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November 09, 2012

Comments

Economies of scale don't work when delivering personal services like medicine.

Iceland, population 319,000. Impressive.

Well, which is it, Mck?

Instead, what I (and maybe Paul Krugman, I don't know) claim is that our healthcare system saves fewer people, and costs more money, than some European ones.

Do you disagree with that?

I'm not sure which of the "some" countries you are referring to, but I'm fairly sure that outcomes are the opposite: the US does better pretty much across the board on outcomes, particularly on cancer survival rates. A lot of the comparatives depend on the metric--how many docs in a given specialty, wait times, number of MRI machines and other diagnostic/treatment modalities available in a given community, etc? Intuitively, I view any countries' numbers as suspect. No country, particularly one in which the quality of healthcare is tied to the governing party, advertises bad results.

And its glæpsamlegt for Píturs sake.

Glad you caught that.

Well, which is it, Mck?

It's the smaller number in both instances. It's easier to treat a smaller number of people, and to order priorities among a smaller group. That a much smaller country can rebound faster than one that is a thousand times larger seems unsurprising.

It's the smaller number in both instances.

Quite right. I got my head turned backwards on that. (Not that I'm now agreeing with you on the facts, necessarily, but I'll concede to the logic on that particular point.)

Source 1

Source 2

Mck, where did you read that US does better than other countries?

Also, "viewing other countries' numbers as suspect" is sort of an ad hominem (ad patria?), and there's no way to debate you if you take that position, unless you can specifically point to indications that the numbers are wrong.

Julian, for cancer survival rates, go to this link, Table 5: http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-027766.pdf

For elective surgery wait times, go to this link: http://www.oecd-ilibrary.org/sites/health_glance-2011-en/06/08/index.html;jsessionid=as008die826bn.delta?contentType=&itemId=/content/chapter/health_glance-2011-59-en&co

Your two cites used life expectancy and infant mortality rates. Both are dependent in part on life style choices and decisions. Unfortunately, both are also demographically sensitive. Europe does not have the US' population homogeneity. Unfortunately, if you break down life expectancy and infant mortality along ethnic lines, you get different sets of numbers that produce a lower average result. Comparing like populations to like produces a more comparable result. Feel free to check this out and fix any error.

My preferred metrics are outcomes and wait times. I haven't been able to find any reliable data on efficacy of surgical outcomes. Intuitively, because our surgeons operate more, I suspect our outcomes are better, but there are good reasons for believing the opposite, e.g. I am anecdotally aware of several surgeons who cut automatically just to get paid. I doubt that is a big issue in Europe.

As for viewing numbers as suspect, no I don't think that is ad hominem. Countries with national health care are motivated to put themselves in the best light. Advocates for private insurance put their numbers in the best light. Put differently, people with vested interests lie and governments are made up of people.

Eventually, we will run out of money. If we haven't already.

Isn't the real question a matter of real resources, not money, which is an artifical tool we use to facilitate the allocation of real resources - a unit of measure in some sense, like inches or feet?

Certainly, there may be competition for the resources required to deliver a given level of healthcare among other potential uses for those same resource, but I never hear anyone discussing that. Instead, everyone talks about money, which can be created out of thin air if necessary.

Why would that be necessary? Maybe there's a lot of fat in our economy that would be cut in favor of healthcare. Why shouldn't healthcare be a high priority? Doesn't healthcare provide jobs, many of which are highly rewarding and challenging? Doesn't it yield value in improving and prolonging life? What's more important than that?

Or, if everyone has access to healthcare, might we end up using less of it (per year, per capita), since people won't be waiting until they're critical before getting treatment?

Anyway, you don't worry about running out of feet when you're building something out of lumber. You worry about running out of wood. No one says, "Well, we have plenty of wood, but we've run out of feet by which to measure it. We'll have to halt construction until we can get some more feet."

McTex, we've discussed this before but cancer survival rates aren't necessarily meaningful. For example, in the US, we screen for prostate cancer very aggressively using tests that have a high false positive rate. As a result, we perform lots surgeries and then pat ourselves on the back for our very high prostate cancer survival rates. But the truth is a large fraction of those "cancers" were never going to cause significant health problems, at least not until long after heart disease killed the patient anyway. But hey, we've got a fee-for-service medical system so and the urologist and surgical oncologist made bank, so I guess it is all good.

"As for viewing numbers as suspect, no I don't think that is ad hominem. Countries with national health care are motivated to put themselves in the best light. Advocates for private insurance put their numbers in the best light. Put differently, people with vested interests lie and governments are made up of people."

it is an ad hominem. You are impugning the truth value of a statement based on the source of the statement.

What's more, if you truly think that vested interests lie and governments are made up of people, why is there any less reason to distrust/discount the sources that you cite?

"Your two cites used life expectancy and infant mortality rates. Both are dependent in part on life style choices and decisions."

You cite cancer rates and elective surgery wait times. Are those less dependent on lifestyle choices and decisions? You say "[m]y preferred metrics are outcomes and wait times," but why should outcomes exclude infant mortality and life expectancy?

"Unfortunately, both are also demographically sensitive. Europe does not have the US' population homogeneity."

Europe is not a country, it's a continent, and I have no idea why Europe's heterogeneity should matter. See the JAMA source:

Countries in order of their average ranking on the health indicators (with the first being the best) are Japan, Sweden, Canada, France, Australia, Spain, Finland, the Netherlands, the United Kingdom, Denmark, Belgium, the United States, and Germany.

