This is the final part of a four-part debate. To read the previous installments, click on the links below.
Part 1, Monday: David Gratzer
Part 2, Tuesday: Jonathan Cohn
Part 3, Wednesday: David Gratzer
Thursday, April 19
Thank you, again, for the gracious response--and for participating in this debate. The perspective of physicians is, for all the obvious reasons, crucial as we talk about redesigning our health care system. And you have already contributed many insights.
Still, I have to take issue with some of your concluding thoughts. Let's start by looking, one last time, at the statistics. I began my original essay with overall statistics on health outcomes--including the very crudest, such as infant mortality, as well as more finely tuned ones, such as disability adjusted life expectancy. You criticize the value of these because, you say, all of them take into account other factors like accidental injury and environment. I do not deny this; indeed, I believe I acknowledged their limits up-front (as I do in my book). But I also believe they still have significant value. We may not know exactly how important the health care delivery system is to life expectancy, but we know that the health care system plays at least some significant role. And yet, on these measures, the United States fares poorly--and not just poorly, but very poorly in some instances.
I then moved to the statistics you prefer, about treatment of various ailments. You have focused on three cancers--breast, prostate, and colorectal--where the United States seems to have the most success at curing people diagnosed with the disease. (I've seen conflicting data on colorectal, by the way, though I think that's due to different definitions in different countries.) This, you say, is proof we are offering better medical care than other countries.
Once again, I had acknowledged these statistics preemptively--back in my very first essay. And I'd given a two-fold response. I pointed out that other countries outperform the United States when it comes to treating other diseases--including some other cancers--and that even the numbers you cite may be misleading, because there are good reasons to think we're over-treating breast and prostate cancers. Chief among them: the fact that the portion of the whole population dying from these diseases isn't markedly higher in other countries--only the portion diagnosed with them, suggesting we may be curing a lot of non-lethal cancers.
Rather than argue with this point--which, as I assume you know, is consistent with a lot of what we've been learning about prostate cancer recently--you noted that we have many Nobel Prize winners and that our cure rate for cancer overall has improved more dramatically than in other countries.
Well, OK. But so what? The relationship between medical innovation and health insurance is tenuous at best; it likely has more to do with, say, research funding from the National Institutes of Health. If we have more Nobel Prize winners, credit goes to our higher education system, which really is the best in the world (for a whole other set of reasons). And, while it's nice that we're getting better and better at curing cancer, if we're still behind other countries--as we are in those other examples I mentioned--why does the rate of improvement matter so much? If you brought modern cancer treatment to an impoverished Third World nation, I'm sure the cure rate there would rise, too. Would you suggest patients go there?
The fact that U.S. companies developed half of all new major medicines tells me very little given how many newly developed medicines add questionable value. And, given how many bylines I frequently see on medical journal articles--it's not uncommon to see a dozen or more, spanning the globe, for one research paper--the fact that American researchers played a "key role" in 80 percent of recent medical advances sounds to me like a statistical inevitability given the size of our population.
Here I need to defend Professor Gerard Anderson one last time. Yes, his study considered criteria like suicide and smoking. But he broke them all out individually. Those weren't the only areas where the United States lagged. It also lagged when it came to cure rates on several diseases--the very criteria you say matters most.
Let me be clear: My point is not that the United States is demonstrably worse overall when it comes to medical care. As I frequently say, I wouldn't bet the house on any one of these statistics individually, given their inevitable inaccuracy. Nor is it clear that the qualities Americans like in the health care--easy access to doctors, wide availability of technology--really does amount to better medical care per se.
But when so many statistics show the United States lagging--and only a few of questionable meaning show the United States ahead--I don't see how anybody can make a persuasive case that we're actually getting better health care than the other highly developed countries of the world.
Now let's talk about rationing. To my objection that you've ignored the countries that don't have long waiting lines, such as France and Japan and Switzerland, you said:
[P]ublic systems are relatively similar--they simply attempt to ration health care in one way or another. In my travels and in my conversations with colleagues, I have yet to come across any particularly interesting approaches to health care management in the countries you list. It's not that governments have pioneered novel types of primary care or that they have rethought the institutional provision of services. These countries simply use wage and prices controls to temper demand. Sure, the Canadian and British approaches seem particularly problematic, but France has its share of dissatisfaction and problems..
A few points here: If you haven't seen government being innovative about health care management, you should check out the newest literature--particularly the news out of Great Britain, where they're pushing ahead with efforts to promote cost-effective care. As I said earlier, I don't love their system because they spend so little--they really do impose rationing, the kind neither you nor I would like. But maybe, because they spend so little, they're getting very good at squeezing every bit of value out of their dollars. (Er, pounds.) Their efforts are starting to get a lot of attention in the academic community, particularly when it comes to pharmaceuticals. And these efforts, I'm told, build closely on what the Australians have been doing.
As for France, yes, let's look at those links. You cited, first, a newspaper article about the growing concern about the financial sustainability of their health care system. Well, fine--except that they spend less than we do! If the cost of health care is your primary concern, then surely they're doing better than we are. A lot better, as a matter of fact. I also see that the article referred to the internationally recognized high quality of French medical care. It seems to me this article makes my point rather than refutes it.
The deaths from the French heat wave are, indeed, tragic. But most of those deaths were of people in nursing homes. Are you up on the state of nursing homes in the United States--and long-term care more generally? I don't think that's a comparison you want to start making, because the United States won't look good there, either.
Is France's system perfect? Germany's? Switzerland's? (And thanks to reader/commenter blackton for repeatedly reminding me of Japan's excellent performance, which deserves more attention and study.) Of course not. I never said they were. In fact, if you look closely, you'll see they're dealing with the same issues we are--about how to pay for their systems and how to improve the quality of care, which is disturbingly uneven. But they are in a better position to address those problems, because their universal health care systems cost less overall and because centralization seems a more promising route to improving quality than anything we've seen from the private sector--which, as you may recall, has been promising better quality for 20 years now.
The biggest point about rationing, though, is that you barely acknowledge the rationing that takes place here--let alone recognize its significance. More than 40 million people have no insurance. In a two-year period, almost one-third of the population will go without insurance at one time or another. Financial barriers to care are legendary--and the people who experience them routinely ration their own care.
At the end of your most recent essay, you suggest what we need is more competition--a solution you outline in your book, The Cure. I've argued against this point of view before and do so, again, in my own book. So I won't belabor those arguments here. But I will give a plug to yours: It is a briskly and clearly written treatise and I commend you for it, particularly since you are a physician by training and not a writer. (Doing one job well is tough enough; doing two jobs well, now that is impressive!) I'd also recommend it to anybody who wants a smart and lucid defense of the conservative vision for health care. It's important to have these debates because these are important matters. And, while I don't share your views on them, I am truly grateful for the time and talent you've devoted to exploring them.