to deliver better medicine at lower cost. Countries like Canada and Great Britain and France have simply found ways to ration the care their citizens need.

Best,
David