So you're telling me that those countries ranked higher than the US don't have the ethnic homogeneity of the US? And that's why they do better on indicators like infant mortality and life expectancy?

"Unfortunately, if you break down life expectancy and infant mortality along ethnic lines, you get different sets of numbers that produce a lower average result. Comparing like populations to like produces a more comparable result. Feel free to check this out and fix any error."

Here, what I think you're saying is that the U.S.'s infant mortality and life expectancy numbers are being dragged down by minorities (black and hispanic people, probably), and that we should be comparing the outcomes for white people in the US with white people in Europe.

I hope that upon reflection you will understand why this is a deeply repellent argument. You're saying we shouldn't factor in how ethnicities who are disproportionately poor are faring under our healthcare system.

Why not?

"Instead, everyone talks about money, which can be created out of thin air if necessary."
When the Federal Reserve (government) does it, it's call monetary easing. When a private entity does it, it's called counterfeiting.

"When the Federal Reserve (government) does it, it's call monetary easing. When a private entity does it, it's called counterfeiting."

When I carry my TV to my dad's house, it's called moving, when you carry my TV to your dad's house, it's called theft.

Did I just blow your mind?

When the Federal Reserve (government) does it, it's call monetary easing. When a private entity does it, it's called counterfeiting.

I'm not sure what your point is. This is as it should be.

Regardless of who creates money out of thin air, it's still theft.

"Regardless of who creates money out of thin air, it's still theft."

Let me guess: because it reduces the value of units of that currency for everyone else.

If I build a hot dog shack next to your hot dog shack and you lose customers to me, is that theft?

No. Not all conduct that reduces value is theft. Printing more money is not theft. We live in a democracy that elects politicians who are ostensibly accountable to us, and they appoint people who set monetary policy. You may not like monetary policy, but the fact that it goes on without your personal approval does not make it theft.

Regardless of who creates money out of thin air, it's still theft.

I guess that settles it. Thanks!

Money is stuff of low to no intrinsic value (yes, that includes gold) that only lives by the trust put into it.

"If I build a hot dog shack next to your hot dog shack and you lose customers to me, is that theft?"
Then I should be able to issue my own currency and let people pick the currency they think holds the best value.
"Printing more money is not theft."
Tell that to the Chinese and others holding US dollars. At some point, they may get tired of having their pockets picked.

My preferred metrics are outcomes and wait times.

Great! Then you can perhaps answer some questions

1) What is the ideal mean wait time for all elective, non-life-saving surgeries, and how are you arriving at this figure? Can you then break it down by surgery type, and explain how you arrived at those figures as well?

2) Outcomes for what? Measured by what? Just cancer, or other stuff, too? How many years of life after remission is acceptable? Is "infant mortality" not an outcome?

I think I get it: The government's stealing all the stuff that wouldn't exist if it hadn't created money out of thin air when it creates money out of thin air.

We should prefer much higher taxation and much lower spending, with all the attendant economic calamity. People like to say we'll become Greece if we don't fix our deficits. The truth is, the fastest way to become Greece is to try to fix our deficits when economic conditions won't allow it.

To each his own.

Why does CharlesWT hate Article 1, Section 8? Whence the disrespect for the wishes of our Founders?

"Money is stuff of low to no intrinsic value (yes, that includes gold) that only lives by the trust put into it."
Gold, at least, has a verifiable physical existence. Unlike the promises of politicians and governments.

Tell that to the Chinese and others holding US dollars.

Highlighting the Chinese, who peg their currency to ours so they can sell us stuff, is an interesting choice. I can't wait for the new regime of economic-isolationist exporters to arise. It should be quite the trick.

Then I should be able to issue my own currency and let people pick the currency they think holds the best value.

Umm, can't you do that right now? Bitcoin is hardly the only digital currency around. What exactly is stopping you?

Gold, at least, has a verifiable physical existence. Unlike the promises of politicians and governments.

Barter to your heart's content, or, better yet, live off the land. The rest of us have organized ourselves in another fashion. It does have its problems, but it's generally worked out quite well in terms of standard of living and quality of life - not that I wouldn't strive for improvement in many areas where improvement seems sorely needed. But I'd work within the system rather than replacing it, in spite of politicians and government being part of it.

So, rather than being a right, health care is a 'conferred benefit'. We can agree among ourselves, as a country, to confer this benefit, but only if we have the means to pay for it without undue imposition on those who are writing the checks. What we lack are the means. We have over-conferred on the benefit side.

This is, IMO, a sensible analysis.

I agree that neither health care, nor health insurance, are rights. I would go even a little further and argue that talking about them as if they were rights confuses the issue, quite a bit.

Publicly provided health insurance is a benefit that we may, or may not, agree to confer, to whatever degree we choose to confer it.

All of that said, I would add the following.

The consequences of not having access to health care are generally larger than for lots of other goods and services. And, those consequences in many cases impinge on public life. There is, IMO, a public interest in basic health care being broadly accessible.

The cost of health care has for many years increased at a rate greater than inflation and/or the growth of the economy as a whole. As a sector of the economy, it threatens to starve other crucial things of resources. So, there is also IMO a public motivation for intervening in the health care industry.

The US spends more in public money on health care than many equivalent countries, AND IN ADDITION spends more in private money. We spend MUCH MUCH more on health care, and if you broaden your metrics beyond the somewhat narrow focus of outcomes for specific cancers and wait times for elective surgery, we DO NOT have a much much better result. Again, IMO this argues for public intervention in the health care industry.

Private markets are great when they work, and the general preference - the default option - should normally be to leave them alone.

