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Universal Health Scare

When private health care fails. A TNR debate, Day 2

This is the second part of a four-part debate. To read the previous installment, click on the link below.

Part 1, Monday: David Gratzer

Tuesday, April 17

Dear David,

One reason I was pleased that you would be debating universal health care with me is that you are a physician. I know that these issues are not mere abstractions to you. They are human lives, which you've seen up close. And, based on your description of some problems you saw in Canadian medicine, I believe that your opposition to universal health care reflects an honest belief that--despite the lofty claims proponents like myself make--it will actually leave the people worse off, not better.

Still, I can't help but wonder if your experience in Canada hasn't led you to some misinformed conclusions. It is certainly true that Canada has waiting lines for many elective services. This, as you say, is a form of rationing. There is no point in denying it--or denying that, for many Canadians, these waits mean real and unnecessary hardship. I'll even add a point you didn't mention: Waiting time for elective surgery is unlikely to register on many health indicators, because it doesn't lead to observable, measurable consequences like death or disability. It simply causes pain (and, if you want to think in economic terms, lost productivity), which is hard to measure but no less real for that fact.

But the question is not whether Canada rations--it's whether Canada's rationing is worse than ours. That's less clear. The United States also has more than 40 million people without insurance. Canada, for all intents and purposes, has none. And, as I'm sure you are aware, these people frequently wait for services--if, indeed, they seek them at all. Their care is rationed all the time. They, too, will experience long waits for tests and procedures. They, too, will suffer adverse health outcomes. Some of this reflects culture and environment, but the vast majority of studies on this--and there have been, as I'm sure you know, quite a lot--conclude that access to medical care is a big factor, as well.

One way to think of Canada is that it rations its care in a more egalitarian way than we do. It's a one-size-fits-all, single-payer system, so everybody is subject to the same limitations. Here in the United States, we have enormous disparities, where people with insurance tend to have pretty good access to care while people without have lousy access. You could argue that it's basically a wash--that, really, it's all about which way you prefer to ration. But that would overlook one key difference: They spend a whole lot less than we do. So both of our countries are rationing, but Canada does it for a lower price. Tell me again why that makes our system clearly superior?

But, really, I'd rather not talk about Canada anymore. Or Great Britain, for that matter. The critics of universal health care generally dwell on these two countries. And I couldn't help but notice that almost every data point you cited came from one of those two. I know this focus has something to do with the cultural affinity between our countries and the ease with which we share data, thanks to common language. (Plus, in your case, Canada is your original home.) But it's also pretty misleading, at least insofar as those two countries are supposed to be proxies for what universal health care is like.

Great Britain and Canada, after all, are two of the most centralized systems in the world. The British have true socialized medicine--by which I mean that doctors actually work directly for the government. Canada has a pure single-payer system that effectively has no role for private insurance. Both also spend less than the United States--in the case of Great Britain, much less.

As I assume you know, it is possible to spend more and have a slightly less centralized system. When you do, the results are much better.

I have cited France as such a country, although others--Germany, Japan, and Switzerland come quickly to mind--would fit this description, as well. Structurally, they are pretty different from each other. What they have in common is that they combine universal coverage with easy access to medical care. None of these countries have systematic waiting-line problems, according to the Organization for Economic Cooperation and Development. In fact, access to medical care tends to be even easier in these countries than it is in the United States. They see doctors more and have more time in hospitals.

To be sure, more doctor visits don't necessarily equal better medical care. But the best information we have suggests these countries generally do as well, if not better, than the United States, on overall health outcomes. You spent a lot of time arguing that infant mortality and life expectancy were poor proxies for health--which, you may have noticed, I acknowledged right up front. That's why I proceeded to offer some more carefully constructed statistics, like "disability adjusted life expectancy" and "potential years of life lost," which are designed to hone in on the effects of medical care--and where the United States also lags (even behind Canada, I might add). I'm curious: Do you think these statistics are meaningless as well? If so, why?

I suggested that it's wrong to assume the United States has the best high-tech care. I noted, first, that it's a country with universal health care--Japan--that actually leads the world in the relative prevalence of high-tech equipment. Then I mentioned several diseases in which other countries--Australia, France, Sweden--had better cure rates than the United States. You responded to all of this by, once again, talking about ... Great Britain and Canada. Well, OK. But what about all those other countries? If universal coverage inevitably leads to worse medical care, why are they doing better than us some of the time?

To back up my claim, I cited the research of some prominent health policy scholars--including Professor Gerard Anderson of Johns Hopkins, widely considered the nation's leading expert on the subject. You dismissed the study as confusing longer health stays with quality health care. But perhaps you were thinking of a different study? The one I had in mind was "How Does the Quality of Care Compare in Five Countries?," which ran in the May/June 2004 edition of Health Affairs. It examined more than 20 criteria, from immunization rates to survival for various diseases. Relative to the other four countries surveyed--none of which, by the way, are among what I would consider the best-performing universal health systems--the United States did very well on some criteria, very poorly on others.

I assume you'd argue some of the statistics (like suicide rates) have less to do with health care than, say, underlying social and economic issues in the countries. Fine. But what about survival rates for Hodgkin's disease, cervical cancer, or liver and kidney transplants--all categories where other countries were superior to the United States? Surely this must have some significance, since, after all, you yourself pulled out survival statistics for some other cancers as proof of the alleged U.S. superiority. (Of course, that was another instance when you indicted universal health insurance everywhere by pulling out statistics from Great Britain.)

You also brought up the World Health Organization (WHO) study. And it's true, as you say, that its criteria were weighted to favor countries that had broad access to care--putting the United States at a disadvantage. That's one reason I didn't cite the WHO study in my article. I didn't want to get into that whole discussion.

But, since you brought it up, I feel compelled to say one more thing: Why shouldn't access be part of the equation? Particularly given the difficulty in measuring health outcomes, access to care (and affordability of care) is the one thing we can measure definitively. And it's the one area where the United States most conspicuously does worse than the rest of the world--by whole orders of magnitude.

I can understand why you might not like to talk about this: It doesn't make our system look particularly appealing. But for a lot of other people--particularly the ones without access--I think it might matter a whole lot.