When they function in ways that impinge negatively on the public well being, IMO public intervention makes sense.

I think ACA is a less-than-optimal Rube-Goldenberg frankenstein's monster version of health care reform, but for better or worse it's the best we could do. It's not perfect, but it's better than nothing, and it's a step, again IMVHO, in the right direction.

I expect a large number of the regulations and provisions to be changed over time, and I think that's both fine and appropriate.

But the cost of health care, period, no matter who pays for it, is going to be one of a very small handful of make-or-break problems for the nation over the next 20 or 30 years.

I don't think it's something that can left purely to private markets to sort out.

"Regardless of who creates money out of thin air, it's still theft."

Well, it turned out, according to Teddy Roosevelt, that having a second-story man of last resort was the only way to counteract the ability of your every day second-story men, like J.P. Morgan, to make everyone else's money disappear into thin air by other means.

I'm trying to think after Bear Stearns, Lehman Brothers and company in 2007-2008 reduced the money stock of the entire f*cking world, how it is that someone who, absent the Federal Reserve, had gold to pay for the last can of tuna fish thought they were NOT going to be set upon fatally by the rest of us.

I'd like to know too the provenance of the many more frequent financial panics experienced prior to the Federal Reserve Act.

Hey, you know what? That the entire system is a bullsh*t confidence game is granted. That we should leave the bullsh*t confidence game to Jaime Diamond and company is itself Bullsh*t.

Jaime Diamond and company need a bigger bullsh*tter, for the time being Ben Bernacke and fellow Governors of the Federal Reserve, to watch them and print the money the former destroy from time to time.

Since Phil Gramm and Robert Rubin convinced Congress and the White House that Jaime Diamond (the biggest name and thus symbolically mentioned here) didn't need to be watched by anyone else.

By the way, don't let it get out that our entire way of life and standard of living depends on credit way beyond the world's gold reserves depends on this fragile lens of bullsh*t we rest on.

Let's keep it our secret here at OBWI.

Lest everyone else panic and Ron Paul is left holding the last can of tuna fish.

Then I should be able to issue my own currency and let people pick the currency they think holds the best value.

Nope, sorry, that's a designated power of the US Congress. Amend the Constitution if you don't like it.

Edited to add upon seeing Turb's post: Do whatever you want, just don't expect to, you know, buy anything anywhere.

Dimon, darnit. Not Diamond.

Not Selma Diamond. Not Jared Diamond.

Diamond Jaime Dimon.

Turbulence, making your own currency (not forging an existing one, that's something else) is illegal in many countries, including the US iirc. It's not just that the state hates rivals but using a currency not officially sanctioned is seen and treated as tax evasion (since it skips sales tax/value added tax/equivalent tax for transactions). That also means that pure barter is not strictly legal (although on a small scale it rarely gets prosecuted). Paying taxes in kind has been outlawed long ago.

There's a growing movement to use cell phones to transfer value bypassing middlemen including banks and governments.

making your own currency (not forging an existing one, that's something else) is illegal in many countries, including the US iirc.

Are you certain? Years ago I worked at a startup with a few guys who were interested in alternative digital currencies. The impression I got from them was that this sort of thing was legal as long as you were careful to ensure that conversions between your currency and US dollars were not anonymous.

There's a growing movement to use cell phones to transfer value bypassing middlemen including banks and governments.

No one could possibly be so ignorant as to find this plausible. I yearn to learn more about this "movement". Please, do tell.

There's a growing movement to use cell phones to transfer value bypassing middlemen including banks and governments.

"Hey Eddy, izzat you?"
"Yeah, russell, it's me"
"Can I borrow your car?"

CharlesWT:

I must be missing something.

You mean I can pay a merchant by bypassing banks and governments?

From whence do these payments originate? From thin air? From my BANK account, insured by the government?

From some other account/entity containing what currency? Earned and paid by whom? An electronic blip? Backed up by the full faith and credit (see previous rant on the thin lens of .. etc) of whom? Ebay?

To be received by the merchant and used to replenish inventory from suppliers using what currency?

Wasn't there a candidate in 2010 who suggested purchasing medical care with an alternative currency denominated in chickens?

How were the chickens procured in the first place?

Yeah, I know about eggs, but where did the chicken producer get the eggs in the first place?

From the doctor who received too many chickens that laid too many eggs?

That sounds suspiciously like inflation most fowl.

I almost referred to the chicken lady in my last post. If payment in kind was still legal (it isn't) the doctor would have to pay the first eggs from the chicken from the patient to the state or he would have failed his tax obligations (income tax in this case).

Tax evasion is illegal. If someone pays you in non-US-currency, you have to figure out the fair market value of the transaction and make sure you pay the appropriate taxes. But the issue here is that tax evasion is a crime, not that paying in non-US-currency is illegal.

A foreign currency would be a sanctioned currency (all that full faith and credit stuff that states command). But if you would come up with a new currency (1 Turb = 144 Lences) and use it for anything else but board games, the state would come down on you first for violating its coinage privilege and secondly for the tax evasion.
I guess defunct currencies* are treated like made-up ones.

*the European currencies replaced by the Euro are a special case since some states still accept them as legal tender

That also means that pure barter is not strictly legal

This is not true in the US.

But if you would come up with a new currency (1 Turb = 144 Lences) and use it for anything else but board games, the state would come down on you first for violating its coinage privilege and secondly for the tax evasion.

I don't believe that's true in the US. There are a bunch of businesses that accept bitcoin that don't seem to have suffered any legal sanction. What's more, there are online virtual game currencies with very large dollar value amounts; these also have not seen any sanction from US governments except regarding tax evasion and money laundering concerns.

Tell that to the Chinese and others holding US dollars.

Well: not quite. I winced every time Mitt talked about how much of our debt China owns; that was actually a great deal more true last year than it is right now. Here's the latest miserable debt doughnut.

Who owns most of our debt is us. China owns less than 10% of our debt.

Ok, now that I look into that "a great deal more true last year than it is right now", that only applies to short-term T-bills and not to overall debt holdings.

Still, Japan is kind of a close second to China, in terms of individual countries that hold US debt.

Although obopay is tied to official currencies and banking systems, it allows you to make instant funds transfers outside of traditional bank and credit card systems using your mobile phone. Amazon, Google and others are getting into the non-traditional funds transfer business.

While I can't find support for my previous comment, it may only be a matter of time before someone uses cloud computing and other technologies to set up a virtual banking system that would be hard for governments to corner. Maybe they already have. After all, there's a huge demand to be able to move money under the radar of governments.

In the mean time, carrots are the ticket.

Although obopay is tied to official currencies and banking systems,

obopay is a company that sells stuff to banks.

it allows you to make instant funds transfers outside of traditional bank and credit card systems using your mobile phone.

No, it doesn't.

Amazon, Google and others are getting into the non-traditional funds transfer business.

No, they're not. In any event, non-traditional funds transfer is a far cry from currency transfers that bypass banks and governments. And it is a very far cry from a large movement of people doing so right now.

it may only be a matter of time before someone uses cloud computing and other technologies to set up a virtual banking system that would be hard for governments to corner.

No, it won't be. You clearly don't know a damn thing about how technology works, let alone how the banking system works.

After all, there's a huge demand to be able to move money under the radar of governments.

We call that money laundering. It is a serious crime.

So let's think this out as if we were writing a futuristic movie script regarding a virtual economy of some size existing under the radar of government and avoiding all taxation.

Say, Smeagle, one segment of the futuristic virtual economy existing only in the cloud, is run by, it turns out, some combination of Russian Mafia and an ideology-soaked Paul Ryan/Galt type who, it also turns out, are malevolent grifters by nature, and inevitably and one day, this cloud economy and all of the "currency deposits" it is holding in virtual la-la-land (just like now, except that my bullsh*t currency metaphor bank account down at the local bank at least has someone keeping track of it if things go haywire) from topless car wash owners in Texas and such who have seceded from the regular economy because they don't like paying taxes to governments, especially those run by black dudes, disappears with a mouse click into cyber outlaw Barbados Rmoney oblivion taking all of the deposits, the virtual currency, the virtual carrots with it, never to be seen or found again.

Who are the victims going to call to get their money back?

The government? Which has fired the Federal Reserve, the FBI, the CIA, the wiretappers, the banking account snoops, the IRS inspectors, etc etc because the tax drain has pretty much put the kabosh on law enforcement as well as any other government function?

"After all, there's a huge demand to be able to move money under the radar of governments."

Yeah, I look forward to doing business in the same bazaar with international arms dealers and heroin and cocaine cartels in order to buy my groceries without government snooping around.

Not that the banks aren't laundering arms merchants and drug dealers money already, but still.

Here, what I think you're saying is that the U.S.'s infant mortality and life expectancy numbers are being dragged down by minorities (black and hispanic people, probably), and that we should be comparing the outcomes for white people in the US with white people in Europe.

I hope that upon reflection you will understand why this is a deeply repellent argument. You're saying we shouldn't factor in how ethnicities who are disproportionately poor are faring under our healthcare system.

Why not?

Anytime race or ethnicity enters a conversation, the tone and tenor change, regardless of intent or, often, context.

If you are going to compare anything among populations, then the valid comparison is comparing like to like. Whether it is income, test scores, admissions,education attainment, what have you and for whatever reason, we often divide along ethnic/racial lines. The question then arises whether there are differences along these lines and what the underlying reasons for those differences might be. If noting those differences--as opposed to conclusions one draws from the differences--is repugnant or repellent or racist or whatever, just tell me now and I'll put my head in the sand. In the meantime, those differences will persist whether repellent or not. If, on average, Caucasians outlive African Americans, that is a fact, not an opinion and censoring that fact won't make it go away.

Julian, you mind read when you write, "what I think you're saying is that the U.S.'s infant mortality and life expectancy numbers are being dragged down by minorities (black and hispanic people, probably)." Your phrase 'dragging down' coupled with your subjective judgement 'repellent' allows for the reasonable inference that you are imputing racist motives to me.

If we are going to look at life expectancy as an indicator of a given country's health care delivery, then we have to compare like to like. In this case, European extraction in the US compares favorably with European results. The 'why?' of that is a separate issue: access to healthcare, poverty, education, or some combination of the three. But, on the efficacy of US vs Europe on healthcare delivery, it is either a tie or statistically too close to call for Caucasians. So, as to Caucasians, you can't draw any conclusions based on this metric.

You well might draw conclusions within the US by race and by state and by urban vs rural. All of these, I strongly suspect, will yield different results by ethnicity.

Great! Then you can perhaps answer some questions

I could, but you typically load your questions up in such a way as to make the exercise more work than it's worth. Short answer: there aren't a lot of data reliably pulled into one location that doesn't require a lot of digging through the weeds. I tried to indicate that the choice of metric is subjective and that there isn't, AFAIK, one that follows surgical results. I picked surgery wait times and cancer survival because both are contingent upon availability of and access to timely medical intervention. Life span can be but isn't necessarily as directly related.

We spend MUCH MUCH more on health care, and if you broaden your metrics beyond the somewhat narrow focus of outcomes for specific cancers and wait times for elective surgery, we DO NOT have a much much better result.

How do we know this and what is the standard for "better result"? Not being argumentative here, just wondering how one compares a country of 40 million people with one of 300 plus million and reliably concludes that one system is better than another. I am betting that there are things we do in the US 'better' that China simply because we don't have a billion plus people banging around.

Instead, everyone talks about money, which can be created out of thin air if necessary.

Sure it can, at which time it loses all of its value and, lacking some other medium of exchange, we are all penniless. So, either we are proposing screwing the dumbasses who bought our debt by devaluing our currency to the point of being meaningless or we're blowing smoke--no one is seriously going to devalue in that fashion.

But the cost of health care, period, no matter who pays for it, is going to be one of a very small handful of make-or-break problems for the nation over the next 20 or 30 years.

I don't think it's something that can left purely to private markets to sort out.

Maybe. We're talking about what the future holds, which is inherently unknowable. Where I question your statement is the implicit notion that if the market can't fix a problem--here, the problem is health care--the government can. That is an unproven premise. The evidence of government successfully discharging, over the long term and sustainably, something as expensive and expansive as health care does not exist. The hope is that government can do this. What if government fails? Or, worse yet, fails utterly? These are also on the range of possible outcomes. If government fails utterly, it leaves a vaccuum far worse than our present problems. Far worse. One of the many angles of ACA that scare me a lot--not for me, but for my children and very-soon-to-be-born grandchild--is that ACA will so suppress innovation and the supply of high skilled docs with attendant high end diagnostic equipment and modalities that the long term quality of medicine will decline precipitously, not to mention bankrupting the country. I am not predicting this will happen, only expressing grave concern that it could happen.

Sure it can, at which time it loses all of its value and, lacking some other medium of exchange, we are all penniless.

Really? Why hasn't that happened then? When the Treasury issues bond to cover deficit spending and the Fed buys those bonds on the open market a short time later, how is that functionally different from creating money from thin air with a few strokes on a keyboard? I mean, we could certainly overdo it, but we have high levels of unemployment and underutilized capacity for production now, with dreaded deficits and QE1 and 2, all the while with low inflation and really low interest rates.

If people shift from doing nothing (or from making motorcycles and cigarettes, or whatever) to providing healthcare, how is that going to devalue our currency? And you still have no response to the issue of real reasources being expended. Russell touched on it, and I agree we should use as few resources as necessary to achieve the best outcomes as are feasible (something I believe about everything we, as humans, do), but that's a different issue from "running out of money."

I did a quick search and life expectancy for white people in the US in 2009 was 78.8 years (from a CDC table pdf file here ) and life expectancy in Great Britain in 2010 was a little over 80 years. link

So a slightly better result and they pay less for health care.

What struck me about the health care debate in the US was that outside of blogs it seemed to be structured as "Can we afford this massive government intervention into the health care system?" At blogs I would read the claims people make here--that other Western industrialized countries get better results than we do with less money spent on their health care system. Now even if that was wrong (and I don't think it is), comparisons between the US and other countries should have been part of the debate. But I don't think it was.

I singled out whites because that was brought up. I actually agree with Julian --not that McKT is making a racist argument intentionally or unintentionally, but that the low life expectancy of American minorities is part of the overall picture. Anyway, Great Britain has minorities too, though I don't know what the percentages are. Even so, comparing American whites to the average in Great Britain, Britain wins.

Whether it is income, test scores, admissions,education attainment, what have you and for whatever reason, we often divide along ethnic/racial lines.

We do that to test how just our various systems are as regards race and ethnicity. We do that to identify problems of discrimination and lack of opportunity for groups we already know aren't doing so well. But you would need to control for things like education and income to properly test for differences among races and ethnicities as it regards health outcomes. I think the obvious reasons some races and ethnicities, to the extent we're even capable of defining such meaninfully, do better than others health-wise are the other factors like income and education.

Why do you think race and ethnicity, in and of themselves, would be significant factors in broad-based health outcomes (as opposed to specific things like Tay–Sachs disease or sickle-cell anaemia, which we already know affect certain groups)?

Why do you think race and ethnicity, in and of themselves, would be significant factors in broad-based health outcomes (as opposed to specific things like Tay–Sachs disease or sickle-cell anaemia, which we already know affect certain groups)?

They aren't if there is no difference across racial lines and I never said 'in and of themselves'--in fact, people keep adding to what I say. But here's the point: you control for ethnicity and see if there is a difference. If there is a difference, you note it. I suspect the smaller ethnic demographics in Europe have less of a variance, maybe even no variance, from Caucasians in health care delivery. Let's say that's the case: a notable disparity in the US between white and black people, but not in Europe and assume that the European black population is statistically significant. If that were the case, then you'd conclude, at least in part, the US black community is under-served by the health care delivery system.

Now, another note about race: suppose African Americans outlived Caucasians, all things being equal. Would anyone object to that fact being noted? Would anyone object to defending the efficacy of US healthcare delivery by insisting that Caucasians in Europe not be compared with African Americans in the US because of the demonstrated (for the purpose of this discussion) fact that African Americans live longer?

If that is ok, then the reverse out to be ok, if all else is equal. We know things aren't equal in the US in terms of economics, education etc. What we don't know is whether, for some obscure and presently unknown reason, different ethnicities live longer, on average. That could well be the case. The average may be months, it may be a couple of years. If so, that disparity becomes a fact of life and relevant to average life expectancy in the US compared to populations that are not ethnically comparable.

McK:

What do you think of the theory that healthcare outcomes like infant mortality and life expectancy divide along racial lines largely because minorities (and especially African Americans) are disproportionately poor?

If that's the case, then even granting your assumption that the healthcare system we have is as good for our white people as it is for the UK's white people (which Donald Johnson disputes), then our healthcare system is much much worse for our poor people.

Do you agree or disagree?

What do you think of the theory that healthcare outcomes like infant mortality and life expectancy divide along racial lines largely because minorities (and especially African Americans) are disproportionately poor?

If that's the case, then even granting your assumption that the healthcare system we have is as good for our white people as it is for the UK's white people (which Donald Johnson disputes), then our healthcare system is much much worse for our poor people.

Do you agree or disagree?

I agree somewhat and think that you are conflating 'poor' and 'being a minority'. Let's take four ethnicities: Asian, Caucasian, African American and Hispanic and then further control for education and employment level. My guess is that poorer healthcare outcomes will aggregate in that subset which is defined by lower education and lower skilled/unskilled employment, irrespective of ethnicity. This is a function of education as well as a number of social pathologies that flow from a sub-subset within the low income/low education subset, that being the third and fourth generation of poverty/limited education attainment.

IOW, ignorance is a byproduct of chronic poverty which is all too often self-replicating down through generations. In many cases, my sense is that many people simply don't know how to take care of themselves in a healthy way (hell, go to McDonalds, which another story, and why our life expectancy is likely to decline in the out years) and this is passed along to their children who grow up never knowing any better. It may be partially access to healthcare, but that is only part of it. Smoking, alcohol and drug abuse, diet, lack of prenatal attention to diet, etc, etc. All of these drive life expectancy. I strongly suspect that the 5% outlive the 80% regardless of ethnicity.

Well, speaking of all those other factors, here's a piece from the New Yorker in 2004--I didn't realize how long ago it was until I looked it up. Anyway, the claim is that Europeans are getting steadily taller and Americans aren't. Perhaps it's those European nanny state attitudes at work.

link

Perhaps it's those European nanny state attitudes at work.

No. It's the gravitational pull of our fat guts hanging over our belts pulling us in the opposite direction.

I picked surgery wait times and cancer survival because both are contingent upon availability of and access to timely medical intervention.

So, again, what do you want them to be? What's an acceptable value or range? Are those of the previously mentioned nations acceptable or unacceptable vis a vis the US? If unacceptable, why? How much variation is acceptable.

In many cases, my sense is that many people simply don't know how to take care of themselves in a healthy way (hell, go to McDonalds, which another story, and why our life expectancy is likely to decline in the out years) and this is passed along to their children who grow up never knowing any better.

I would suggest that you look into large-scale packaged food producers' and chain restaurants' well-funded contribution to this being the case, or at the typical/aggregate conservative response whenever anyone suggests that maybe school lunches could have more broccoli and fewer tater tots, but I can't imagine much would be accomplished by my doing so.

Also, this: "Life span can be but isn't necessarily as directly related [to timely access to medical care]" is going to require a lot more than simple assertion.

Isn't it great that we can quit arguing about it, and that we can test it now. If it weren't for the ACA, there would be the status quo. The status quo didn't work for a huge number of people.

So, again, what do you want them to be? What's an acceptable value or range? Are those of the previously mentioned nations acceptable or unacceptable vis a vis the US? If unacceptable, why? How much variation is acceptable.

What's a fair wage? How many children should you have? What is a decent standard of living? How far is up? I guess it depends.

If you have a broken hip and can't ambulate and your muscles are atrophying and you have to wait six months to get a replacement, that's too much.

If the wait time is 1-2 months, that's not good either, but it's better than six months.

There isn't an objective standard. From personal experience, when my back went out 5 years ago and I couldn't stand, walk or sit (or use the bathroom for any purpose without what seemed like all the freaking pain in the world), any wait time was too much. My wait time turned out to 2 weeks to get a spinal injection which did the trick. I can tell you for a fact that if you're lying in bed and can't move, can't get to work, after about a week, depression sets in, time stands still and it gets worse everyday. If ACA produces longer lines than we already have, that will not be good for anyone, to say the least.

whenever anyone suggests that maybe school lunches could have more broccoli and fewer tater tots, but I can't imagine much would be accomplished by my doing so.

Because no one can actually choose their meal on their own responsibly? Because the ignorant masses haven't been duly and suitably indoctrinated in healthy lifestyles? Understood. Let's have a federal directive on healthy school lunches. Back when our kids were at home, we had family directives on eating well, backed up by the usual parental coercion tactics. However, I don't think a school system can tell Johnny or Julie they can't watch TV or have dessert if they don't eat all their broccoli or tell them 'no lunch tomorrow if you don't eat what you are served today' and have it stick.

While we're at it, let's monitor how much sleep people get, how much TV they watch, let's mandate an hour a day of exercise and require courses in sensitivity. And dental hygiene--did you brush and floss? No? Ok, no cookie for you.

People know, or should know, what is healthy. Shocker, many people don't really care. Go figure. It isn't just another conservative conspiracy to screw people over. Really, it isn't.

Also, this: "Life span can be but isn't necessarily as directly related [to timely access to medical care]" is going to require a lot more than simple assertion.

Well, it's a combination of two things: first, don't take me out of context and then, when you don't, it's a matter of logic.

Here's what I said:

"I picked surgery wait times and cancer survival because both are contingent upon availability of and access to timely medical intervention. Life span can be but isn't necessarily as directly related."

1. Surgery wait times--lesser wait times correlates to having more docs and more surgical suites, i.e. more access to timely medical intervention.

2. Better cancer survival rates--are often a product of earlier diagnosis and shorter time lapse between diagnose and treatment. Again, this is quicker/greater access to timely medical intervention.

3. Why lifespan isn't as directly related as 1 and 2 above--because you can have virtually unlimited access to the best healthcare in the world but if you are a smoker, an excessive drinker, sedentary and obese, it won't do you much good. If you have limited access to healthcare, but live a healthy lifestyle, you can fix on that side of the equation what gets lost on the other. If you are genetically predisposed to live long, or not, access to healthcare may not be much of a determinant regardless.

How do we know this and what is the standard for "better result"?

So, two questions:

How do we know this (i.e., the outcomes in the US are not significantly better than in comparable countries)?

We know this because there is a very large body of research dedicated to finding this very thing out.

One commonly cited source is the OECD, there are also many other organizations who do nothing else but crunch these kinds of statistics day in and day out.

It's what they do, and they're good at it.

What is the standard for "better result"?

There likely is no single standard for better result. The OECD stuff, for example, focuses on life expectancy. Other research focuses on specific issues like obesity, or prevalence of chronic disease, or any of a number of other issues.

The US has very good results for certain fairly specific things. We're good at cancer outcomes, we have a very high availability of sophisticated medical technologies like MRIs and other imaging technologies.

We are mediocre at plain vanilla basic preventative health care, and at a fairly wide spectrum of plain vanilla quality-of-life measures.

There is absolutely no question, whatsoever, that our all-in per-capita expenditure on health care is head and shoulders above any and all other nations.

You are correct that no two nations are exactly alike, and in fact no two nations other than US are exactly alike. So, to some degree, any comparison is apples to oranges.

But the preponderance of evidence is that we pay a hell of a lot more, and do not get a hell of a lot better result.

Where I question your statement is the implicit notion that if the market can't fix a problem--here, the problem is health care--the government can.

The difference between relying on the market to 'fix a problem' and the government to 'fix a problem' is that the government can actually have an intent, relative to the problem at hand. The market really doesn't.

So, if there actually is a problem, the market will not provide a solution. It will provide a *result*, which is a different thing altogether. And, that result will be a function of which of all possible outcomes yields the most efficient deployment of resources, especially capital.

In the case of health care, the most efficient deployment of resources might come by making no health care, at all, available to a large swath of the population.

For reasons -- very good, legitimate, and compelling reasons, that have nothing to do with economics per se -- we might as a polity decide that we don't want to settle for that outcome.

Basically, to me, saying that we can't interfere in 'the market' when it is producing results that we find unacceptable is like saying that you can't board up your windows when a hurricane comes, because that would be interfering with the weather.

"The market" is just a description of a complex system. There is no overarching intelligence, it's just the result of millions and millions of very local decisions made by millions and millions of people, none of whom has a total or even a very large understanding of the dynamics of the system as a whole.

The "market" has no agency, or intelligence, or intent. It's our description of what happens when millions of people provide and sell goods and services. Relying on it to produce an optimal outcome by any measure other than efficient use of resources is like relying on the weather to never blow your house down.

That is an unproven premise. The evidence of government successfully discharging, over the long term and sustainably, something as expensive and expansive as health care does not exist.

The question on the table is not government providing health *care*. The question on the table is government regulating the terms under which primarily private actors provide health *insurance*.

The US government actually has a pretty good track record of running public health insurance programs, even at fairly large scales. So, if a purely public payer option was politically feasible, IMO that would be a reasonable path.

It remains to be seen how effective government will be at managing the interaction of a mongrel mix of private and public actors. I'm sure the results will be mixed.

But, at a minimum, it allows for the public *intent* -- the purposeful goal that health care be available to a broad range of the population -- to be a factor in the mess.

"One of the many angles of ACA that scare me a lot--not for me, but for my children and very-soon-to-be-born grandchild--is that ACA will so suppress innovation and the supply of high skilled docs with attendant high end diagnostic equipment and modalities that the long term quality of medicine will decline precipitously, not to mention bankrupting the country"

Then you should be in favor of single-payer healthcare. Since the one example we have of government monopsony is defense/security. Does that service look like it is suffering from lack of innovation, a dearth of high-end equipment, withering R & D, and an undersupply of skilled labor, such as mechanical/aerospace engineers?

Of course the potential *bankrupting of the country* is still a lingering possibility, but if we're going to bankrupt ourselves (or come uncomfortably close to it), I'd rather it be from 'overspending' on making ourselves healthier and happier, and exporting that technology and know-how to the rest of the world (rather than merely subsidizing it for the rest of the world, as we do now). Instead of, you know, exporting death and destruction to the rest of the world. Just my opinion.

As for why we spend so much more than the rest of the developed world on health care, there is good evidence that it has more to do with paying higher prices for medical goods and services, rather than overutilization or an unhealthy population:

http://content.healthaffairs.org/content/22/3/89.abstract

I also don't understand why people who want to maintain a market-based healthcare financing and delivery system would be opposed to the PPACA, since it seeks to maintain a largely private financing and delivery system, but addresses several market failures such as free riders (mandate), asymmetric cost/benefit information (IPAB) and excessive pricing power (insurance exchanges).

In fact, it's markety-ness is probably why the Heritage Foundation came up with it in the first place. And why Mitt Romney instituted it in MA, even going so far as to say that it would be a good model for the nation. Of course that was before he had to do the GOP Auto Da Fe.

All of this is despite the fact that Kenneth Arrow explained almost 50 years ago why people don't regard health care like any other good or service that can be readily commoditized and so well-provided by an unregulated market:

http://www.who.int/bulletin/volumes/82/2/PHCBP.pdf

He still seems to think we have not been able to overcome those human obstactles to make a market-based healthcare system work:

http://delong.typepad.com/sdj/2010/08/uwe-reinhardt-on-kenneth-arrow-on-health-care.html

"You clearly don't know a damn thing about how technology works, let alone how the banking system works."
True enough. However, something in the direction of what I was thinking about:

Banking In The Cloud

I looked at the OECD statistics for wait time for elective surgery that McKinneyTexas linked to. And what that said was: Only those respondents who had specialist consultations or elective surgery in the last year or two were asked to specify waiting times. So the wait time for people who didn't have elective surgery because they couldn't afford it? Not counted. And how do people in the US who don't have health insurance get elective surgery? Emergency rooms don't do it. As a measure of efficiency once you're inside the health care system, elective wait surgery is one possible statistic. As a measure of healthcare for the whole population, it's hopeless.

As for the rest of McKinneyTexas' statements: if there is a significant racial component to life expectancy, then why does the Virgin Islands have higher life expectancy than the US? (Much smaller population, but even so, it argues against genetic factors). If you look at the CIA statistics on life expectancy at the top there are countries from a range of ethnicities.

He worries about his children and grandchildren not getting healthcare? Well, the NHS has been going for over 60 years. Bismarck started introducing public health insurance in Germany in 1883. It's also interesting to note that China is currently trying to extend health insurance to more and more people (coming from a very low base). But then what can the US learn from anyone else?

"As for the rest of McKinneyTexas' statements: if there is a significant racial component to life expectancy, then why does the Virgin Islands have higher life expectancy than the US?"

Because race, here, is just a proxy for culture.

We will frequently talk about "black" unemployment, or "black" single motherhood, or "black" what have you, but what we're actually looking at is a rather dysfunctional subculture which just happens to be correlated with race.

But you're generally screwed if you're a member of this culture, even if you're white, and doing ok if you're not a member, even if you're black. On employment, education, health, and so forth. It's the culture, not the race, and we're too fixated on race to look past it to see that.

There isn't an objective standard.

Well, I'm glad that we've at least gotten to this point. You chose factors which appear support your preferred policy option. Noted.

I can tell you for a fact that if you're lying in bed and can't move, can't get to work, after about a week, depression sets in, time stands still and it gets worse everyday.

Try laying in bed for three weeks, on painkillers, following major orthopedic leg surgery. It'll make you want to kill yourself. (No joke - after that experience I've refused to take Vicodin for anything ever again.)

Because no one can actually choose their meal on their own responsibly? Because the ignorant masses haven't been duly and suitably indoctrinated in healthy lifestyles? Understood

I hope you aren't being sarcastic, because surely as an attorney you understand that sometimes one's choices, or even one's ability to make choices, are constrained by wholly external factors.

what we're actually looking at is a rather dysfunctional subculture which just happens to be correlated with race.

This is IMO an extremely apt point. Thanks for this Brett.

I would add, perhaps, two things:

1. the correlation with black skin, specifically, should really be extended, because the cultural phenomena show up in communities of many ethnicities. Which doesn't contradict anything you've said, on the contrary, it's just something I would like to call out.

2. the subculture in question doesn't exist apart from the larger American culture, it's part of it, and is in no small part a product of the larger culture.

To follow up on Russell's point: 'the cultural phenomena show up in communities of many ethnicities'. A common right-wing argument about why most European countries' life expectancy is better than that of the US is that Europe is more racially homogenous. However, as the life expectancy statistics I quoted confirm, race in itself isn't a determining factor.

Among European Caucasians, there are also subcultures which have noticeably worse health problems than others. (I'll leave to one side for the moment the question of whether these are more due to individual failings or society's adverse treatment/neglect of such subcultures).For example in the UK, there's the Glasgow effect (and Scotland in general has poor health standards). And yet the UK as a whole has better life expectancy than the US. Other European countries have similar subcultures, and yet the EU still has higher life expectancy than the US.

So you're left with two possible solutions: either the US has a substantially higher number of people in dysfunctional subcultures (and you'd then need to ask why?). Or the US is less good at dealing with the healthcare of society as a whole.

Related: Babies Born in Mississippi Are Less Likely to Reach First Birthday Than Those Born in the Rest of U.S.

Interesting:

Other factors that increase a mother's chances of giving birth prematurely: If she's a teenager, if she's obese, or if she's black. As it happens, Mississippi had the highest teen birth rate in the U.S. in 2010, currently leads the country in obesity, and 40% of its infants are born to black women. Black women are 50% more likely to give birth prematurely, the reasons behind which remain mysterious to the CDC, but state health officer Mary Currier tells CNN, "It is my belief that is largely due to poverty and the social determinants of health."
A 50% difference is statistically significant, and cannot be chalked up to "culture" alone.

Here's a cool link on orthopedic surgery. I'll join in the fray directly.

http://www.youtube.com/watch_popup?v=xMYjfb_M9wM&vq=large

I know all I need to know about orthopedic surgery, and still have the plate and 6 pins to prove it!

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